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1
PEDIATRICS
THE
HYGIENIC AND MEDICAL TREATMENT
OP
CHILDREN
BY
THOMAS MORGAN KOTCH, M.D.
I'KUFBSSOK OF TIIK DIHKASEtj OK CUILDKEN, IIAKVAKI) UNIVEKSITY
ILLUSTRATED
r II r I- A i> K I, r III a
J. B. LTPPIXCOTT COMPANY
1897
Copyright, 1896,
BY
J. B. LippiNcoTT Company.
Electrotypeo and Printed tv J. B. Lippincott Company. Philadelphia, Pa., U. 8. A.
TO
NELSON SLATER BARTLETT,
IK BEOOQNITION OF HIS INTEBEST AND ENTHUSIASM
IN PROMOTING
THE STUDY OF PEDIATRICS.
PREFACE.
A FEW words arc perhaps DOf^icd to explain what I have undertakea
to do in the followiog ^>ag«?s, and the meth<3<i nf arrangement and classi*
fieation which haa been employed* There ha^s been no attempt te> make
such elas^ifieationB as infectious and non-infeetions diseases, because our
knowledge of the ibrmer is increasing the mimber of that elaas so rapklly
tliat Ibr me it no longer eoustitutes a praetiejil division ibr teaching* The
btx)k begins with a consideration of the infant at birth, and follows it
thiYJiigb its various stages oi" development up to pulxTtv. After dwelling
ratlier more at length on normal development than is usiiid in works on
IKtlia tries, the abnormal conditions are discussed. Beginning with the dis-
eases which woukl natumlly be met with in the early periods of life, and
devesting considerable space to my observations on the bki^id of infants and
of young childivn, the diseai«:!a of the diffcix^nt oi*gans an* then considered.
With the ext^eptiou of a few rare diseases of which it was impossible to
get satisfaetc^ry types, the illustrations repre^seut actual cases ot* my own,
heretofore unpublished. The <:^lored illustrations have i-eceived ray closest
attention^ and the patients were seen personally with the artist, so as to
insure aecuraey.
The establish merit of milk-laboratories during the last three years lias
mai^ked a new era in preventive medicine, and has made possible the scien-
tific feeding of infants. As I believe that the medical tivatmeut of the
various abnormal conditions arising in infantas is in the future t<» \je largely
dietetic rather than by means of drugs, I have given unusual promiueuee to
the part of the work which is devot4xl to feeing.
I ha%^e also endeavored, in cM>nj miction witii my colleagues in the Ameri-
can Pediatric Stx-iety, to simplify tlie nomenclature of the varioas disea-ses,
in order that physicians in diflerent localities should by using identical
names be the better able to aid one another in their investigations, A
revision of the nomenclature of ga^tro-euterie diseases and of ttiose of the
mrmth was especially called for on aooount of the changes which have
followed our inerea^^ing kno%v ledge of the etiology of these diseases,
T. M, RoTCH.
BoATON, Mass., Ocloter, 1895.
I
CONTENTS.
DIVISION I.
INTRODUCTORY.— THE INFANT AT TERM.
PAOB
Lkctube I. — Introductory. — The foetal circulation 17
LxcTUBK II.— The infant at term 28
Vemix caseusa 28
Cord 24
Spine 26
Neck 80
Head 80
Thorax 88
Abdomen 44
Pelvis 48
Bladder 48
. Uterus 48
Temperature 48
Pulse 48
Respiration 48
Height 49
Weight 49
Vitality • . . . . 49
Hands 49
Feet 49
Bone marrow 61
Functions 61
Blood 62
Lymphatic system 62
Urine 68
Intestinal discharges 68
DIVISION n.
NORMAL DEVELOPMENT.
LxcTDRK III.— Spine 66
Neck 69
Head 60
Thorax 70
LxcTUBE IV. — Abdomen 77
Temperature 94
Pulse 94
Respiration 96
Height 96
Weight 97
Feet 105
Bone marrow 107
Skin 107
vii
Vm CONTENTS.
Lkcturx iy,—Ccmiinued, paob
Cord 110
Functions 110
Blood Ill
Lymphatic system Ill
Thyxx>idbody Ill
Urine Ill
Intestinal discharges 117
Infantile skeletons 118
Normal infants 119
Topographical anatomy of the early periods of life 120
DIVISION m.
HYGIENE OF THE NURSERY.
LxcTURE v.— The nursery 126
Intertrigo 182
Seborrhoea capitis of infants 182
Clothing 182
Feet and shoes 188
Sleep 140
Outdoor air 140
Nursery-maids 141
Mouth 141
School 142
Importance of correcting defects of posture 142
Vaccination 147
DIVISION IV.
FEEDING.
Lecture YI. — The general principles underlying all methods of infant feeding ... 158
Lecture VII. — The first nutritive period 168
1. Maternal feeding 158
2. Direct substitute feeding 209
Lecture VIII. — The first nutritive period (continued) 214
8. Indirect substitute feeding 214
Lecture IX.— Indire<;t substitute feeding (continued) 280
General remarks on substitute feeding 280
Comparison of woman's and cow's milk 285
Milk-laboratories • 245
Lecture X.— Home modification . . 276
General remarks on artificial foods for infants 279
Lecture XI. — The second and third nutritive periods 284
DIVISION V.
Lecture XII. — Premature infants 288
DIVISION VI.
GENERAL PRINCIPLES OF EXAMINATION AND TREATMENT.
Lecture XIII. — Method of examining a sick child 318
Drues 326
OONTENTO. IX
DIVISION vn.
THE BLOOD IN INFANCY AND CHILDHOOD.
PAQS
Lkctubk XIV. — Literature 829
Nomenclature 880
Blood-key 881
Methods 882
Chemistry -834
Origin 886
Foetal blood 887
The normal conditions of the blood in early life 889
LscTUBE XV.— The pathology of the blood in early life 848
Premature infanta 848
New-born infants 849
Leucocytosis 850
Leucaemia 851
Oligooythiemia 858
Primary anaemia 865
Chlorosis 855
Anaemia progressiva pemiciosa 856
Anaemia infantum pseudo leuksemica (von Jaksch) 859
Secondary anaemias 866
Treatment of diseases of the blood 866
Congenital syphilis 867
Rhachitis 868
LxcTURE XVI.— The blood in individual diseases 870
Typhoid fever 870
Scarlet fever 871
Measles 871
Variola 871
Diphtheria 872
Pneumonia 872
Broncho-pneumonia 878
Pneumonia and empyema 873
Empyema 87^
Miliary tuberculosis 874
Tubercular meningitis 874
Hydrocephalus 875
Chorea 876
Nephritis 876
Tubercular peritonitis 377
Infantile atrophy 877
Periostitis 378
Scorbutus 379
Icterus neonatorum 879
Sclerema neonatorum 379
LXCTUBE XVII.— Parasites of the blood 380
Literature of the blood in early life 898
DIVISION vm.
DISEASES OF THE NEW-BORN.
LKCTT7BS XVIII.— Maternal impressions 404
The head 404
The neck 416
LscTUBK XIX.— The trunk 418
X 00NTENT8.
PAGB
Lkcture XX. — The eztremitiei 486
General dUeaset 440
DIVISION EX.
Lbctube XXI.— Diaeasee of the skin 466
DIVISION X.
SYPHILIS—ERYSIPELAS— THE EXANTHEMATA.
Lecture XXII.— Syphilis 487
Lecture XXIII. — Erysipelas 612
Lecture XXIV.— Variola— Varicella 617
Lecture XXV.— Scariet fever 682
Lecture XXVI.— Measles 678
Rubella 688
DIVISION XI.
DISEASES OF THE NERVOUS SYSTEM AND THE MYOPATHIES.
Lecture XXVII. — Introduction 690
Lecture XXVIII. — I. Organic nervous diseases 694
Brain 694
Lecture XXIX. — Tubercular meningitis 608
Lecture XXX. — Thrombosis of the cerebral sinuses 626
Hydrocephalus 629
Lecture XXXI.— Cerebral abscess 648
Cerebral paralysis 648
Athetosis 661
Intra-cranial tumors 662
Intra-cranial syphilis 668
Idiocy 670
Mirror writing 678
Lecture XXXII.— Cord 676
Myelitis 676
Poliomyelitis anterior 676
Paralysis caused by caries of the spine 688
Hereditary ataxia (Friedreich's disease) 689
Locomotor ataxia 689
Syringomyelia 690
Lecture XXXIII.— Brain and cord 691
Multiple cerebro-spinal sclerosis 691
Cerebn>8pinal meningitis 692
Lecture XXXIV. — Peripheral nerves 704
Neuritis 704-
Paralysis of the new-bom 706
Neuralgia 709
Lecture XXXV. — II. Nervous diseases presumably organic 711
Chorea 711
Epilepsy 724
Insanity 781
Lecture XXXVI. — III. Functional nervous diseases. (1) Probably central . . . 782
Hysteria 782
Hypnotism 786
OONTENTB. 21
Lectubs XXXyi.—Qmiinued, pagi
Catelepsy 786
Simulated diseases 786
Insolation 786
Concussion 788
Temporary amnesia 789
Temporary aphasia 789
Arrested psychical development 740
Retarded speech 740
Headaches 741
Vertigo 748
Sensitive spine 744
Tetany 744
Pavor noctumus (central) 746
LxcTURE XXXVII.— IV. Functional nervous diseases. (2) BeAex 746
Pavor noctumus (peripheral) 746
Dental reflex * 746
Reflex nystagmus 747
Reflex of the ear 747
Reflex of the larynx 747
Paroxysmal gasping 749
Reflex of the lung 760
Reflex cough 761
Reflex of the heart : 761
Reflex of the stomach 762
Reflex of the bladder 762
Reflex of the vagina 762
Reflex of the rectum 762
LxcTURE XXXVIII. — Convulsions 764
Tremor 762
LxcTUBE XXXIX.— The myopathies 768
Progressive muscular atrophy 768
Pseudo-hypertpophic muscular paralysis 768
Myotonia congenita (Thomson's disease) 778
DIVISION xn.
DISEASES OP THE MOUTH, NOSE, NASO-PHARYNX, AND PHARYNX.
Lecture XL. — Stomatitis catarrhalis . . , 776
Stomatitis herpetica 779
Stomatitis ulcerosa 781
Stomatitis mycetogenetica 784
Glossitis 793
Microglossiu 794
Macn>glos8ia 794
Difficult dentition 795
Lecture XLI. — Diseases of the nose, naso-pharynx, and pharynx 801
Lecture XLII.— Diphtheria 821
DIVISION xm.
DISEASES OF THE (ESOPHAGUS, STOMACH, AND INTESTINE.
Lecture XLIII. — Introduction 884
(Esophagus 834
Stomach and intestine 886
Xll CONTENTS.
PAGB
Lecture XLIV. — Diseases of the Btomach g40
Lecture XLV. — Diseases of the intestine g68
DIVISION XIV.
Lecture XLVl. — Diseases of the liver, pancreas, spleen, and peritoneum 914
DIVISION XV.
Lbgtubb XLVII. — Diseases of the kidneys, bladder, and genitals 927
Kidneys 927
Supra-renal capsules 940
Bladder 942
Genitals 948
DIVISION XVI.
DISEASES OF THE LARYNX, TRACHEA, LUNGS, AND PLEURA.
Lecture XLVIII.— Laryngospasmus 949
New growths 949
Foreign bodies 950
(Edema 960
Laryngitis 951
Lecture XLIX.— Diseases of the lungs 954
Bronchitis 954
Broncho-pneumonia 962
Atelectasis 979
Lobar pneumonia 980
Gangrene 986
Tuberculosis 998
Pertussis 998
Asthma 1004
Periodic catarrh 1005
Lecture L. — Diseases of the pleura 1007
DIVISION xvn.
DISEASES OF THE HEART AND PERICARDIUM.
Lecture LI. — Diseases of the heart 1019
Lecture LII.— Diseases of the pericardium 1046
DIVISION xvm.
UNCLASSIFIED DISEASES.
Lecture LIII. — Rhachitis 1065
Scorbutus 1075
Rheumatism 1080
Purpura 1086
Diabetes 1088
Tuberculosis 1089
Epidemic influenza 1092
Diseases of the thyroid gland 1095
Diseases of the cervical lymph-glands 1101
Parotitis 1104
Diseases of the ear 1105
PEDIATRICS.
DIVISION L
INTRODUCTORY-THE INFANT AT TERM
LECTURE I.
INTRODUCTORY.-^THE FCETAL CIRCULATION.
Gextlemen%— We are to-day bejiriiining the study of a branch of
luedifine whieli will lie of the greatest praetit^l iin|x>rtance to you in your
future careers. Those of you who enter into geneml practice will at once
be called upon to treat infant-^ autl children. The proper appreciation of
the sensitive tern pe mm cuts anil nntls of tills cla^s of patients will be of
great aid in successfully estal>lisiiing your practice among tlnxse whose favor-
able opinion may make or mar your professional suc^cess. The difficulties to
be surmonnttd in cori^ectly diagnosticating and treating young childn*n are
far greater than those which you encounter in adult life. The reason for
this is tliat ibr adult cases yon have some standard by which you can l)e
guidt^d, l>eing yourselves adults. What standard, however, have you for
the feelings and sensitive orgauixation of tlic child ? None within your-
selves ; it must all come from long and patient i»bstTvation, with its re-
sulting cx|>tTienc>\ The mere knowkxlgi:* that a:*rtain diseases exist, and
the usual methods of diagnosticating theuK prove to be very inadecjuate
when we are brought face to face with a sick and fretful child, or with an
infant who is unable to de^ribe its symptoms. Much additional knowledge
is needed to enable us to understand the variet^^ of symptoms which may
arise in the same dist^ase according to the age and individuality of the
patient. It is now well i-ccognize*! that there is a necessity for making a
special study of children beyond what 18 learned in the general cHuidd study
of adults* As our knowledge advances, we leara to appreciate that the
various methods of treatment must be modified to correspond not so much
2 17
18 PEDIATRICS.
to the special disease as to the special group of symptoms brought about by
the age of the individual and the phase of its development. In studying,
then, the different stages of development in children, we are in reality-
acquiring an alphabet, which when once thoroughly mastered will enable ils
to read the otherwise obscure language presented to us for translation by the
various diseases of early life. The proper method of learning to understand
sick infants and children is first to notice their peculiarities in health and to
follow these peculiarities through the different stages of their development
up to puberty. Thus, a pulse which would indicate an abnormal condi-
tion in the adult, or a convulsion which would be of serious inqwrt in the
older subject, may often be but physiological or of slight consetjuence in the
child. In fact, there are a large number of physiological and anatomical
truths concerning the young the knowledge of which will simphTy to a
great degree otherwise almost insurmountable difficulties in diagriosih. The
lack of this preliminary training, this alphabet, places the student who is
endeavoring to understand diseases in children, in the position of attempt-
ing to read without having first learned his letters. It is our province in
this course of lectures to begin with tlie human being at birth, to study it as
it is presented to us in the early hours of life, and to follow it in its develojv
ment during the periods of infancy and childhood up to the age of puberty.
It then approaches so nearly in its development to the adult that its diseases
assume the type of adolescence, and your studies carrj' you into the province
of general clinical medicine. For purposes of simplicity, we speak of infants
and children, the anatomical and physiological conditions being sufficiently
apparent to warrant this distinction between them. The period of infancy
is usually spoken of as covering about the first two years of life. Its most
distinctive features are presented in the first twelve months, the second year,
month by month, rapidly approaching tlie conditions which exist in child-
hood. The second year, however, is influenced to such a degree by the
various growing functions and tissues that its picture lx)th in health and
in disease resembles more closely the infant than the child. Childhood is
empirically reckoned from the end of infancy to puberty, or the beginning
of adolescence. A distinction must be made between the sexes, tlie girl
becoming a fully-developed woman some years before the boy becomes
a man. The age of puberty is usually reckoned as beginning from the
twelfth to the fourteenth year. Much latitude as to age, however, must
be given for the special idiosyncrasy of the individual, and also for the
climate, as it has been found that children who live in a warm climate
arrive at the age of puberty much earlier than those who are exi>osed ti>
the lower ranges of temperature. In taking the i)eri(xl of birth as a start-
ing-point for our studies we must not overlook the fact that it is simply a
stage of development with which w^e are dealing, and not a perfected being.
The better, therefore, you understand the evolution of the embryo to the
infant, the better will you be prepared to appreciate the evolution of the
infant to the child and of the child to the adult. It is esi>ccially important
FCETAL CIRCULATION.
19
to understand the stage of development which exists just before birtli, for
00 this depends tha knowlctlge whether we have a physiologically and
anatomiciiUy normal Ix'iug iR^fore us, or one that is abnonnaK Remember
that disease dfx»s not merely menu a pathfilogieal eliaiige in the tissues, but^
as is esj>eeially well exemijlititd iu the infant, may simply mean a I'etarda-
tion or arrest of development. Thus, what would be perfectly normal
anat-f^mieaily at the seventh month of mtra-iiterine life may at birth be
abuf^rmal, and heuoe constitute a disease. In like nianuer what may be
normal at birth may if it persists into the second and third weeks become
an abnormal <'ondit!on. Disease, therefore, is a relative term. \A^e may,
howeverj simplify our classification of diseases by adopting two bi-oad
divisions corresponding to the changes which take place during intra- and
extra-uterine life. By congenital diseases we mean tbose reuniting imm
changes occurring during intra-uteriue life. These may arise* from an
arrest of develo[>meut or from a continuation of normal intra-nterine con-
ditions beyond the usual jM^rifxl of their cessation ; also those which are
(*austMl b\' pathological pnxx^ses such as inflammation. By ac<|nired, we
mean a pathological condition of existiug tissues occurring afler birth, and
witliout regard to the stage of development
If we thonnighly understand the anatomical conditions existing jnst
before birth, we ean intelligently examine the young human Ix^ing as it
emerges fn>m the uterus, and can judge in the early days of iu existence*
whether we have under our care a normal intant or one that is to nettl
special treatment.
FCETAL CIECULATION.— The chief anatomical change which takes
plact? at birth is the transititui from the intra-uterine circulatory mechanism
to a form jMlaptwl to extra-uterine lite ; in other woixls, from the oxygena-
tioD of the bhxRl tlirough the placenta to the same pnx'c^ss carried on by
the lungs. A general knowledge of the feetal circulation is, then, evidently
of wusiderable im|Mjrtan*x* for you to acfpiirc*, esixxnully when you c^jusider
that a liu*ge projxjrtiou of the cases of er>ngenital lieart disease which you
will Ix' called ujx^n to diagnosticate is represented by perftn.'tly normal pre-
natal conditions, such as ahsence of the ventricular septum, an open diwius
arteriosus ^ or a pufnit foramen ovale.
This diagram (Diagram 1) represents the course of the (red) oxygenated
blocnJ from the placenta to the infant, and that of the darker (bhic) dtxixi-
dhiA hloijd from the infant back to the placenta. We must tM insider that in
the foetus the lungs are lu a Cijllajised, inert condition, jwrfbrming no part in
the fictal eeouomy, but remaining tpiiesci'nt until calle<] ujw»n to jKTform their
s|x^cial faucet ion at birth. The true lung of the foetus, therefore, is n^pixj-
sentiMl by the placenta of the mother. It is here that the I>1<xk] is oxygen-
ate*l, and is carrieil by means of the nmbilieal vein dirci'tly tlmmgli the
imiliilicns of the iietus to the liver, as seen in the diagram. In the liver, the
unibilictil vein divides into thitH' branches : (1) the smallest, carries the bliKxl
directly to the liver tissue, whence it is i-eturued as iu the adult to the inferior
20 PEDIATRICS.
cava by the hepatic veins ; (2) the largest portion meet8 and mixes with the
blood from the portal system, and is distributed with it to the liver ; (3)
the remaining portion is carried, by a vessel called the dudus venogus,
directly to the inferior cava, where it meets the deoxidized blood from the
lower extremities, mixes with it, and is carried to the right auricle : here,
instead of passing as in the adult into the right ventricle, it is directed
by a membrane, called the Eustachian valve, through an opening between
the two auricles, called the foramen ovale, into the left auricle. It then
passes into the left ventricle through the mitral valve, and thence through
the aortic valve into the aorta. The greater part of the blood-current is
then carried by the carotid and subclavian arteries to the head and upper
extremities, where, after doing its work in vitalizing the tissues and taking
up their waste (a small portion also parsing, as usual, into the descending
aorta), it is returned as deoxidized blood through the veins to the superior
cava into the right auricle, thence through the tricuspid valves into the
right ventricle, and up through the pulmonary artery, where a small portion
is distributed as usual to the lungs, while the remaining portion is carried
directly over to the descending aorta by a vessel called the ductus arteriosua.
It here mixes with the small portion of oxygenated aortic blood mentioned
above, and passes down the aorta, being distributed on its way, as in the
adult, until it reaches the internal iliac arteries. From these arteries it is
carried, by branches called tlie umbilical arteries, through the umbilicus back
to the cord and placenta. Thus, by simply referring to this diagram, we can
tell at a glance which part of tlie young infant should be most developed,
and the reasons for it. A noticeable point of clini(«l interest, in tracing the
course of the foetal circulation, is that the fresh oxygenated blood is mainly
carried to the liver, head, and upper extremities, while the devitalized blood
is distributed to the tliorax and lower extremities. We should therefore
expect, and we shall find it to l^ true, when we examine a normal new-bom
infant, that the head is larger than the thorax, that the abdomen is prominent
from ccjntaiuing the large liver, and that the legs are insignificant and
l)oorly developed.
When the placental circulation Ls cut off, an increased amoimt of blood
is carried by the pulmonary artery to the lungs, and by degrees the foetal
circulation Ls replaced by that of extra-uterine life.
The du^us venosus and duciua arteynosus become fibrous cords.
The Eustachian valve disapi^ears.
The foi-amen ovale closes.
The umbilical vein and umbilical arteries become obliterated, with the
exception of the lower parts of tlie latter.
All these changes, however, do not take place simultaneously, which is a
point to be remembered in making a differential diagnosis of cardiac disease
during the first ten days of infancy. We sliould therefore endeavor to bear
in mind at about what time these changes take place. The following table
will^ I think, assist you in accomplishing this :
F(ETAL CIRCULATION,
21
TABLE L
POST-NATAL CHANGES OF FCETAL CONDITIONS.
Buotus Venosufl.— Tbe ductus venosus boi^omes u tlbmus cord in tbe flseure of the ductuf
vern»sus in (Vom two to five diiys*
SUBtaobian Valve. — The mtm-uterino function of tbe Eustacbiun valve practicaUy
dUtippears at once at births but its reoiains can be found for an indefinite period^ as you
fee in this heart disst^ctetl by Dr, F. Dexter (Fig. l^^ facing pag<? 74),
Foramen Ovale. — Tbe foramen ovale usually closes about tbe tenth day, but the upp^r
piirt sometimf-»a never cIob^. The closed foramen ovale is seen in this same heart
di§ed by Dr. F. Dexter (Fig. 19, facing page 74).
Ductus Arteriosus. — The ductus arterioBm h about L5 cm. (] inch) long, has a diameter
of about .25 era, (J inch)| and is usually, so far as being pervious lo the blood is con-
cerned, obliterated in Trctm four to ten days. It* i-emains, forming a flbrc>us cord
connecting the pulmonary' artery and the aorta^ can be seen in this heart dissected by
Dr. F. Dexter (Fig 20, facing page 74).
Umbilical Vein,— The umbilical vein becomes tbe round ligament of the liver, and is
obliterated in from two to Hve duys. A& pointtKi out by Jacob! , it dltfors from tbe
arteries very mueb leas than is usual with tbe veius and arteries in other parts of tbe
buKiy. lU muscular layer is very large and strong,
tTmbllioal Arteries, — The umbilical arteries in their upper parts become obliterated
in from two to five days, forming the anterior true ligaments of tbe bladder, while
the lower parts remain pervious and fomx the superior vesical arteries Tbe umbilical
artenejs are u&ually thick and strong, owing to tbe great development of their mujscular
layer.
Thus you mil observe that during the first two weeks of iufancy we
Heart, natoml siM. at two daySw A marks i\u a miu'ks the pulmonary artery ; DA marlu ih^
ductus anerlc6U<^
may have eouditious existiug ph} siijlogioally which ailer tliat time would
become pathological, and hence, to be well groimded iu the diagnosb of
22 PEDIATRICS.
disease in the infant, we must appreciate the importance of these facts and
retain them for future use.
The heart is the organ on which, from the importance of it8 function to
the system in general, our interest is at once centred at birth. It is well,
therefore, ibr you to know exactly how it should look normally, and how
large it should be.
This heart (Fig. 1, page 21) was taken from an infant two days old ; it
is of normal size, and shows the ductus arteriosus connecting the aorta and
the pulmonary artery.
This metallic injection of the heart and blood-vessels of the foetus (Fig.
2), made by Dr. S. J. Mixter, shows you very clearly the ductus arteriosus
and the ramifications of the various branches of the pulmonary artery and
the aoHa.
You must, of course, remember that where a cavity existed in the heart
and vessels of the foetus, the metal preparation shows a solid mass. Thus
yOu can learn exactly the appearance of the inner surfaces of the right and
left auricles and ventricles, the pulmonar}' artery, the ductus arteriosus,
and the aorta.
¥m. 2.
Mct&Ufc Injecticm of fa-tAl hejirt nnd blm^d-ve^H^b : A mark* the uorta : PA nitirks the
pulmonM^ry urlery ; D A miirkH the iliii^tua iirterU*ii4,
THE INFANT AT TEBM.
LECTURE II.
THE INFANT AT TERM.
Vehnix Caseosa — Cord— Spi NIC — Nsck— Head — Thorax — ABDOiTEN — Teiitfera-
TiTRE — Pulsk — Rkspiratiok-— Height— Weioht— Vitality— Hands— Feet —
Bone Marrow— Functions — Blood— -Lymphatic System^ Urine — Intes-
tinal DL^rHAROES.
By the iiifaiit at term we meat] one tliat has been bom at the terniiua-
tion (►f Avhat is cHuisidc^rwl tlie usual j>eriod of pregnancy, two hundred and
eighty days,
I shall by shomug you actual case^ of normally develojied infants in the
early flays of life endeavor to teai'h you what onnditions are important ihr
you to remember as distinguishing marks from the abnormal cases which I
shall present for your insjK'ction later.
Til us infiint (Case 1), on© hour old, represent* the appearance of a nonnallj developed
ftptii?^ when it first emerges from the utems* The reddened skin^ &t you see, is covered in
niiiriy parts thickly by a subsUnce
iimde up of the contents of the iiivi- Case 1.
hioik- hiti^ in which th*^ ftelus liji>
hefn flouting, and of the excretion
of ihe sehnceous glands. This sub-
f^timcei whifh b calted the pernix
enBtxtsa^ mu*4t be removed in ordor
thfit we may study the ijifant as it
nonnalty appeare in the first Btage
of it= existence. It h evident, ht»w-
ever, tlnit the infant it* horn with
highly developed sehaceou* glandii,
which at times pniduce a secretion
go excessive as to bt difficult to
get rid of 1 n certain rare ease* also
this >ebaceous inatler is so universal and so impcnetmble as to constitute a disease of serious
import, and ut time« even tcj cau.^ death. Infants are ako lK*m with the akin almoet entirely
fi^e from the vernlx anx^nm, «o that it i* not necessarily present* and in fact I have had
h* wait for some time hefon? I could get a subject which would present Ihi* ct>ndition
fftifficif^ntly marked for illui^tration. You will also notice the dark fjecal diK^harj^e, called
meconium, which i^ coming frt>m the anu^^ and which is so eharacteriBtic of the early hours
of life.
Thi« infant was shown to you merely to represent the vemix easeoaa, while what we
nre especially called upitn to deal with is the new-born infant freed from its amniotic cover-
ini; and with it* entire aurface prepared for our inspection.
For tlie purpose of illustmting tliis eon<lition I will now show you
another infaut (Case 2, Fronti^pieee) :
A male, two days old. Its birth- weight waa 3^00 grammes (8} pounds) ; it£ length is
4H0ni!n. (19 incbes) ; the circumference of its head is 84 cm. {l^ inches) ; the circumference
Infant Imra lately after btrth. covered alinotti entirely
with the veruix caseoai, o-nd having a dischAiige of me-
conium.
24 PEDIATRICS.
of its thorax is 88 cm. (18 inches) ; and the circumference of its abdomen is 86.6 cm. (14
inches).
The infant has just been bathed, and presents the color of a healthy
skin reacting normally to the temperature of the water, 36.6® C. (98® F.),
and that of the room, 21.1° C. (70° F.). I have chosen this particular case
as representing best what a strong healthy infant should look like. I shall
presently show you that it is somewhat larger than the average infant at
two days. In reality, however, so far as my experience goes, the size of
this infant corresponds very closely to that of most healthy infants that are
bom outside of hospitals in families who live in comfortable homes of their
own and in healthy localities. The delicate pink of the skin, the well-
rounded body and limbs, the vigorous crj', the warm extremities, already
b^inning to move with activity, and the strong grasp of the little hands,
all justify me in showing you what at this age may be 'looked upon as the
picture of health.
The hair at birth is often thick, dark, and quite long, perhaps 2 to 5
cm. (1 or 2 inches) ; but we also frequently find the hair to be short, fine,
some shade of light brown, small in amount, and, as you see on examining
this infant's head, the temples to be bald and the hair to come down to a
rounded point on the forehead. The eyes are almost always as you see in
this case, half open when awake, expressionless, and of a dull grayish blue.
Notice also what your study of the foetal circulation explained so well, the
large head in comparison with the thorax, the arms more rouilded and large
in proportion to the 1^, and the prominent abdomen.
CORD. — I have had the dressing removed in order that you should be
able to study the cord minutely. You see how it is already drj'iug up
preparatory to falling off on the sixth or seventh day. The cord in health
does not often receive much attention from the physician, and usually it is
familiar in its appearance to the nurse only. Yet it is quite ]m|x>rtant for
you to know how it should look normally up to the day when it separates
from the umbilicus, for at times you are called upon to decide w hether it is
diseased, and unless you are familiar with it in health your opinion will not
be of much value as to whether you have an abnormal condition before you.
You see the slightly reddened areola where it joins and is to part fi*om the
abdominal wall. The three vessels are easily picked out, and differ in color.
The two dark, almost black, lines twisting in and out around the single
greenish-yellow and broader lino are the umbilical arteries. The flat yellow
line is what remains of the umbilical vein.
Palpation, percussion, and auscultation show that the heart has about the
same proportionate position in reference to the lungs as is found in the adult,
but that the liver occupies much more space, coming fully 1 to 2 cm. (J to
1 inch) below the edge of the ribs in the right hypochondriac and the epi-
gastric regions, and encroaching on the lung-space in the right back to the
extent of fully one rib and interspace. The testicles have descended, and
the bladder, which is evidently full of urine, presents an area of dulness of
THE INFAIiT AT TERM.
25
abcjut 2 cm. (1 inch^just above the pubes in the raedian line. Thk eor-
rolxirates the importiint fact, to which I shall refer later, tliat the bladder is
an aijdominal rather than a pelvie organ in the infant and the young child.
The dull aiTa of the spleen ct>rrt»8iK>nds in it8 position tx> tliiit found in the
adult, but h scarcely perceptible.
I shnnkl like yon to attain carefully in your minds thi^ jierfeet pietuiL'
of a hnmau Ix^ing at term, for it is the centr^il |H>int irom which vN'ill diverge
many interesting conditions of the Inter and higher developmeot which I
have undertaken to elmmlate ibr you in tJici^^ lectures.
We shall next study more in detail certain anatomical and physiologi<ial
truths relating to the infant at term, but having reference to what is usually
found to exist in the a%-ei*age iuikut rather than in the individuah
The figui'es which I shall pivs*.*nt to you must necessarily be accepted
io a general way, and will oflcn be Ibund lacking in exactness simply
hiec^ause there are so many exceptions to general rules tnken from large
numbers of cases. In my own experience, however, they have proved to
be so near to the trtith a^ to Ix* exceedingly valuable in my clinical work,
I have for many years had them verified in a number of large clinics and
in my private pmctit^, and they at least form a very fair basis for you to
start with.
I shall now call your attention in a general way to a number of new-
born infants of various weights and dcgi^ee^s of development, and show you
that there are certain characteristics conim^jn to them all and cori'esponding
to the i^ritxl of birth. I ani e.s(>ecially indebted to Professor Thomas
Dwight for the assistance wliicli he has given me thnnigh his own original
investigations and for his verification of my clinical and anatomical work,
the results of which I shall now lay l>efore you. You must pardon me if,
ibr the purpose of impressing u|>on yon what I consider of absolute imi>or-
tance, I seem to repeat unuec^essarily at times,
Rememl>er als(» tliat I do not attempt nor deem it wise to give you
tlie f^implete anatomy and physiology of the |KTi<xl of life we are studying.
I shall merely pi(*k imt ibr your use the practi(*^d points in these jx'rirxls
wliich will aid you in cliniwil diagnosis and treatment. The great imjxjr-
tance of thoroughly understanding the normal anatomy and physiology of
human l>eings Ix^fbre attempting to deal with the mor1)iil e<:inditions >vhieb
arise in them is now sf> well i*ecf»guizt^ that no pivlimiuary rt^marks ai'e
necdid to show how vital t*> all atlvauw in clinical medicine is the proper
reading of anatomical and physiulr>gii'al truths. There are several jxiiuts in
the anatomy and physiology of the new-lxjrn infant which would Ije better
undei'sttHxl if the faet were Ixirue io mind that in many respects the body
at this age is more adapted to its intra-nterine life and U^ its meitus of
exit into the external world than to the c<jnditions which surround it in
extra-uterine life,
Kotice these infanta a few hours old, as they are held up for your
inspection hy the nurses. By having one with its face (Case Z) and the
26 PEDIATRICS.
other with its back (Case 4) towards you, you can easily follow what I am
about to tell you of the anatomical conditions characteristic of this early
period of life.
This infant's (Case 3) face is, as you see, swollen and the features are out
of shape. This condition is not uncommon at birth : it comes from pressure^
and will soon pass off.
The cord, you see, has already been dressed with cotton.
The anatomical points so evident at birth as belonging to intra-uterine
life, and the peculiarities of the foetal circulation, I have already dwelt
upon, and I shall now point out to you tlie characteristics of the new-bom
trunk. This is egg-shaped, the larger end being below. The pelvis
as a r^ion hardly exists, and the thorax is very small when compared
with the large abdomen. The latter is very large, owing to the dispropor-
tionate development of the liver, presumably a great organ of nutrition
during foetal life. A striking peculiarity is the almost complete absence
of shoulders, which with the arms are relatively insignificant outgrowths
from the sharp end of the ^g. I shall later consider the thorax in
detail, but I may now mention that it is evident that its small size, its
Avant of solidity, and the slight development of the pectoral and shoulder
muscles indicate that its action in respiration must be very different from
that in adult life.
The greatest breadth of the trunk is in the region of the lower ribs.
During intra-uterine life, and especially at the time of delivery, great
flexibility and compressibility are requisite. Respiration has not yet oc-
curred, and the assimilation of nutriment for the growth of the body and
for preparing the rudiments of future organs has been the function most
actively employed. When, therefore, we study the new-born infant we
must remember that we see it at an essentially transitional stage. Adapta-
tions, the marked utility of which is past, still i)ersist, and new functions
are carried on with very imperfect apparatus. These general principles
having been stated, I can now discuss more in detail the spine.
SPINE. — One of the most beautiful of anatomical preparations is this
cleanly dissected spine of an infant at birth suspended in a jar of alcohol
(Fig. 3).
Owing to the removal of the other parts, its shape (if there be any at this
age) is lost, but it is excellent for the study of the comjwnent parts. It is a
wonder of lightness and flexibility. There is little bone and much cartilage
and fibrous tissue. It can be twisted and bent at will in any direction.
Tx)oked at critically, it appears relatively broader in proportion to its length
tlian does the adult spine. The height of the vertebne is relatively less, and
appears even less than it is, from the fact that the broad, narrow, bony
nucleus of the vertebral body, which catches the eye, does not represent the
whole thickness of the body, as it is embedded in cartilage.
At this early stage of development the whole column is cartilaginous,
with the exception of the nuclei of the bodies of the vertebrae and those of
^^^m THE INFANT AI
' TERM, ^1
^m the taminEe on either side, formiog a small
Fig. 3. j
^m portion of the Wly and the bciginmng
^^^^■^■■^^l
^H of the arck
^^^^^^B^^^H
^B The time of the ctjnsolidatiuii of the
^^^^^^^^^^^^^mm J0r^^^H
^H bodies is not accurately kuown, but thi^
^H will lie s|K>ken of bi the lecture oo de*
^^^^^H V^l
^^^^ velopment*
^^^^^B ri^
^^^B lu the young embryo, the proijoi*tiou
^^^^^^S fmM
^^^^ of tlie neck in the movable part of tlie
^^^^^Mt f^M
^H spine is greater than that of the loins, a
^H condition vvbieh U reversed in the achilt.
^H where the neck m les*s, being a little over
^^^^^Bl ^^^
^H one-fiitb, and the loins a little less than
^^^^^r ^^1
^H one-third. In fact, the pm^Minlious of
^H tlie spine change considerably from an
^^^^^V ' AB
^H early period of intm-nterine life to that
^^^^^B -' JB
^H of the perfected adult condition. At
^^^^^K -^m
^H birth, however, the change has progressed
^^^^B ' ^1
^H sufficiently to make thest> two |iarts very ;
^^^^^B
^H nearly equal. The unifin of the lamiiue
^^^^^B ^1
^m to ii)vm the spine Ijegias in the upper
^^^^^^^V ^ ^^1
^H part of the spine sooner than in the huu-
^^^^^B ^^1
^H bar i*egiou, Throughout the gi-eater part
^^^^B ^1
^H tliey are nearly united, and in some plac^es
^^^^^B^ ^H
^H aiT qnite Joincxb at liirth.
^^^^B^' ^
^H I mention these details not ex[MN*ting
^^^^^B ^^i|H
^^^ yon to remember them, but for future
^^^^B ^
^^^B reference in cases wbere the spine is in-
^^^^IL
^^^™ volved in diagnosis, and |>erhaps for in-
^^^^^v
^^^^ telligent orthtqHxlic treatment. What I
^^^^^B M
^^^B am alxmt to tell you will also lye valuable
^^^^B« ^
^^^^ in directing the care of the normal child
^^^^B ^2
^H in regard to its sitting and standing.
^^^^^ 1
^M You see on examining these infants
^B 1
^H (Cases 3 and 4) how pliable and easily
^K ^ -flH
^H bent in all directions is the spine, and
^m how their backs can be made to take
^^^^^^L.
^^^^^^^L
^H alm(»st any curve.
^H You will alsti undei-stand Ix^ttcr what
^^^^k^
^B I am about to say if you will examine
^^^^^^^te_^.j
^H closely this diagram of three spinal curves,
^^^^^^^H^HJ
^M representing (1) the natural curve at i
rJiswc'llon of ihe fpine aivl peh*ti
^H birth, (2) the curve whicli comes espe-
U)ru infant. Wameii Mufieiiui. H
vetbity.
^H eially in tlie eemcal region when the
^H infant has learned to sit up and the sup
rincuniljent head has tO|
28
PEDIATRICS.
ported, and (3) the additional dorsal and increased lumbar curves which
appear when the child stands and walks, and which correspond to those of
the adult condition.
Infant tt birth.
Diagram 2.
SPINAL CURVES.
Infant sitting.
Infant standing.
Front — ♦
(1) (2) (3)
C represent* cervical curve ; D represents doisal curve ; L represents lumbar curve ; S represents
sacral curve.
A great deal has been written about the curves of the spine in new-bom
children, and their appearance in the embrj'o. Much of this literature is
a monument of wasted ingenuity. The truth is, that at birth, Avhen the
child is lying in what may be called its normal position, — that is to say, on
its side, witli the head flexed and the thighs drawn up, — the whole spinal
column presents one long concavity from the atlas to the coccyx, the front
of which is subdivided into two cur\'es by the slight projection of the
promontor}'^ of the sacrum. Above this there is a tolerably regular con-
cavity. The head can be thrown bac^k so as to make a slight convexity in
the neck, and by bringing the knees against the table (the infant being on
its back) the lumbar region will spring forward ; but the former of these
positions is rather unnatural, and the latter impossible without assistance.
THE INFANT AT TERM,
29
The coucavity of tlie thoracic curve remaiu-s to l>e clisensscd, and this k the
tmly one of the curves above the sacriun tlmt can lie r^aid to have any real
existence at this age. When, Iiowever, we analyze more fully the existence
of thii^ curve, \vc begin to doubt whether it is alWr all so very real, for,
though the sternum and ribs have some n'taiuing influeuce, it is possible
by bending the l>i>dy tmckward to obliterate this curve also. We can tlien
c<tnsich'r the part of the spine above the sacrum as essentially a fibrous and
cartilai^iinHLs hhJ witli a munlK^r of separate disks of Ijone emlxHldiHl in it at
dittci-ent jilaees. The extent of the movements possible at birth, b<ith in the
dissected spitie and in the whnle Ixxly, Ls very remarkable, as is i^bo\m by
these few experiments. The first was on the haly of a female child at birth
large and welt nourished. The aWominal viscera having been removed, it
wns very easy to Ix-nd the head liack si> rt^ to touch the buttocks. The head
and extremities were then rcmiived, the ribs cut near the junction of the
cartilages, and the spine and pelvis roughly cleaned. It was then jxissiblei
by some straining, to iK-ud the spine Iwickwaiil so that the atlas and coccyx
met. It was, however, easy to bend it backwaitl sr^ as to make an an-h, the
at his and coc^cyx resting on the table. It was noticed that the middle part
of the spine \vm the most flexible, the dorsal concavity of atler-lite l^eiog
easily changed into a CM>nvcxity* The lumbar region appearwl to lie more
pliant than the c^'rvicaL The pf>int of greatest motion was appaix'utly
lx4wci?n the eleventh and t\velfth dorsal vertebra?. The whole spine, with
eacli of the cervical, dorsal, and lumbar regions, IxmkIk forward with al)out
the same reudineSxS that it dms baekwaril. It may at fii-st appear surprising
that it does not bend very much more when, as already said, we look on
flexion as the normal |x>siti(ai of the infant; but it nuist Imj iTmcmlx»re<l that
this elfSwL't is largely due to the great liead which Iw'nds fbrwaRl on the sjiine,
and that the alwve statement as apfjlinl to the spine alter the head has l>een
i-emoved is more rt»markable than apjiears at first sight. Lateral motion
is very free, though it is not fpiite nnnuxed witli torsion. The athis can
without effort be Imaight to the level of the sacrum either to the leil or to
the right. The bending Is prettj" regular through the different regions. In
torsion, the sacrum Ix^iug fixed, the spine could \)e twisted ^o tliat the atlas
lo<jktil backward, antl could even, with some straining, l>e carrie<l through
more than half a circle. From rather crude measni-ementis it apjjeared that^
under the alx»ve ctuiditions, the rotation in the ci^'vical region was thn^High
an aiT* of 4o^, in the dorsal region 90°, and io the lumbar region 45°,
Experiments were then made on the intact b<xly of a girl thirteen years old.
The head c*>uld ca'^ily Ix* made to toucii the hec4s, and it <>ould Vie 1x;*ut so as
t*» fit into the middle of the back. Forward flexion apiwmn^l little greater
than that of the adult, which is to be aa^uinted IJir liy the s]>ac<^ taken by
the head, A\'hcn the jx^lvis was fi xetl, the head could l>e nutated through
alxiut three-quarters of a circle. The spine, thorax, and pelvis were next
made into a ligamentous preparation, and the spine could then be b^ut back-
waixl until the atlas was almost within an inch of the pelvis, (It is to be
30 PEDIATRICS.
remembered that, unlike the last preparation, the sternum in this case was
still in place.)
Under these conditions the spine could be flexed so as to make the atlas
touch the upper end of the sternum and the jwlvis the lower. Lateral
motion was easy until it reached such a degree that the ribs on the flexed
side came in contact. When the pelvis was fixed, the spine could easily be
rotated through an arc of 90° without the action of the atlas.
Professor Dwight has ix)inted out the rather remarkable fisict that at
all ages, from birth upward, the spine of the fourth lumbar vertebra is (as
in the adult) on a level with the highest point of the crest of the ilium.
Under certain circumstances this might advantageously be used as a starting-
point from which to count. At birth the spinal cord descends only the space
of about one vertebra lower than in the adult. The third lumbar spine,
which should mark its termination, cannot be ea'^ily recognized under three
years, but the correspondence of the top of the ilium with the fourth ver-
tebral spine allows its jxisition to be estimated. It might be desirable to
know how far the cavity of the spinal dura mater descends inside the
sacrum. Recent investigations by Dr. R. Wagner show that in children
under a year old it ends usually near the top of the third sacral vertebra,
which makes it a little lower than its usual termination in the adult The
point on the surface corresponding to this could be approximately esti-
mated without any definite landmarks.
NECK. — Now notice the large heads and short necks of these infants
(Cases 3 and 4, facing page 26).
It is customary to say that young babies have no necks ; and yet when
speaking of the spine I stated that the cer\'ical r^ion of the vertebral
column of the infant and young child is relatively longer than in the adult.
From this point of view the shortness of the infant's neck must be seeming
rather than real, but from a clinical stand-jwiut it is real enough. The
causes of the short neck are first the large head, which naturally falls for-
ward, covering the upper portion, and next the high position of the sternum
encroaching on it from below. The large proportion of subcutaneous fat
tends to make the neck apjx^ar still shorter.
Symington, referring to the soft parts, says, " The peculiarity of this
part of the child's neck is not that it is relatively short, but that it is higher
in relation to the vertical column than in the adult." He has shown by a
series of obser\'ation8 that the lar>"ux is at first placed much higher than
later. In the adult the lower border of the cricoid is about on a level with
the top of the seventh vertebra. In the infant it usually seems to be near
the lower lx)rder of the fourth vertebra.
HEAD. — As a rule, if you take the measurements of the head over the
middle of the forehead and around to the occipital protuberance, you will
find that at birth the circumference is about 33 cm. (13 inches).
FoNTANELLES. — The opening between the frontal bones and the ante-
rior borders of the parietal bones is called the anterior fontaneUe, and, though
THE IXFAKT AT TERM.
31
soIlle^vhat depressed below the level of the buiies at Av^t, should stx>n be
alM)iit ou a level with them* liB aim is variable^ but is usually alx>ut 1 to 2
cm, [h to I inch) loug, and abuut 1 em, (J ineh) wide. In the early days and
even wiX'ks of inilmey the frontal suture is usually open in its upjier part.
The anterior fontanelle at term is well rejtreseuted in this skelettm of the
infant at terra. (Leeture IV., Fig. 33, page 118.)
The oix'uiui^ Ix^tween the oec*ipital booe and the iK)sterior edges of the
parietal bont^ is miieh smaller, is of k^s siguifieauee than the anterior oj>en-
ing, is often temporarily obliterated by the overlapping of the bones, and is
called the pmitvior fonfmit'lle. You 8ee it here Ix-autifully shown in the
skull of a new-lMjrn infant.
Fio. 4.
SkuU of Infiint at term, ostnral slse. Faaterior view, shoiiring parietal and occipital booee and pneteilor
fontaneUe. Warrea Museum, Harvard! Unlvendty,
Face and Cranium. — You will notice that the proportion of the face
to the cranium in these infants (Cases 3 and 4, faeing page 26) is strikingly
different fi-om what we mtH:^t in adults, wliere it i» as one to two, while
aee^jrding to Fmriep the face in the infant is in the skull as one to eight.
If we contrast the fmnt view of the faee and cranium of the in&nt and
of the adult by etmnting as fatv all Mow a line at the tops of the orbital
arches, and as skull all that is ^nm alx>ve that line, considering it projected
on a verticiil plane as in a pliot^^^^graph, w*e find that in the infant the skull
forms about one-halt'i and in the adult much less.
32 PEDIATRICS.
It is found that the height of the orbit bears pretty nearly the same pro-
portion to the skull at all ages, but that it equals barely a third of the adult
face, while it makes nearly a half of it at birth. While the top of the nasal
opening retains pretty nearly the same relation to the orbit at all ages, its
lower border is but verj' little below the lowest point of the orbit at birth,
while it is much below it in the adult. In the latter, a line connecting the
lowest points of the malar bones crosses the nasal cavity, or at least touches
its lower border, while in the infant it runs almost half-way between the
lower border and the edge of the alveolar process. The breadth of the skull
in its greatest diameter in the infant etjuals, or even exceeds, the total height
of the skull and the face, while in the adult it is but about three-quarters of
it. Still more striking is the difference between the length and the breadth
of the face at different stages. The breadth, measured between the most dis-
tant points of the zygomata, is to the height of the face in the adult about as
nine to eight, while at birth it is ])erhaps as much as ten to four.
The side view is equally or even more characteristic. The auditory
meatus is situated about midway between the front and the back in the
infant, but in the adult it is decidedly behind the middle. The face appears
to be but an insignificant part of the whole structure.
Jaws. — The lower jaw is almost on the same plane as tlie mastoid
process of the temporal bone, and the upj)er border of the zygoma is about
on a level with the floor of the nasal cavity, while in the adult it is at or
near the level of the floor of the orbit. It is evident that a very important
factor in the adult face is the development of the jaws and of the teeth, and
that it is due to their rudimentary condition that the face is so small in
infancy. The difference in the comparative development of the lower jaw
at birth and at three years is well exemplified by these two skulls (Division
II., Lecture III., Fig. 16, page 67).
Gums. — The gums do not meet in the new-bom (McClellan). They are
composed of a dense fibrous tissue covered by vascular mucous membrane
of very slight sensibility, and are protective to the growing teeth.
All these points you will find of practical importance when you are
asked to determine whether the face and skull at various ages are normal,
or present some vice of formation.
Young infants frequently have at birth quite a startling shape to their
heads, produced by pressure. One side of the skull may be flattened while
the other bulges, or the natural diameters of the head may be altered, pre-
senting a long narrow head instead of the round, well-formed cranium.
These different shapes give at times an idiotic expression to the infant which
causes much distress to the parents. In almost every case in my experi-
ence these abnormal appearances pass away as the skull and brain grow,
and do not, as a rule, indicate disease unless very extreme, so that it is well
to state this fact to the parents at once and thus to relieve their minds.
Naso-pharynx. — A knowledge of the change in size and shape of the
nasal cavities and naso-pharynx in the course of growth is very important.
THE INFANT AT TERM.
S3
Valuable work has been done by Professor Disse on this subject He
divides the nasal cavity into the vestibule in front, the exit behind, and the
intermediate [x^rtiou^ which consists of an upix^r olfactory region, occupying
the ethmoidal portion of the ciivity, and a lower respiratory region, occupy-
ing the maxillary part- Id the infant the nosal cavity is relatively long
and shallow, and the respiratory portion is very narn^w.
These casts in fusible metal taken from the Warren Museum of t-he
Harvard Metlieal SchcM>l were made by Dr» S. J. Mixter, and, as you see,
show a striking differencie between the infant and the adult in the projjor^
tions of the inierior meatus.
Fio. 5.
I M marks inferior me^tot ; IT marki Inferior turbinate booe ; A marks nutnim.
Warren Mitteum« Harvard Uuiversity.
Observe timt in the adult preparation the metal runs deej) under the
inferior turbinate b>ne in the Ihrm of a long cylinder, while in the infant,
though the inferior tiirl)iiiate projects slightly into the nasal cavity, there is
but a very minute expansion below it, and none passLng up beliind it
8
34 PEDIATRICS.
Aooording to Professor Dwight, the height of the posterior nares at birtb
is 6 to 7 mm., and the breadth between the pterygoid processes at the hard
palate is 9 mm.
In infancy, the posterior border of the vomer is very oblique. Situated
just behind the nasal cavity is the upper or nasal portion of the pharynx,
which shares in its changes. I may perhaps be permitted to doubt whether
many practitioners who have not had the advantage of modem anatomical
teaching appreciate how small a cavity the naso-pharynx is even in the adult.
Its height is twenty millimetres, and its antero-posterior diameter, from the
hard palate back, is twenty to twenty-two millimetres. In the infant it is
very much smaller. It is less of a vestibule and more of a narrow passage
running obliquely backward and downward from the constricted opening
of the posterior nares. The soil palate of the child seems to be placed
more horizontally than in the adult, and bounds its anterior portion below.
Kostanecki gives tlie height at birth as ten millimetres, and its antero-
posterior diameter as fourteen or fifteen millimetres.
I do not give you Professor Dwight's observations on this point, as it
seems to me that its shape is so peculiar that measurements are deceptive, or
at least inadequate to give the proper idea. Imagine the posterior nares (not
the inferior meatus alone, but the whole opening on either side) large enough
to admit the end of a medium-sized male catheter, and that this leads into
the passage just mentioned, and you can conceive how a congestion of the
nasal mucous membrane in infancy, with the addition of the mucous secre-
tion, may effectually close the opening from the nose to the pharynx.
It is, perhaps, not sufficiently recognized clinically how important a
function is performed by the nasal passages in early infancy, — far more
im{K)rtant, indeed, than at any other age. I can, in fact, say that the age
of the infant is in inverse ratio to the dangers which may arise from ob-
struction of the nares.
These dangers, consequent on obstruction, congestion, and the resulting
mechanical disturbance of neighboring parts, thus leading to actual disease
of those parts, become in the new-bom infant of most serious and even vital
import.
In my own practice I have seen an infant die of simple acute nasal
catarrh in the first two or three days of life. In this case the infant was,
indeed, puny and ill eared for. Nothing abnormal could be detected in the
throat, or, in fact, anywhere, except in the nares, which were completely
occluded by the congestion and tumefaction resulting from an acute inflam-
mation of the nasal mucous membrane. Occurring, as the case did, in the
earlier years of my practice, I did not appreciate as I do now the extreme
importance of the naso-pharyngeal function of the young subject. There-
fore, after prescribing the usual remedies for such cases, on the second day
of the infant's life, I was surprised to learn that it had died suddenly on
the third day.
This unfortunate experience, however, served to draw my attention to
THE INFANT AT TERM.
36
the proper treatineot of thb class of cases, and there is no doubt that, with
due appreciation of the value of the nasal ftmctiou and the danger of
allowing it to be interiereiJ with, we can, as a rule, even in extremely weak
infants, prevent a fatal I'esult*
I ^yeak of this case in a*nnectioD with the anatomical conditions of the
naso-pharyiix in nitler that you should appreciate the fact that the,'^ details,
which are somewhat difficult to n^meml)er, are not merely oi* theoretical
interest, but have a practical bearing on disease. I shall also refer to this
case and its proper treatment in a later lecture when we arc considering
diseases of the thniat and nose.
Lymph- Vessels of the Pharynx. — An anattimieal condition of great
importance, which T shall esi>ecially dwell cm when I speak of pliaryngeal
diphtherin, is that in rnimparison with the iaueial tonsils, which aiv relatively
poor in absorl>ents, we find an exeettlingly rich plextLs of absorlx^nts in the
yK>sterior wall of the nasopharynx.
Eustachian Tubes. — The Eustacliian tulx* in its clinical a^[>ect. is so
closely assofiatetl with the uasiKpharynx that it can best be sj3<jken of in
connection with it. In the fVetus tlie nasal opemng is Ix-low the level of the
haril palate, which it readies at birth. While in the adult the cartilaginous
portitin slants dfiwnwartl, nevcrthclcfvs the 0{iening of the tiilx' is opposite a
higher part of the nose than in the child. At birth the tube is hiirizontal
or nearly so*
Professor Dwight lias shown me tlie o|Kndng of the Eustachian tulx^ at
birth just alK>ve tlie level of the liai*d palate, and, in a child a year or more
old, a little below the line of the {mlate. This statement may perhaps be
misleading. It nnist be bonie in mind that even if the oi}4?uing of the
tubt^ be Ix^low the level of the hard palate^ the sort palate none the less runs
beneath it, shuttmg it off from the cavity of the moutli and the juissage
fnjm it to the fauces.
In the infant and the young child there is but a slight development of
the end of the cartilage which makes in the adult so pn>minent a fold at the
back of the pharyngeal of^ening of the tul>e, and by its prominence dcies
much to determine the depth of the fossa of Rosenmuller, the n^vss l>ehind
it at the latcnd jiostcrior angles of the pliarynx. ^Vt l»irth this prominence
hardly exists. The ttjienmg of the tulie Is at first verj' small. That the
catlictcrizatioo of the tul«^ at this age jiresents great diffictdties of its own,
apiut fn>m the intrartability (if the patieut, is sufficiently obvious.
The tube in infancy, while of cTuirse shorter than in the adult, is stated
to lui* not only relatively, but absolutely, wider at its narrowest point, M'hich
may explain the ea^e with which catarrhal processes travel at tliat age to the
middle ear.
Faucial Tonsils — Pharyngeal Tonsil — Lymphoid Tissue. — The
faucial tonsils, the pharyngeal t<jnsil, the lymphoid masses under the mucous
membrane of the posterior thinl of the tongue, the lymphoid tissue aljout
the orifices of the Eustachian tubes, to say nothing of irregular aggregations
36 PEDIATRICS.
of the same tissue in the neighborhood, form a lymphoid ring around
the pharynx which is most important. It is to be notioed that the passage
from the nose, as well as that from the mouth, is guarded by this appa-
ratus. That its function is in part protective seems very probable, in spite
of the fact that when hypertrophied it gives rise to serious trouble. Be-
fore birth this system is but slightly developed. Indeed, the follicles at
the back of the tongue are not always to be found at that time. I r^ret that
Professor Dwight has not had material enough to aid me in adding much
to the little that is known as to the progressive development of the tonsils.
Killian states that the pharyngeal tonsil is at birth a raised bunch containing
adenoid tissue with ridges running in various directions, often more or less
converging to a point, and rarely running directly forward and backward.
A pocket in the pharyngeal tonsil is the famous bursa pharyngea. It is
clinically important merely as a recess in which inflammation may linger
and secretions be retained.
As for the physiology of the tonsils, in which I include all the adenoid
tissue of this region, I will mention that Stohr showed tliat leucocj^tes make
their way from them through the mucous membrane to escape into the
throat This process begins with life. He found the infiltration of the
surface of the tonsil of a child of three months much greater than in the
case of new-bom infants.
The supposition that this system is protective receives support from
Killian's observation that the pharyngeal tonsil is much developed in mam-
mals that live in the dust of houses. MetschnikofF^s theory, that leucocytes
devour bacteria, does not seem to be supported : nevertlieless, it is not im-
possible that this lymphatic ring forms a bulwark against septic invasion.
St<')hr's observations of the escape of white corpuscles do not necessarily
conflict with the view that the tonsils absorb the secretions of the ]mrts
in front. If these secretions are irritating, inflammation of the tonsils may
result. The effects of enlargement of the faucial tonsils are well known ;
those of hyjwrtrophy of the pharyngeal tonsil have been recognized only
within a few years. Indeed, I imagine that it has not been more than ten
or twelve years since the general practitioner became aware of the existence
of such a structure. The small size of the naso-pharynx in the infant and
the young child must not be forgotten, for it ex])lains its obliteration by the
enlargement of the pharyngeal tonsil.
Mouth. — I wish you now to get a general idea of the mouths of these
young infants as I open them for your inspection. You see the whitish^
comparatively dry tongue, which, with the lips, cheeks, and roof of the
mouth, immediately closes around the inserted finger and produces the sen-
sation of sucking. The mouth, then, as a whole, is pre-eminently an organ
intended for the reception of a liquid food, its mechanism being that of suc-
tion. It is a natural and necessary passage-way to the organs of digestion,
but is not at first, as I shall explain to you later, intended to aid the diges-
tion by a salivary secretion.
THE INFANT AT TKFiM,
87
Gums. — The gums have already l>een descril:>ed od page 32,
Teeth.— At birth there are t^venty embn o teeth, ten in each jaw^ envel-
ofMPtl in their resf>octive tiM)th-sacs» protected ahf>ve by the ^ubmucNrus tissue
and niuooua membrane, no either side by alveolar Ixme^substance, and below
by the groove in the maxillaiy bone from which the alveoli have developed.
I do o*>t pn>p>se to undertake a p^cneral description of the cavity of the
mouth, but shall merely call attention to some esjiecial points in conucctioii
with the dii^'u.ssion of the relatiuus of tlie phaiynx. A median section of
the infant's head shows very strikingly the want of height of the naso-
phar}^nx aud the great obliquit}^ (appixjaching the horizoutal) of tlie pos-
terior edge of the vomer. The naso-pharynx is relatively very long from
before backward. Strange as it may seem, the distance from the back of
the hard palate to the scjtt jjai'ts of the Lack of the pharynx (excluding the
tonsil) is abjtit as great at birth as in the adult.
This statement appears incredible, but is easily proved by measurement.
The tongue of the infant is greatly wanting in vertical thicknej?^, and is
shown on such a section to be long and low. The sort palate rests, there-
fore, on the tongue, and, the moutli being closed, nina in the main backward,
dcsccDding very much less than in the adolt The uvula is rudimentaiy
(Merkcl), It seems to me that, owing to the depth of the pharynx (fr^^m
before backwanl), tlie s<jft palate is unable to shut off the pai^sage to tlie
nas<j-pharynx as completely in early infancy as subseciuently.
It is very curious that, in spite of these j>e€uliarities, the distance from
the ti|> of the uvula to the top of the epiglottis is rt*!atively as slight in the
infant as later.
Hard Palate, — I shall nowf^ll your attention to the level of the hard
palate, and to what vertebne are behind the mouth at different ages. This
may be studietl in connection with the position of the lan^nx already men-
tionetl. We find by examining anatomical spet^imens that at birth and in
the early months of life the line of the hard palate, e^mthinctl backwaixl,
would strike near the top of the basiHiccipital, that is, near its junction with
the sphenoid, or j^erhaps even strike the latter. Accordingly, at this age,
if the finger be iutroduciHLl directly backwanl through the mouth, pushing
the soft palate ujjward, it will strike the occipital Iwuie, and, Ix^ing carrietl a
little downward, will pass over the arch of the atlas, the base of the odon-
toid, and the ImxIv pmper of the axk. Going still lower, the top of the
third ti?rvical vei-ctcbra might be felt, but the larynx would hardly j)erinit
the fingLT to go lower, aud the parts are so small that I doubt if mneh
c*juld lx_* recognized lnJow the axis,
Bkain, — The brain of the new-lx»rn infant is proportionately very much
larger than in the adult, bearing a relation of about 16 to 1, (Vierordt.)
E^'E, — Tlie eye is anatomically perfectly developed in the new-born,
(x^^cC1ellan.)
Ear,— The de\'elopment of the ear, m stated by McClellan, is in its
several parts very unequal. The structures of the internal ear, the tympanio
38 PEDIATBIG8.
cavity, and the auditory ossicles are fully formed at birth, while the ex-
ternal auditory meatus, the Eustachian tube, and the mastoid portion of the
temporal bone undergo many modifications before their full development at
puberty. At birth the meatus passes inward and inclines downward, and
the membrana tympani is almast horizontal, conditions to be remembered as
necessitating a little different management of the ear speculum from what
you are taught in the examination of the adult ear. (Vide Lecture III.,
page 65.)
The mastoid antrum exists at birth, but the cells do not develop until
later.
Petro-Squamobal Suture. — An important anatomical condition ex-
isting at birth is, that the petro^qtuimosal mUure is open, allowing a close
connection between the blood-vessels of the brain and the middle ear, with
its resulting clinical significance.
THORAX. — The thorax of the infant forms the upper and smaller end
of the egg-shaped body which I have already described the trunk as pre-
senting. As I have pointed out, the small shoulders of the infant make the
chest very different from that of the adult. Besides this, the whole shape
of the thorax is very peculiar. The proportion of the dorsal r^ion of the
spinal column is pretty nearly the same tliroughout life, but the thorax
itself varies greatly. At birth the thorax is very insignificant. In front
the breast-bone is relatively much smaller than that of the adult male, but
not ver}' different fix)m some very small breast-bones which are occasionally
met with in women. I shall consider this in detail later, and I now merely
mention that the lower part is but slightly developed. The borders of the
ribs diverge relatively rapidly. This is perhaps due to the great breadth
of the abdomen.
Top of the Sternum. — The sides of the thorax are not relatively so
long as in the adult, which is probably partly due to the lesser development
of the lower ribs and partly to the very important characteristic of the
infant's thorax, — namely, that the top of the sternum is placed higher than
in the adult. The top of the sternum in the latter is about on a level with
the disk between the second and third dorsal vertebra. The top of the
sternum, according to Symington, is opposite about the middle of the first
dorsal vertebra in the new-born infant, and a fh)zen section by Riidinger
shows it to be rather below the middle of the first.
Diameters. — Another most important peculiarity of the infantile and
child's thorax is its want of breadth. In the adult throughout the thorax,
from about the level of the second costal cartilage, or even a little higher,
to the top of the diaphragm, the antero-posterior diameter of the interior
of the thorax is to the transverse as one to ti^'o and a half or one to three,
there being, of course, a certain amount of variation. At birth, on the
other hand, it is as two to three.
It is well known that in the infant the ribs are more nearly horizontal
than in adult life. A striking feature of the young infant's chest is that the
THE INFANT AT TEBM.
39
^m form the sides of the cliest, and the stern urn and cartilages the front. I
vi'iU now give a more detailed description of the hitter parts, which are of
great Lmjxjrtanee for t%vo reasons : lii'st^ L*n iUM/ouiit of their influence on the
tvjx* of respimtion, and, siietxmdly, L>eeaLise the mstal eartilagej? aix? uaed as
landmarks for the organs beneath them.
OssiFKJATioN. — At birth the sternum is praetir-ally a strip of cartilage
in which a varying number of Ixune-oeutres have been deposited* There is
one for the manubrium and usually one or tw^o for the second and third
pieces, those for the latter lx4ng very fre(|uently double* These, however,
an* mere thickenings ot* the cartilaginous strip, which is flexible and pliable
in all ilirections. The divisions of the sternum in iniancy are plainly seen
in the.se skeletons, especially in the larger one, which Ls nlueteeD months old.
(I^ecture IV., Figs, 33 and 34, page 118.)
Movement of Rias. — ^A word a** to the movements of the ribs will
be of mterest before we discuss the mechanism oi' respiration as a whole.
The movements of the adult rihs are very imperfb'tly explaim^l in many
of the tn:^atise8 on anatomy, and in others the explanation is lalxired
and complicated. A ligamentous preparation of the spine, with a small
piece of each rib in miUj shows the following state of affairs. The fli^t
rib moves up and doi^ii on a single axLs running through t!ie head of the
rib resting against the b<3dy of the vertebi-a and its tubercle on tlie trans-
vei'se process. This movement is a prlectly simple one, the fmot of the rib
moving up and down, and no otlter movement is iK^ssible. In the secund
rib the eotiditiuus am pnietically the same ; but m the thiixl there appeai-s a
new ieature, whieJi is more developed farther down. It is that the tubercle
of the rib no longer ix^inaius iu \y\ikee uti the transverse pn.»cess, but slides up
and down on it, so that while the iiuier cud of the axis R-maius stationary
the out€T end is raised (in respiration), and amsequently we have, in addi-
tion U> the raising of the tbrward end of the rib, a swinging npwai-d of its
outvsard eouv^exitj', which may be reierred to a rcjtation on an imaginary
anter<>po9terior axis. Skijjping now to the last rib, which has no tubercle
and rests on no transverse pnxt?ss, we find that we can raise or depress it,
move it forward or baekwaixl, aud cirt*iunduct it, by carrying it fnim one
of these positions to another. This is true in a less degree of the eleventh
rib, and pc*rhaps to some extent of the ttmth. Tlie raising of the front of
the ribs not only increases the auteropjsterior diameter of the chest, but, by
bringing the lateral convexity af each ril> to a higlicr level, alsi ineivases
the transverse diameter ; this is further increast<l by the rotation of the
lun^T ribs on an antero-posterior axis. The tmxlom of the lowest rilj©
all4)ws them to be pulltMl Ijaekwanl and downwanl hy the muscles of the
back, thereby giving a firmer attachment to the diaphragm, and tJxus favor-
ing its et:mtraction, or they mav Ik* drawn inward by it or ujiwanl, following
tlie outer rilis. It is to te remembered tliat in such a ligameutous piY*|>ara-
tion the movements are far more extensive than they can be iu life, owing to
the restmint exercised by the sternum and costal cartilages as well as by the
40 PEDIATRICS.
soil parts. The influenoe of the sternum is especially important, as in the
adult the body is in one piece, and the amount of motion between it and the
manubrium is probably not often great
Respiration. — An important feature in the mechanism of thoracic
respiration is the rigidity of the thorax. In the infant at birth this rigidity
is almost wholly absent, as it is found only in the ribs.
The sternum, as has already been said, is at this age practically a per-
fectly flexible strip of cartilage, for the small {X)ints of ossification in it only
modify the softness of certain separate parts. The dorsal r^on of the
spine is not fixed as a concavity, but can be bent freely backward. The
motions of the ribs are, as Professor Dwight has satisfied me from our ob-
servations on the dissected spine, practically the same as in the adult, but
the effect of these motions is different. In the first place, as has been
shown, the ribs are more nearly horizontal, and the thorax, even afler death,
is in what is called the inspiratory condition. The nearly horizontal first
rib can hardly rise any higher unless the whole spine is bent backward.
The ribs, being straighter than in the adult, do not when raised increase
the breadth of the chest to the same d^ree. The nature of the infantile
respiratory movements is far from easy to analyze. Sometimes it seems
abdominal and sometimes thoracic. The fact is, that at first it is of a very
indefinite type. The thorax seems to expand as it can. It is common to
see its lower part drawn inward by the contraction of the diaphragm.
An examination of the living subject during the different periods of
infancy has been made by me witli considerable interest, and my results
coincide closely with what I had already been led to expect from my ana-
tomical and physiological studies. At birth no especial part of the respira-
tory apparatus has attained a sufficient development to insure its continuous
equable action, and I have therefore found, as would be expected, insular
respiratory movements and no decided type of respiration.
A sufficient number of observations, however, have not yet been made
to warrant our stating any especial age at which the type of respiration in
the two sexes separates and the female infant assumes the thoracic type of
respiration. But if the breathing of the infant is essentially irr^ular in
type, it is admirably adapted to the wants of its age. The elastic thorax
can give way under pressure and expand in almost any direction. The
flexible sternum submits to liberties which no adult breast-bone would
endure. One-half of the chest may be compressed and yet the other go on
acting independently.
The facts concerning the shape of the infant's thorax, which I have
already pointed out, — namely, that the top of the sternum is higher,
reckoning from the spine, that the ribs are more nearly horizontal, and that
(probably) the lower part of the sternum is relatively less developed than in
the adult, — necessarily imply certain peculiarities in the relations of the
internal parts. There is, however, a difficulty in understanding and stating
these peculiarities, which, though sufficiently evident, is often overlooked.
THE INB'ANT AT TERM,
41
and which may occasion both obscurity and eonfiision. This is the want
of a generally accepted standai*d by which to judge of the position of these
partfi. Is thit^ t^taodard to be the spine or the front of the ehewt ? We can-
not use l>oth indLstTiminHtelVj for their relations diifer w*ith the age. It is
clear that the spine is the more fixed point of the two, and therefore tlie
l)etter scientifically ; but fur most clinical pm-poses it is desirable to refer
to the front of the bc>dy.
Diaphragm. — I shall now speak of the position of the diaphragm.
This, as h well known^ risers highci^t on tlie right over the summit of the
liver, 18 a little lower on the left, and luwer still at its tendmous centre in
the metlian line. It is genemlly state<l that the diaphragm h higlier in the
child than in the adult. Dwight's observations, jTartly original, partly on
the frozen sections of other iraters, give the fi>l lowing result. In the
infant the diaphragm apf^ears to be opposite the disk between the eighth
aad ninth doi'sal vertebne.
We now come to the insertion of the front of the diaphragm. In the
infant it appears us if there were a lower ins<^rtion of tlie diaphragm to the
sternum and the seventh wxstal cartilages tlian in tlie adult. Usually the
line runs from one cf»stal arch to the <Hher, soraewliat al)ove the apex of the
ensift>rm cartilage, leaving, tliert^fore, a space on either eide of the latter,
where the interior of tlie thorax is against the alxlominal walls. It is re-
markable how vague and various are the statements in anatomies on this
point in the adult. The sternal origin of the diaphragm h^ said in some
instances to arise from the ensiform near its bas4?, and in others near its
apex* Undoubteilly there is ground for Iwjth assertions. In the tw^o well-
known metlian frozen sections of the b<»dy by Bmune, it arises ki the male
at the aj»ex of the ensiform, and in the female near its base. I hesitate,
therefore, to assert that there is any difference in the point* of attachment in
the infantj but the etftrt is ditfiTcnt ntme the less. Owing, jK^rliaps, to tlie
greater flexibility of tlie IkhIv and to tlie less firm attaclunent of the internal
parts one to another, it certainly seems that at least after death the thorat^ic
cavity is more accessible at the sides of tlie ensiform than it is in the adult.
In the adult it may be nA low as the middle of the tenth veitebra, but
more often probably will be at tlie disk ahive it or the lower part of the
nintli vertebra and ot^'casionally liigher* In Riidinger's median section of a
woman in the la^^t months of prt^gnancy, it is as high as the lower liorder of
the eighth. We may conclude tliat, while there is some variatinu, on the
whole, the central point of the diapliragni Ls in the mfant higher m relation
to the spine than later in life, and that it gradually l>e<*i3mes lower. How
high the diaphragm ris4*s laterally is hanl to stiy, for it is a piint very diffi-
cult to observe. Acet»rding to Kolliker, in the fcetus at term, on tlie right,
it realties the level of the anterior end of the fourth cjirtilnge, and on the
left that of the fourth intcnx^stal spatx^ Henke adds to this (piotatiuu that
certainly after respiration has iM'gim it will never be s*i high again.
There Ls another )xtint c<»ncerning tlie attat*hment of the diaphragm to
42
PEDIATRICS,
tlie fnmt of tlie chest which will most conveniently be considered a little
hiter : so, keeping this in reserve, 1 shall pa^is on to a consideration of the
tliomcic organs.
Thymi's Gland, — The thymus gland exists at birtJi, and lies above and'^
to some extent before the heart. It will be referred to later in the lecture
on Development. (Fig, 18, page 73.)
Heart* — The most striking peculiarity of the infant's heart is that it is
less covered by the lungs than in adult lite. Together with the thymus
gland it forms a s<*lid mass fnjm the posterior me<;liastinuni to the sternum,
pushing the limgs iiu* apart. It is to be notitt^, however, that the pleural
cavities extend as far forward as in the adults The relations of the heart
to the chest- walls are curious in the iniant, for these anterior walls are, as
ab\'ady statt<l, high in relation to the spine, yet the heart itself Is high in
relation to tlie walls. At least tht^ up(>er half of it is so. Witli regard to
the apex and the lower lx>rders the relations are less certain. We usually
find the imjjulse of
FiQ. 6. the heart rather higher
and nearer to the mam-
mary line ill the infant
than in the adult. The
weight of the heart at
l>irth is 20.6 grammes
(:il)out I ounee), ae*
rnrding to Boyd, and I
its proportiuu to the
rest of the body is
largt^st at about the
time of birth.
It will be well for
you in this ermnee-
tiou to examiue again
carefully this heart
of the new-lxjrn in-
fant which I have
already shuwn you,
(Ix^cture 1., Fig. 1,
page 21.) As the
foramen ovale Ls so
often ojjen at birth, I
should also like you to
lamili arize yourselves
with what a patent
foramen ovale looks like, as setii in this specimen (Fig. 6) of an older
iniaiit's hejjrt» where you see tliere Ls a free and |>ermaneut nuiuectioii
between the right and left aiirif^les. The heart Ls slightly hyjK'rtrophied.
Bight fturicle and venlrirle, Infaat's heart. Opeti romniea ovale,
marked F.O. Warren MuKeumT Harvard ritfvt'n«ity.
J
Section t)t ftetal Iuhk at 'n iiKiiuhfi, showing devetapmcni of brunilil i iit> alviHill.
I of ialknt's lung ut 10 Di'Onthf, sbowLug inrrviuHKl imiiiortlotiot^ nniouut of parenchTiiMi
iti pompiidvin with the liistal condillon ; distenrtcHl itlveolL
THE INFAKT AT TERM.
43
Common Carotib Artery, — The cjommon carotid artery has in the new-
bom half the lenpth of the dascendiiig aorta, but this pnijxirtioa is much less-
ened at a more advaoced age, when the vertebral TOlunin inerea^s in length.
Veins, — Acwjrtling to Jacobi, there a!"e one hundred valves in the veins
of the lower extremities of the new-boro.
PCLMOXARY Artery, — The pulmonary artery also, w^ .stated by Jsuyjhi,
h fn»m two to foiu* centimetres (thim^-funrths to one and five-eightli:? inches)
larger than the desc^^nding aorta.
Lung. — I have already referred to the fact that the liver encrtjaeheft so
much upon the space which on the right side of the thoirax is oocupii^ later
by the lung that an important ditierenee Ls Ibund l>etween the percussion of
the right and the left lung. On the right side the eleventh rib behind marks
the lower birder of the lung, while it dest^nds as low as the twelfth rih on
the left side. In front the lung exttnidn to abjut the fourth or fiftli rib ou
the right side and the sixth rib on the left side. The lung at birtli is char*
acterized by its embryonic type. The infimt^s lung repn_*sents an intcrme-
diate condition of growth^ which illustrates the gradual change from the ftetal
to tlie adult eondition. These photo-micrographs (Figs. 7, 8, facing page
42), made by Nortliriip, of sections of a foetal lung at five months aod of
an infant's lung at ti_*n months, exjdatn the anat*7mical conditions at birth.
These conditions have been carefully studial by North nip, who de^en^es
great credit for the work wliich be lias done on tliis subJH-t, and wliich will
be referred to later in the lecture on Devclojmieut, and also in that an the
Lungs. This author in s|:>eaking of the rharacteristirs i^f the lung in infan-
tile life says that if we examine the lung of a five mouths' fa?tus it is ibund
that the bronchi institute the entire respiratory tra<'t thus far develojied.
At the terminal cud oi* tlic bronchi there are Imd-likc dihitations, wliieh are
the rudimentary air-spaces. Between these dilatations, and separating them
from each other, is hx^se, delicate c<inoe<'tivc tissue, which makes up the
remaining bulk of the lung, so that what subs*^^pM'ntly l>ecT»mes the alveoli
is about equal io extent to the previous bronchial development Tliia
nidimcntary air-space is d(*stincd to enlarge, sulxlivide, and finally, in early
adult life, to occupy all the availal>Ie n.mm among the bn>nchial bmnchcs.
The lo<:>9e connective tissue becomes finally thin, dense bands constituting
the stroma. This serves to distribute the vascular net-work, and uikju this
are laid the close-fitting epithelial linings of tlic air-spaces. In fictal lite
the mucous membrane lining the bnjuchial tulx^s is LHkst-ly attached to the
muscular walls, aud is commonly seen lying in wavy folds within the e<:»n-
tractile ring, where the same delicate oiuuective tissue loos(*ly hrilds the
growing tissues together. As has imm said, the aemting jioitions of the
lungs develop as bnd-like dilatations at the tips of the smallest bronchi.
These dilatations in the aiurse of their development extend int4> the stroma.
The epithelium, changing from the columnar tyjK? characteristic of the smaller
bronchi, covers tbe newly-made Avails a\ ith flat respiratory epithelium. At
Inrth the loose connective-tissue stroma of the fretaJ lung of five months has
44 PEDIATRICS.
been condensed into rather thick alveolar walls. Another feature of the
child's lungs as contrasted with those of adults is the behavior of the blood-
vessels. Being loosely restrained in the walls, they easily become distended
and tortuous and encroach upon the cavity of the alveoli. With small
alveoli, thick walls, and abundant distribution of vessels, it is easy to under-
stand how, in hypostasis, distention of the vessels may be an important factor
in displacing the air in feeble subjects with weakened respiratory vigor and
partially obstructed bronchi. Finally, the lung of the infant differs from
that of the adult mainly in the following respects. Proportionately the
extent of the bronchial tubes is greater than that of the air-spaces. The
connective-tissue stroma is likewise in greater abundance and tends to cellu-
lar proliferation. The submucous connective tissue of the bronchi is loose
and more abundantly supplied with nuclei, and its vessels are held more
loosely. The cells lining the air-spaces form a continuous layer. The
alveoli are small, their epithelium proliferates abundantly, and the absorb-
ents accomplish their work slowly, the blood-vessels playing a more im-
portant r6le. These facts are to be borne in mind in connection with the
bronchial lesion which forms so important a part of broncho-pneumonia.
ABDOMEN. — The essential differences between the abdomen of the
infant and that of the adult are, firstj the great size of the liver in the former.
Liver. — This organ, especially on the right side of the abdomen, en-
croaches on the space which is later occupied by other organs. Its relative
weight to that of the whole body at birth is about 1 to 18. (McClellan.)
Kidney. — Second, but of less importance, is the relatively large size of
the kidney and the supra-renal capsules. On the left side of the abdomen
these conditions are not of much importance, but on the right, occurring as
they do in connection with the great size of the liver, the large kidney occu-
pies a lower position, and thus still further curtails the free space in the
right flank. Viewed from the stand-point of the adult condition the rela-
tions are, as has been pointed out by Henke,
much more peculiar on the right than on
the left. The kidney as a whole is lobu-
lated, as you see in this specimen taken
from an infant three days old. (Fig. 9.)
Urio Acid Infarotion. — At birth a
prenatal condition, represented by an
Lobulated kidney, natural size. Infant i*i^ j i j-i •.
three days old. Si? marks the supra-renal Orange or a light-red colored dcposit near
capsule. Warren Museum, Harvard Univer- the pyramids in the straight tubulcS of the
kidney, exists normally. This condition
is called the uric add infardion, and the deposit consists of urate of ammo-
nium, amorphous urates mixed with uric acid cr^^stals, and some epithelial
cells. (Plate III., 5, facing page 112.)
Supra-Benal Capsules. — The supra-renal capsules at birth quite cover
and surmount the kidneys, as you will notice in this same lobulated kidney.
(Fig. 9 ; the supra-renal capsule is indicated by S R.)
THE INFANT AT TERM.
45
P
Stomach. — Altliough it has long Ixxm known that iu the aduJt stomach
the greater part of the lesser curvature is vertical, and the long axis of the
orgau more nearly vertit'al than transverse, yet theM* faoti? have been slow in
Biting into the text-bcrnks and winning general ree^-tguitioa. It is probable
at it has so long l;>een taught that the stomaeli is platx^l transversely be-
cause when the alxloinen is fjf>en*^l a triangular piece of the stomach coines^
into view, bounded on the letl by the t^istal cartilages, on the right by the
edge of the liver, and lielow by a part of its own greater curvature, whieli
runs in a gentle curve from left t*i riglit. If this alone is seen it is very
natural to assume that the stomach is placc<l transverst^ly. The stomach at
birth is remarkably small, and mcire tubular than in the adult, the fundus
being but slightly developed. It is consequently even moi'e vertical than in
the adult, tor it is the eolargemcnt of the greater cul-de-sac that makes the
obliquity of the axis prrmounced.
This stomach (Fig. 10), taken from an infant three hours old, represents
very well the organ at birth. Its ca|)acity is 25 c.c. (|^ omice). The weight
of the infant was 2500 grammes (5i pounds). Although the weight was
below that of the aver-
age infant at birth, the
stomach was of abnnt
the average size, as
was shown by its gas-
tric capa4^nty,
DrODEXUM, — The
duwlenum, in the
adult, has of late
usually l)i»en described
as ring-shaped, but
it gt^ncrdlly presents
pretty- well marked
angles, w iiieh divide it
into a horizontal part
running Ixick^vard, a
descending one akmg
the right side of the
spine, a transvei'se one crossing usually the thiiil lumbar vertebra, and,
finally, an asi^^ndmg part along the left *»f tlie spinal column, winch brings
the end to about the same level a^ the l>eginuing» Sometimes the last two
|»arts are represented by a single one nmniug obii(|nely upward to the li^ft, in
which case the dwxlenum Ls calkd V-shajieiL The first horizontal [)<>rtion
is often somewhat dilated, and its walls are smooth, the valves Ix^inning
usually %vith the dt^x^nding iMirtion. The walls of the duoclennm just
beyond tlie pylorus are lined by a eontinnous layer of Biinuier-s glands,
which extends through the first part, l>ecoming more or l<^ss broken up
towards the end. In the infant the sha|)e of the duodenum, as showu
Slottmt li Tir^rurnl ^l/t\ infiiiit thrt^* htjurs uM,
Warrtii Mu,s4^uiu, Uarvrtnl Iniventlty.
46
PEDIATRICS.
by |jlfl.stor easts, k more nearly that of a ring, the two lower angles being
roimded off. A eon^trietion is oi\eu {(ierhaph usually) seen at the juncticm
of tlio tirst anil .seiXJinl parts, hut I>\vight\s <'asts of the infiiiit'8 (Uuxlemiru
do uiit tiliovv the tbkls, wliich are %^ery striking in the easts? taken from
adults. That h to say, those of the iniatit show a few deep cuta into
the cast instead of n great nmny near togt^tlier. I have seen the folda,
Flu. IL
Cii>^t> of cliimlcnum taken fn>m inruru iitul aduU, tiati;iml aim,
WaTTtn MiiJtiLm, n an- Ard University
however, ver\^ riehly develnpHl in an inlknt of thn^e weekp. In one
ease, that of a female six WH'ks ahl, 1) wight fbini<l the duixlenum of the
V-shaped pattern, and, what is niort^ remarkable, ailer it had j>aased the
gall-bladder it was surmunded by |M/ritonentu so as to swing freely as a lo<ip
snspeudwl from the posterior alxlt^niinal walh As to Brnnner*s glands, a few
observations on young c*hildren have suggested that they w^ere rather less
developed relatively than in the adult, but I am by no means sure that this
THE INFANT AT TERM,
47
FiQ. 12.
Bizt. JijliiuL rive Uuyu ukl. VViin«^u Mu-
st'DiD, Uiinard University.
amii
^ft Cfeci
1^ always the case. The diiodenura has been wmpamil to a traj>, its ends
liein^ always higher than its middle, whieh is thus fitted to retain the fluid
pmrid into it from the liver, the paneix*a.'^»
ami its own glands, besides that which it
reeeives from the stomach.
The diifereiit jxiinti^i eoneeroing the duo-
denum which I have just describetl ai'e well
shown in these casts taken fnimi the adult
and from the infant (Fig, 11), and must be
Ixirne in mind wlieu we are ainsiderin^^ the
digestive funetinus of this important ptirt of"
the intestinal tract.
Tlie nnnilHT and size of the folds tnid
the sha|>e of the <liuKlcnuni in the adult
would tend t«» delay the iut^Fai:;e <»f its t-on-
teut< through it, and thus it also piTvents the
passagt^ of gases from the small intestine ufi-
ward into the sttmiach. If it l)e trne, as 1
lun inclined to think it is, tliat in the in i ant
the system of folds is less dcvelo|>cd, its jias-
sage would be i*elatively easy, which witli a
fluul diet seems desirable.
C^CUM. — ^I should now like you to ex-
amine this sj>ecimen taken from an intant five days okl. It represents the
Cfeeum and api>eudix, and will aid you in understanding an imjK^rtaut dis-
wlneh we shall consider later, — appendhilU.
The ciecuni is au interesting portion of the intestine at any age, and es-
pecially in the child. As is well known, the etecnm descends in the oonrse
of development from under the liver in the middle of the ablomeu to the
right iliac tbs*^a, appaivntly passing first to the right and then descending ;
thus leaving Ix^hind it in its coni-sf* the riglit half of the transverse c^ilon
and the whole of the jusccnding colon. It is u*:^lless t^i say that if it is
possible tor the etecnm to acci)mi^lish this journey it cannot be tiglitly
bt*nnd by the j^eritonenm. On the wutrary, the ca^-um Ixas a complete
[jeritoneal wiat and is jM^Tfectly free* At birth, and very [Kw^sibly for a
year or two afterwai'cls, the ciecnm has not, as a rule, reacln^l its jx-rmanent
position in the riglit iliac fossa, I liave fbnnd it t-o mcit^nrc thiT'c inrlies
in length in au infant eleven weeks old.
Intestim-s, — From what wc know of the dcvelopniciit of the intes-
tinal tract, which was at hrst merely a loop IrKiscly attaciiwl to the |M>isterior
abdominal wall, it is natural to exjwet that in the infant and young child
it should l>e less fixed than in adult life ; and this is in fact the case. The
flittcrcuce is most striking in the large intestine, and is shown particularly
in the c«»cum, ascending colon, and sigmoid flexure. That this condition
gives rise to dangers is evident, and I should say that there is a strong
48 PEDIATRICS.
probability that the cases of infantile intussusception which occur with
unusual frequency during the middle of the first year may arise from
this anatomical peculiarity, and this makes a thorough knowledge of the
anatomy of the caecum important The growth of the different parts of
the intestine has been studied by Treves. He points out that in adults
not only does the length of the intestine vary greatly, but also there is no
constant relation bet^i'een the small and large intestines. A long small in-
testine may be followed by a short large intestine, and vice versa, or both parts
may exceed or fall short of the average. In the foetus at full term the
length of the intestine, and especially of the colon, is singularly constant.
Small Intestine. — The average measurement of the small intestine is
287 cm. (9 feet 5 inches). The greatest variation that I have met with
amounted to 61 cm. (about 2 feet).
Large Intestine. — The large intestine at birth, according to Treves,
measures 56 cm. (about 1 foot 10 inches). So regular are these measure-
ments that the greatest variation that I have met with in the colon was as
little as 12.7 cm. (about 5 inches).
Sigmoid Flexure. — ^But little of the sigmoid flexure is found in the pelvis
at birth.
PELVIS. — The small siz^ of the infant's pelvis is to be noted also as
the cause which, to a greater or less extent, forces the pelvic organs of later
life into the abdomen during infancy. This condition is quite evident in
this spine (Fig. 3, page 27) which I have already shown you.
BLADDER. — In the infant the bladder is practically wholly an ab-
dominal organ. (This fact is well illustrated in Division II,, Lecture III.,
Case 18, page 78.)
UTERUS. — At birth, part of the uterus is above the brim of the pelvis.
TEMPERATURE. — The temperature at birth is slightly higher than
in the adult. It is about 37.2° C. (99° F.).
PULSE. — The pulse varies from 120 to 140 to the minute at birth, and
it is at times irregular, esj)ecially during the first few hours.
RESPIRATION. — The respiration is about 45 to the minute, but it is
of a very irregular type, and if you will closely watch the rise and fidl of
the thoracic walls in this infant (Case 3, page 26) you will see that the
rhythm changes continually. The breathing is superficial, sometimes quick,
and again dying away so as to be almost imperceptible. This condition,
if occurring in an older child, would be a symptom of grave disease, but
may be said to be normal at birth. The rate may be much quicker than
45, and I have frequently observed it as high as 60 or 70.
CHART 1.
/VW\A_^v~-vAW\
Quick Pause Slow Quick
Respiratioii at birth for one-fourth minute. Awake, but quiet
THE IKFAJ^T AT TEEM.
49
HEIGHT. — The new-born infaot^s average height b in the male about
49*5 em* (19| inches); in the female 48,5 cm, (19^ Lnehes),
WEIGHT. — The weight of the male infant is usually rather greater
than that of the female. The average weight in a large uumljer of teases
showed that of the male to be 3250 grammes (7^ |n:)uuds), while that of
the iemale is 3150 grammpi^ (7 pountls), Parker, in a care fill examitiatiou
of 170 infants at birtli, of whom 80 were males and 81 females, fbimd that
the aveitige weight of the males was 3520 grammes (7} pjuiids), while tliat
of the females was 3290 grammes (7| pounds). Tliere is, then, as I have
said when speaking of Case 2, a certaio amoiiut of latitude to be accepted
ill this question of weights. The weight, however^ has so close a con-
nei^tion with the vitality' of the infant, that although we ofk^n see infants of
light weight vigorous and thriving^ and thost^ of considerable weight failing
to gain, yet as a gt^aeral index of vitality the weight m a valuable starting-
point and guide for our treatment. I would impress upon you that all rules
aud averages of this kind are not to l:>e dej^tended ufK>n absolutely* but
simply represent conditions which with otiier important fa<:»tors aid us in
9<ilving the problem of vitality.
VITATJTY. — In the early hours and days of existence it l< the dis-
turbau(?e of tlie equilibrium of tlie infant's vitality which is esj-iecially to be
feared aud combated rather than the s|>eeiHe morbid processes of later child-
hood. We should theR'Ibre in each infant earetully determine the degree
ol' inaiiitirm which we are called iqwn to deal with at this jM^ri^xl of Hie,
and I have personally found it usefid to divide the weak and strong infants
into grouj>s 'accx>nling to their weights, allowing, as I have already explained
to you, a sc>me\vhat lighter weight lor girls than for biys.
Tlii;> table (Table 2) will explain to yon the meaning of what I have
just said :
TABLE 2.
Bdaium of Weight to ViiaUty,
Groups. Wcljrht VlUillty.
1 2000 grsmmes (nbout 4^ fHJUncb) Very luw.
■ 2 2500 '* *' 6J ** , I»w.
■ 8 3000 ** *» 6} *• Fnm
■ 4 aSOO " *' 7J " N»*rmttl.
B 6, ...... . 4000 " '* 8 *' High.
■ 6 4500 *' ^ *• ...... Very high.
HANDS. — At birth it h quite remarkable to fiod with what mtmifest
strength the infant can grasp your finger. The nails are well tbrmi'd.
FEET, — An importatit part of the infaot^h anatfjmy is the foot, and I
take great pleasure in intr^wlnei ng for your study some original Work which
has been done by Dr. John Dane.
Hi?n» is im infant (Ctis*? 5) fnur dwys old. Dr. Dune has taken un iriipreMion of iU
feett which shows very beautifully certuin pointo ahoul th« inst4?p at birtli which are en-
tirely differont from, and in fact I'ontrnvert, what has heretofore be<*n taut^ht on this subject.
The practical importance of this truly eciontiflc and laborious work I shall refer t(t in a
later lecture. , * ... , . , .
4
50
PEDIATRICS,
Dr, Daoe sjieaks of thin infaot and these impressions as follows :
** It has been taught tbat the iiifaut at term is Hat^tJxjted. The aoattunj
of the foot at this a^e allows it to Wnid up afjainst the tibia froci laxity of
Fxo. 13.
Fc'vt iTnprii.-s.sii!in!^ cf in^niinl kifknt four days (jltL Affh Int&ct.
tlie tendo Achillis, and it may seem flat from the strt*tehiiig of the plantar
fascia. The tart is that the areli is^ well formed, with its lionos essentially in
the adult p*>sition. Fat infanta may, indeed, show the beginning of a pad
Fto. 14.
Flat foot iiup(re8sIon« itiCiLat four daye old. Arch broken down.
of adipose tissue under the arch, which becomej^ more marked a*^ the infant
develops, and in ihk way miglit easily h- tliDUght to be flat-fonted/'
These pcjint^^wijl be deal,t with later hi my leetare on Development,
THE INFANT AT TERM.
51
Where Bat foot really exists, the internal border oi' the impregsion shows
an imdiilatiQg appearance, and there is evidence of equal pressure over the
whole uf the tracing, as seen in the tracing taken from the foot of tliis
iniant also tour days old. (Case 6.)
It is interesting and instructive to compare the different appearanoeB
which are present*xl in Fig. 13, showing the well-de\*eloped ai'ch, and tho^e
in Fig. 14, repi*esentiiig the true flat foot
You should als^> examine cui-clully these babies' feet which have pro-
Jut^ these aiiix'urauj'c^s^
BONE MARRO'W. — At birth, and in the early months of life, the
marrow of the Ix^nt's is red, as you sec in a seitiou of tliis bone taken from
an infant seven months old. (Plate II., facing page 108-)
You will notic*^ that the red colter caused by the uumcrf>us injectetl blcM>d-
vessels is moi^e intense at the wntral jK>rtioii of the section of this btum^ than
at the periphery or towai-ds the ends. I merely show it to you as a normal
and characteristic condition of early life, and one which may appear again
at a later [XTiod iu certain diseased conditions.
FUNCTIONS.^ — It is important for you to have a general idea of
w^hich of the functions are abeent, jmrtially dcvelopcKl, or develojied at birth.
The endeavor to call into use an undcvclo|)ed function, to tax a pailly-
developed function » or to overtax a developed one, is pro4luctive of gix?at
harm, and it has in my experience l>een the source of many winditions
which, Imikcil ujion lis diseases, ai'c in reality but proofs that our anatomical
and physiol^jgiail knowledge has been deficient.
Voice. — The normal infant at birth should present a developed voice,
and should cry vigi>rously, tluis assisting tJie lungs to expand aud the new
cdnculatory mechanism t<j l>e well started.
Sight. — Altliough the eye is, as I have already stated, anatomically de-
veloped and is sensitive t*> light, and although the visual perception is alstr
possibly developed, yet there is still a lack of power to inter|:»ret the images
perceived.
Hearing. — The auditory sensations appear to be rather dull during the
first few days of life. This is possibly due to tlie absence of air from tlie
tj'mpiioum and a tumid condition of the tyrapaoic mucous membrane.
Touch. — The sense of touch is well develoj^ed.
Taste. — The sense of taste is well devc!o}x*d»
Smell.^ — The sense of smell is probabl}' well developed ; but this is still
a matter of dispute.
SebaoI'X>ij8 Glakds, — The fuuctidu of the sebaceous glands is fully de-
veloped at birth, as I have already described to you (page 23, Case 1).
Lachrymal Glands. — The secretion of the W-hrymal glands is not
developed at birth. The new-lx»rn infant do€« not she<l tears, a fact of some
clinical consequence in connection with the prognosis as to tlse convalescence
of disease in the early days of life.
Sweat-Glands. — The function of tlie sweat-glands is not developed at
52 PEDIATRICS.
birth as a rule, but acoording to my observations perspiration in certain in-
dividuals certainly occurs at a much earlier period than is usually supposed.
I have seen an infant, premature at the seventh month, perspire freely one
week after it was bom, and in a number of individuals this functiou must
exist in the early days of life.
Salivary Glands. — ^The salivary secretion, as has so clearly been
pointed out by Forchheimer, is not fully established at birth, and conse-
quently the mucous membrane of the mouth is comparatively dry, and, as
you see, these infants' tongues (Cases 3 and 4) have a peculiar whitish color.
This appearance is caused by the epithelium not being washed away by the
saliva to the extent that it is afler the later development of the function of
the salivary glands. The amylolytic function of the saliva is very slightly
present at birth, as has been shown by Zweifel and Korownin, who experi-
mented with infusions of the salivary glands taken from young infants.
The amylolytic action is indeed so insignificant that it merely shovrs us that
the function of the salivar}' glands in the early months of existence is only
partially developed and certainly should not be called into use.
Pancreas. — ^The amylolytic action of the pancreatic secretion at birth
is probably not all developed. The fat digestion is fairly developed at birth.
The albuminoid digestion is fairly developed, but not fully.
Bile. — According to Foster, " the excretor}' functions of the liver are
develo[>ed early, and at about the third month of intra-uterine life bile-pig-
mcut and bile-salts find their way into the intestine. A quantity of bile
secreted during intra-uterine life accumulates in the intestine, especially in
the rectum, and forms, together with the smaller secretion of the rest of the
canal and some desquamated epithelium, the meconium. The distinct for-
mation of bile is an indication that the products of foetal metabolism are no
longer wholly carried off by the maternal circulation, and that to the excre-
tory function of the liver are now added those of the skin and kidney."
BLOOD. — It is impossible by the methods at present known to determine
exactly the total amount of blood in either infant or adult, but, while the
adult's blood is approximately about one-thirteenth of the entire weight of
the body, the infant's is represented by only one-fifleenth. The blood is
ratlier more dense than in the adult, and contains a large amount of haemo-
globin. It is not rich in fibrin, and does not coagulate perfectiy, a fact to be
remembered when we are considering the hemorrhagic disease and haemo-
philia of the new-bom. Soon afler birth some of the globules are still
found to have nuclei, but these soon disappear.
Red Corpuscles. — ^The pro^wrtion of the red globules at birth is about
6,900,000 to the cubic centimetre.
White Corpuscles. — The number of white corpuscles is about three
times as numerous as in the adult's blood, and about 21,000 to the cubic
centimetre.
LYMPHATIC SYSTEM.— The lymphatic system is very active at
birth.
THE INFANT AT TERM. 53
URINE. — The amount of urine secreted during the first two days of life
is very small, and its specific gravity is about 1010. The kidney shows the
condition of the uric acid infarction, and it is not infrequent to find the
napkins stained with a uric acid deposit, such as you see represented on this
napkin (Plate III., 1, facing page 112).
INTESTINAL DISCHARGES. — Unless a discharge of the contents
of the intestine has taken place during the delivery, as is so oflen seen in
breech presentations, it occurs immediately or very soon after birth, as you
have already seen in the first case which I presented to your inspection this
morning.
Meconium. — This discharge which first comes from the intestine is
called the meconium. It is inodorous, viscid, slightly acid, and of a brownish-
black color, such as you see on this napkin taken fix)m an infant a few hours
old (Plate III., 2, facing page 112). The meconium contains mucus, epithe-
lium from the intestinal mucous membrane, epidermal cells, hairs, and fat-
drops from the vemix caseosa which have been swallowed with the amniotic
fluid from time to time. It also, according to Vierordt, contains the con-
stituents of the bile, and its total amount is fix)m sixty to ninety grammes
(two to three ounces), of which the solid part forms about twenty per cent.
The intestinal contents at birth are sterile.
DIVISION 11.
NORMAL DEVELOPMENT.
LECTURE III.
SPINE— NECK.— HEAD.— THORAX.
We have coosidered in a general and practical way the conditions which
exist in the infant at term. The data which we have actjiiired in thiB cx^n-
sideratinu constitute only a part of the aljthal^t which we are endeavoring
to master.
In order to differentiate normal irora abnormal conditions in the growing
infant and child, we must now examine the different &tiif^e8 of development
which c*orres|K>nd to the various ages, and thui* *xunp!ete our auat*jmieal and
phy siologieal al ph a l)et.
Yon reniembc^r the fY»ndition of tlie coitl in Case 2 (Fnintisipiece), which
I showed you at the previous lecture. Yon t^ee that in this infant (Case 7),
Dine days old, the cord
CAfiK 7. has fallen off*. This oc-
cnri-ed t\venty-four hours
ago.
By a process of dis-
integration the C4>rd at
alxtnt the seventh or
eightti day w?paratcs from
the living tissues around
the nmbi liens. A cer-
tarn amount of bleeding
may take plac*^ at tlie
point of separation, but
this Is usually very slight : it may, however, he the beginning of one of the
most serious forms of disease in the new^-lK^rn, umhi/k'a! hiniorrhafie.
Yon will notice how the umbilical d(*prt^^ion is well niarktxl even when
the infant cries, and you will thus distiugnish this normal anatomical con-
dition fijllowing the separation of the et>rd, from the umbilitml jirominenoe
which I shall show you later as representing eaises of umliilical hernia
64
Itirnrtt nine day
an After rec>etit
J
NORMAL DEVELOPMENT.
55
SPINE. — The tiiiie of fonsolidatiou ot* the iMxlies of the vertebrae is not
accurately kiiowu, but it may be roughly stated to begin in the third year,
and, probably, to end iu the seventh. A lar^re numlier oi' observations must
atill l)e majde l>efore the niureh of osi?ifieatioii ean be detenu ined. The state-
ments* regiirdiug this pt>uit are c<->pied ihtm one book t4> another, and are
often quite imaginary.
The union of these ehief centres to form the bxlies of the vertebne begins
ill the himhar regiou, and is first e.oiu|>let*?d there. ThLs nnion, however,
had not taken plaee m the dorsal and cervical regitin of the ehild said to be
tln\^ years old, used for ** The Frozen Sections of a Child" (Dwight). On
the other hand, in a girl of five or six yeai-s, figured by Symington, the
process was found to l>e hardly finished in the lumbar region, and higher up
it seemed abi:»ut the same as in tlie younger ehild.
The process of union of the lam! me is piTjIjably eompletctl in the first
few months of life.
Lentsth. — Aeby gives the following table for the adult spine, showing
b<*th the absolnte and the relative lengtli of the cervical, dorsal, and lumbar
regions (the measui'emeuts are in millimetres) :
Female
Mftl6 ,
TABLE JJ.
Abiioluie.
Cenioal. Ddtmt Lumbnr.
, . . 122.9 4- 205.8 -f- I9CJ3 = 579
. , , 129.9 -f 273.4 H- 184 1^587.4
JRelatitt.
Dorsal.
40 7
4*1.6
Lumtiftr.
32,8
31.8
r
^H Cnnningham obtained strikingly similar proportions in an average of
f the measurements of six males ai]d five females ;
Female 21.12
Miile .... - , . 22.1
TABLE 4,
Cervlcftl*
Female . , . . 2L6
Mule . . , 21.8
45.8
82.8
411.5
31.7
Aeby gives the following table of the average of five inlants, and Cnn-
nin^ham a table of three :
TABLE 5.
IM ft Hrr.
Aeby ...
Cunninghiim
Conical.
Donal.
t^mbur.
. 25.B
47.5
2fJ.8
25,1
48.6
26.4
Tlie following table shows tlie resuh^s of tlu' measurements of the spineB
of ehildren by vari<^»us authorities, a*^ well as by Prtjfessor Dwight The
table nxjuires no ehieidation, lint I shall call attenti<»n to the iTniarkable
uniformity of observations by ditibivnt men in spite of the enxjrs incident
56
PEDIATRICS.
to the personal equation of the measurements and the individual variation
which doubtless exists. The relative length of the dorsal (more properly
the thoracic) region throughout the table is somewhat greater than that of
the adult ; still it appears that afler the age of five or six the proportions
are not far from those of atler-life.
TABLE 6.
Length of Spine to Sacrum.
Absolute Lenoth, in Milumetreb.
Total-lOOi
Age.
Observer.
Cervical.
Dorsal.
Lumbar.
TotaL
Cervical.
Donal.
Lumbar.
8 months . .
Kasenel . .
60
100
68
208
24
48.1
27.9
6 months . .
Aeby . . .
62.6
108
60
215.6
24.8
47.5
27.8
6 months . .
Aebv . . .
68.6
107
61
221.5
24.1
48.6
27.6
10 months . .
Dwight . .
61
125
77
268
28.2
47.5
29.2
2 years, boy .
Kasenel . .
70
140
90
300
28.8
46.7
80
2 years, boy .
Aeby . . .
79.6
153.5
98
381
24
46.4
29.6
8 years, girl .
Dwight . .
78
162
101
341
22.9
47.5
29.6
4 years, ^irl .
Aeby
79.9
162
108.8
345.2
28.1
46.9
29.9
6 vears, bov .
Symington.
Kasenel . .
80
170
104
854
22.6
48
29.4
6 years, \toy .
80
180
135
895
20.8
46.6
84.2
6 years, bov .
Symington.
80
175
106
861 i
22.2
48.6
29.8
9year8,jrirl .
Kasenel . .
• 85
195
150
430
19.8
45.4
84.9
11 years, [wy .
Aeby . . .
91
218.7
153.5
463.2
19.7
47.2
88.1
18 years, jjirl .
Symington.
95
220
136
451
21.6
48.7
29.1
16 years, jjirl .
Aebv . . .
100
221.9
151
472.8
21.1
46.9
81.9
16 years, j^irl .
Aebv . . .
107.5
229.5
152.5
489.5
21.9
46.9
81.1
17 years, girl .
Dwight . .
113
250
161
524
21.6
47.7
80.7
The figures to the left of the double line in the table express the abso-
lute length of the ditferent portions of the spine, in millimetres.
Those to the right are the same figures reduced to terms of 100, within
a fraction.
Flexibility. — I have already shown you how very flexible the spine
is at birth. This flexibility Ixx^omes less as the infant grows older.
In the cadaver of u female child of ten months it was found that exten-
sion was no longer so free as in the earlier months, and it required a strong
pull to make the head touch the nates. The dorsal region, however, could
still be made a)ncave Ix^hind. Flexion was free, especially in the lower part
of the lumbar region, where the jiclvis and legs could be swung forward.
On rotation the head could he turned through an arc of 90° without using
the joint between the atlas and the axis. In a male child of the same age,
extension of the spine was found to Ix^ still more restricted.
CiTRVF>^. — In the last lecture I explained to you that at birth there were
no natural curves in the infant's spine.
An im{)ortant factor in the production of the curves in the cervical
and dorsal regions Is probably the pull of the muscles, as will be presently
described. The dorsal curve seems to be a permanent condition of a part
of the general curve of the Ixxly. As soon as the miLsclas of the back of
KOHMAL. DEVKLOPMENT.
5T
the neck oontrsict bo as to raise the head from the chest, the front of the neck
will be convex, and finally tlua beconac?s the habitual position. As Syming-
ton liiiis |>c»inted out, however, this eer\^ical eurve hi never, properly is^jjea Ic-
ing, eoniHjlidated, tor it can always be obliterated by a change of the posi-
tion of the head. The production of the lumbar eurx^e is more complicated.
If an infant be laid un it^? back on u ta!)le, the knees are raised and fall
apart j if they are br*jught together and fbiTibly pressed dowu, the lumbar
region will spring up frutu the table and tlie beginning of a lumbar curve
will appear. It is suppc^sed that this is caused by the shortness of the ilio-
femoral ligaments, which, wheu the thighs arc brought down, ilex the |)elvis,
throwing the promontory of the sacrum iorwai'd. As the child begins to
stand, the body is inclined forward, and when this is 8traightc*ned by the
musc4es of the back tlie ?ame thing occurs, for of Lsuirse it is uuimpoilant
whether the legs are extended on the trunk or the trunk on the legs. The
credit of this explanation has generally been given to Ballandiu, but it
apfiears to belong to Clcland.
This ciir\^e» thei'elSirc, is fii-st observid when the child is one or two years
old, but it is not until s*.>me time later that it is liabitually present, and I am
not prepared to say when it atlually occurs. It can be obliterated up to adult
life, and I rather suspci't in many eases even later. The influence of the
musc*ular system is important not only in forming two of the spinal curv^es^
but in maintaining them aflenvards. 1 am convinced tliat the greater
rigidity of the btxly that is fciuiid after puberty is largely dep^^ndeut on the
muscles. The tonicity of the must^les has a great deal tti do with ivtainiug
the cm'ves of the spine and with limiting its movements. Many of the feata
of contortionists art* diw to this p^wer of rc^laxing anti^onistic ojuscle,?, and,
as a rule» we iiod in childi^en a greater proportion of raiLsele to tendon than
in adults. It is, thei'efoi'e, due more to the want of power to relax the
muscles than to the lack of a peculiar forraatjou of the bjues and joints
that children cannot p»eribrm many of these fcatj^. The iniportanec of the
muscles in distortions is very great. The spine of the child is flexible in
many ways, and the unruly pull of a muscle may easily pnxluoe a last-
ing effect. Not only sliould the moR^h^ have stn^ngtli enough to maintain
the iigure without ct>u8cions etf'ort, but their action should Ik? symmetrical i>n
both sides, and should also have a pro^wr relative force before and l)ehiod
(Case 47, Lecture V., page 145), Tiie impoitaucc of light gymnastic exer-
cises is now so generally untlcrst<MKl tliat I ntH.Kl do lu) niort- than allude to it.
What, however, is of great practical clinical interest in connec*tion with the
anatomical and physiological facts concx^rni ng the spine, sp<>ken t^f nbov(\ is
the way in which tliey distinctly cmj>hasize the value of this preliminary
knowledge in the study of preventive medicine. This jxnnt will be spoken
of in a later let^ture.
What I have just told you regarding the curves of the spine at different
ages will, I think, be Ix-tter understiMKl and remembered if you will for a
moment again look at these lines (Diagram 2, Lecture II,, page 28), repre-
58 PEDIATRICS.
senting the curveB of the infant's spine at birth and also at different ages up
to the period of standing.
These lines were made at my suggestion by Professor Dwight
Surface Anatomy. — The surface anatomy of the spine id of much
importance in the adult, and must not be overlooked in the child, where it
presents striking differences. In the first place, a prominent feature in the
adult, especially in a muscular male, is that a depression is found wherever
the skeleton shows a prominence, owing to the development of the muscles.
Thus, the skeleton shows a ridge of spines in the middle line of the back,
with a valley on either side ; but during life normally we have a median fur-
row between two swellings formed by muscular masses. In the infant this is
not the case (except perhaps in the neck), but the back is rounded ; later it is
more flattened, and the line of the spinous processes, far from being in a
depression, is rather prominent This is the more remarkable as when we
examine the dissected spine from behind we find it very different fi!X)ni that
of the adult In the infant the laminae look more directly backward^ and
their presence in the median line is marked by knobs and ridges very
different from the spine of the adult Up to a year, or perhaps eighteen
months, the proportions are not very different, but the spine at three shows
that a great change has occurred, for the spinal processes now stand out in
a prominent row, and present very nearly adult proportions. The greatest
difference is in the dorsal spines, which are relatively broader at their points
and less gracefully drawn out than in the adult. The bodies of the vertebrsB
still remain less deep, and therefore the relative positions of the spines and
bodies show less difference than might be expected. For example, the tip
of the spinous process of the seventh dorsal vertebra in the adult reaches
down to the lower border of the body of the eighth vertebra, or the head of
the ninth rib. At three it goes very nearly as far, though its shape is not
the same. At six or seven the spine has made still further progress towards
the adult proportions. By the end of the second year the back of the
living child is not only flatter and broader (the results of continuous
changes), but there is the appearance of the median furrow, and at five or
six the differences in this respect from the adult are not marked. It is
barely possible to count the spines in the infant and young child, and at
three and four years it is not very easy, though less difficult than in the adult
Prominent Spinous Processes. — A source of error is the adjective
" prominens" applied to the seventh oervical vertebra, which naturally sug-
gests that its spine is the most prominent in the back of the neck. This is
not usually the case. The first dorsal spine is the most prominent in that
r^ion. The atlas has no spine at all ; the spinous process of the axis is
thick and prominent, perhaps relatively less marked in the child than in the
adult ; the third and fourth spines are very small ; the fiflh is not much
larger ; but the sixth projects more, and the seventh is said to be usually
the first prominent one. He who trusts, however, to this rule is very liable
to error, for the relative size of the lower cervical spines varies considerably.
NORMAL DEVELOPMENT.
5d
The BLxth may be the first to assume promineaoey and the seventh wrvieal
and fii-st dorsal may exeeixl it but little. It b easier to examine a ehiltl of
thi'ee yeai's and upward than an adult, on account oi' the greater s^jftness
of the tissues, which allows us to feel more deeply in through tfie furrow
oi* the neck, and, having ix^cognixed the axis by alternately flexing and ex-
tending the head, to count the cervical vertebra? in order. If it should be
in any ease absolutely imptjssible to feel tlie third and tlie foiuih, it is better
t<i allow a certain sjmee lor them and to call the next one the tirth than to
assume arbitrarily that a certain one is the seventh. Confirmatorj* evidence
may be gained from the height of the sternum, to which point I shall return
later.
NECK. — I have alr€*ady referred to the ijeculiarities of the infant's neck
at birth. (Lecture II., page IMX)
Cnicoiii Cartilage. — Symington states that in two children respect-
ively five and six years old the lower border of the cricoid cartilage was
foimd to l>e at the lower border of the fifth or at tlie toj> of the sixth verte-
bra, I do not rpiote his observations at intermediate ages, as the position
of the head hi these measurements varie<l a g*.Hxl deal. In a girl of thir*
teen he foimd that it had reached the adult position ; that is, about on a
level with the top of the sevamth vertel>ra.
Epiglottis. — Symingtt>n found also that the top of the epiglottis de*
scends during growth fnim about the level of the lower border of the atlas
to the middle of the tliinl cervical vertebra, or even lower.
Larvnx. — This high ix^sitiou of the larynx would imply a greater jmrt
of the trachea relatively above the sternum, but this is nentralissetl by tlie
high position of the latter. The amount of fat in the nock makt^s the trachea
less accessible. The gi'eater distance of the trafjhea fn>m the surface, as it
deeoeods, and the greater danger of meeting the large arteries and veins
above the steninm in the child, are points of anat^^my s<> well known in
connection with tracheotomy that it seems haixlly worth while to insist on
them.
Tillanx made a series of measurements of the distances from the sternum
to the hyoid, the thyroid, and the cricoid, in men, women, and children of
both sexes.
Distance from Stehkum to Cricx>id. — I give a condensation of his
statements of the distance fr«>m the sternum to the cri<v>id, w^ the most pnu*-
tical. In twelve women it ranged Irom five and a half t^) s*?ven and a half
centimetres, the average being six and a half «*enti metres. In men the
variation • iter, ranging fn>m four and a lialf to eight and a half,
but the a\i ., \:is precisely the same. Among the men wfis a b<>y of fif-
teen and a !i:j1i' years, in whom the distance was seven and a half centi-
metres. Tillaux measured tliirty-one children, ninet^t^n girls luid twelve
boys, ranging imm two years up to ten and a half. There seems no reason
for keeping tlie sext^ distinct, and I furtlier condense the table by giving the
average in the eases of several of the same age, with tlie fi)llowing result :
60 PEDIATRICS.
TABLE 7.
Relation of Cricoid to Sternum.
Yean. Diftanoe ftom Cricoid to
2i 8.6 centimetres.
8 4 "
8} 4 "
4 8.8 "
4i 4 "
6 4.6 "
6 4.9 "
6i 6.6 "
7 6.1 "
H 4.6 «
8 6 "
8i 6.26 ««
9 6.26 "
9J 6.6 *«
10 6.6 "
10} 6.6 "
It seems rather remarkable tliat at ten years the distance should be as
great as in the adult, but this may be accounted for by the subsequent
descent of the larynx, and also, probably, by its proportionate enlargement
(at least in the male) about puberty.
The peculiarities of the relations of the top of the larynx and pharynx
to the spine in the young child are jwiuts of much practical importanoe, to
which I shall return. The changes which occur during growth depend
largely on changes in the base of the skull, and on the downward growth
of the jaws, which will be considered presently.
HEAD. — Circumference. — The measurement of the circumference of
the head increases very rai>idly, and in early childhood almost attains that
of the average adult's head. We must therefore be careftil about giving an
opinion that the head is relatively large for the age of the child. I have
myself measured over one hundred children of different ages in both hospi-
tal and private practice in order to get a general idea of the circumference
of the head and its projXirtion to that of the thorax. The number is, of
course, too small to make any precise average deductions from, but in a
general way I have found these measurements usefnl.
Circumference relative t<^> Thorax. — Thus, I have found that
while at birth the head usually has a (»ircumferencc of 33 cm. (13 inches),
the thorax, measuring over the nip])les and just under the angles of the
scapulae, has a circumference of 1 or 2 cm. ( J to f inch) less. A change in
these measurements and projx)rtious s(M)n takes place. In the fourth to fifth
week, for instance, and extending into the seventh and eighth weeks, 38 cm.
(15 inches) for the head and 35 to 36 cm. (14 to 14| inches) for the thorax
I have found to be not uncommon figures. In like manner at five or six
montlis 42 to 45 cm. (16J to 18 inches) for the head and 41 to 42 cm. (16^
to 16 J inches) for the thorax are figuns (M»curring in my measurements. At
nine months it is not uncommon to find 45.5 cm. (18 inches) for the head
NORUAI. BEVKLOPMENT,
61
and 48 cm. (17 inches) for the thorax. At the end of the first year in a
number of cases I found that the circumference of the thorax had reiiched
and L'VOQ i^iirjias?^ that of the head, as .^een in this infant (Case 8), where
the bead i^ 45.5 cm. (18 inchetj) and the thorax 47.5 cm, (18| inchejii). In
exceptional caaes the thorax surpasses the head at a much earlier period ;
and I ha%^e even seen it to l^e a trifle larger at birtli, but this is unusual. I
have recently measured a he^ilthy infant whose weight at birtli iivas 3800
grammes (8 J pounds), whose head meaj^ured 34 cm. (13 J inches) and whose
thorax also measurt»d 34 cm. (13i inelics). In the second year I find very
varying figures^ and the head often still remains lai^r than the thorax.
Thus, in thes^e two infants wbicli I shall now show you, one (Case 0), who
is eighteen months old, has a bead measuring 49 em. (19i inches) in circum-
ference, and a thorax 46 cm. (18} inches), wlule the other (Case 10), also
eighteen mouths old, has a bead measuring 47 cm. (18 J inchet*), and a
thorax 45 cm. (17| inches)* Here is another infant (Case 11), twenty-one
montlis old, who has a head 51 cm. (20} inches) and a thorax 50 cm. (19|
inches) in circunifereucx?. My measurement's have been taken mostly fmm
boys. The girls that I have measured seem proportionately for the miOB
age to show smaller measurements of the thomx, and t4i have the tbomx
overtakiog in its circumference the bead at a rather later date than i.s the
case with boys. By the second year tlie thorax has almost always overtaken
and sui"passed the head. I will now show you some measurements of the
head and thorax from two to thirteen years which I happen to find in my
notes. They were all males, aud it muiit l>e remem leered that they are not
exact averages for a large number of cases, but merely measurements w^hieh I
found corresponded in a numlier of children of these different ages, I pre-
sent them as showing especially how it lMK'<»mes uoti«^able when the circum*
ferentxi of the head is taken at random in your general practice, that after
the second year the measui-ements of the head corn^{>f>nd pretty closely, and
depend upon the individual rather than upon the age. The thorax, on the
eontraryj seems to increase year by year.
TABLE 8,
{^eumferenceg of Head arid Thorajc from Thoo to Thirteen Veara.
Males.
Ye&TS. HencL
2. ....,, . 48 cm. (19 inches) .
3 51 cm, (20| inches) .
4 63 cth. (21 inches) .
6 - . &3 cm. (21 inchefl) *
6 . 62 cm. (20J inches) .
7 , 64 cm, (21 J inches) .
8 63 cm. (21 inches) .
9 64 cm. (211 inches) ,
10 ...,-... 68 enj. (21 inches) .
11 56 cm. (22i inches) .
12. . 58,6 cm, (21 i inches)
18 64 cm. (211 inches) *
Thomac.
d. (20| inches).
i> (21f inches).
1. (21} inches).
1. (21 f inches).
1. (21| inches).
1. (21 J inches).
1. (23Ji inches).
1* (24 inches).
1. (24J inches).
h (24J inches).
). (24} inches).
1. (26 inches).
62
PEDIATRICS.
This series gf circles, representing the circumferences of the head, thorax,
and abdomen, will, I think^ show you at a glance what you may expect as
to the relations of these parts of the child in the first year. They represent
the average of a number of actual cases which I have had an opportunity of
closely watching in their nurseries from birth to one year.
Early Weeks.
Diagram 8.
SizMoDthfl.
Head.
Twelve Mooths.
Relative ciroimferences of head, thorax, and abdomen.
The general idea which yon can get from these diagrams will, I know,
help you in your nursery practice, where you have to determine in a few
minutes whether an infant is fairly developed. No esi)ecial significanoe need
l)e given to the circumference of the alxlomon in this connection beyond
what I have previously said concerning the liver, as its measurements, of
KORKAL DEVEIX>PMENT, 63
course, varj^ very mut*h oormallj according to the degree of distention
preflent
The fact that I have representecl the head and thorax equal in the mid-
dle of the year, and the thorax larger than the head at the end of the year,
does not establish any rule for these periods, as you see from what I have
previously said. The diagram merely in a very simple way enmiciates
FiQ. 16,
InAuit Bkull« natural si^e. Anterior fonUn^lle 4X3 ctn.
W«iTen Museum p HiLn^ani Dulvcnlly.
that, althrni^li there is ^reat aetivity ^hn^^Ti in the growth of the head, this
activity is still greater in regard to the thorax,
FoNTAKELLES. — The posterior foniant'U(% although ordinarily quite jjer-
eeptihle at liirtli, m^m disap|>f*ars, eithfr from overlapjiinoj of the hme or
fmm a permanent closure, and h ti^uully imj>enx»ptible by the sixth week.
The anterior fonianeile, so far m my oliservation is concerne<l, seems to
grow larger as the infant grows older, up to about the nintli mouth ; tliis
64 PEDIATRICS.
point is, however, disputed, and the increase may be apparent rather than
real. It also seems to remain stationar}^ or almost so, from the ninth to
the twelilh month, and then decreases slowly. It should be closed by the
nineteenth to the twentieth month.
When we study the disease rhachitis you will understand how important
is a knowledge of the closure of the fontanelles.
This skull (Fig. 15, page 63) of an infant in the early weeks of life shows
very well the increase of the diameter of the anterior fontanelle. While,
as you see, in this skeleton of the infant at term (Fig. 33, page 118) the
measurements were 3 X 2 cm. (1^ X & inches), this fontanelle measures 4x3
cm. (If X IJ inches).
Face and Cranium. — As I stated in a previous lecture (Lectare II.,
page 31), the proixirtion of the face to the cranium in infancy is as 1 to 8.
Froriep has also made observations on this point in older children, and finds
the following proportions :
TABLE 9.
Proportions of Face to Cranium.
Age. Akoe. Craoinm.
Early infancy 1 to 8
2 years 1 to 6
6 years 1 to 4
10 years 1 to 8
Adult female 1 to 2J
Adult male 1 to 2
The small size of the facial portion of the skull in infancy and early
childhood is well shown in these skulls (Fig. 16, page 67) of the infant at
birth and at three years, and also in these skeletons (Figs. 33 and 34, page
118) of the infant at birth and at nineteen months.
As the (?hild develops, very important changes occur in the base of the
skull, one of the greatest of which is the downward growth of the face.
Originally the base of the skull is practically flat The sudden rise of the
basilar pn)cess in front of the foramen magnum, the angle formed with it
by the body of the sphenoid, and then the sharp descent of the vomer, are
adult characteristics of which at birth there is little trace. The nasal cavity
is sliallow and relatively long, the posterior nares are small, and the vomer
approaches the horizontal. The naso-pharynx has, therefore, very little
height. The alveolar processes are still undeveloped, and ihe ramus of the
lower jaw is very obli(jue, so that the cavity of the mouth is small. As a
consequence, the larynx is, as wc have seen, placed very high up. One
of the chief causes of its descent is the downward growth of the face.
Brain. — Much credit is due to Dr. Greorge McClellan, of Philadelphia,
for his careful and laborious work, extending over many years, on the
anatomy of the different i)eriods of life. His careful dissection of the
infant's brain is ver\' valuable for reference, and I wish to acknowledge the
use which I have made of it. I desire also to express my appreciation of
the anatomical work on infants done by Dr. J. W. Ballantyne, of Edinboi^u
y NORMAL DEVELOPMENT. 66
Dura Mater* — An impt^i'tant anatoDiii^l tNjiidititm in t-oDnection with
the brains of young subjects is that the dura mater is adherent to the skull,
ainl thuB |>revent^i the collet-tiou of extravasations between it and the bone.
Subarachnoid Space. — The subarachnoitl space usually contains a
larger amount of Huid in i-liildhood than in later life.
Growth. — ^I have already nientioueil the large propoitioaate size of the
brain at birth (Lec^ture IL, page ^M),
Up to the seventh year tlie bmiu shows an active growi-h, and after that
year ineix"a-*es slowly in weight. The involutions are not fully develojied
at birth, and are gradually iH^rfeetod ils tlie ehild grows older. The various
centres of the brain whieln gradually Ixxxmie s(> highly devel(>|Kxl in later
ehildhood have but little action, so far as we can judge, at birth and iu the
early weeks.
Ear. — The os8e<ius meatus is not developed until about the fourth year.
In introducing rl*e aural s|>eculuni under four yeai^ of age, yon should
therefor*' draw the ear forwanl axid downwaix] instead of up wan! and back-
ward as ill older child rt^n and adults, ur the canal will be Lniit on itj^elf.
Petro-Squamosal Suture. — The time at wliich the pdro^quammal
mUure closes Is not at present know^n.
Naso-Pharvnx. — ^Now% if you will again examine these fusible metal
casts (Fig. 5, page 33)^ you will see, as I have already jx»int<xl out to you,
in this one taken from an infant, that although the inferior turbinate projects
slightly into the cavity of the nose, yet there is but a very minute expansion
b(*luw it and none parsing up iK^hind it.
According to Disse, it Is this part which shows the greatest growth. It
begins to increase in height directly after biilh, and goes on jUTtty rapidly
till the beginning of dentition, when it is slow till the se<^>nd year is «jm-
pleted. After the first set of teeth are cut, the gi'owth is ra|>id till the end
of the seventh year. The increase in breadth m-curs in the last- men ti<ined
period, which alsfi is the time in which the growth of the olfiictory |>ortion
is most marked. Disse states that the posterior o|>ening doubles its size in
six months, remains stationary till the end of tlie second year, and then
incrcaiiies again,
Profess4>r Dwight^s measurements on bones are as follows :
TABLE 10.
BrMdcit between Pit.'i7-
i,ge. Height of Posterior Nato. nAA Procenes «t Hard
About ]>irth . , C to 7 miUiinotree. d mtUimetre*.
From 12 to 16 inonttiB IH ** 16 **
'* 12 to 18 ** i:* ** 16 «*
** Uto20 »* H ** 17
** 18 months to 8 years .... 15 ** 21 **
K ♦* 2 to 4 yeara . , . . 15 ** 20 **
H About 6 years . IB *' 90 "
H 7or8yettrt. *M 22 **
H About n year» 18 *' 22
■ 17 yeare, female , 22 ^' 20 •'
66 PEDIATRICS.
We may compare with the above, ten measurementB which Professor
Dwight has made on adult skulls. I give both the average and the extremes
of variation.
Tablk 11.
Breadth between Ptery-
Ten Adults. Height of Poeterior Nares. gold ProoeMoa at Haid
Palate.
Average 28.4 millimetres. 27.7 millimetres.
Extreme 28 and 81 " 24 and 81 «
These figures show that the height does not gain the predominanoe until
adult age. At the end of the seventh month the nasal cavity approaches the
adult shape, though it seems broad in proportion, and has not, of course,
attained its full size. Merkol has shown that in later adolescence the
growth of the respiratory portion takes place chiefly in the middle nieatus.
In infancy the posterior border of the vomer is very oblique. With the
growth downward of the jaw this obliquity is much diminished at the age
of seven or eight years.
Eustachian Tubes. — The course of the Eustachian tube and the posi-
tion of its opening undergo changes corresponding to the development of
the nasal cavity. As I have already told you, at birth the tube is horizon-
tal, or nearly so. In the adult the cartilaginous portion slants downward.
Nevertheless, the opening of the tube is opposite a higher part of the nose
in the adult than in the child. In the foetus the opening is below the level
of the hard palate, which it reacihes at birth. Up to the ninth month after
birth, according to Disse, there Ls but little change. After that time, how-
ever, the oi>ening is distinctly higher than the floor of the nasal cavities.
At four years, Kunkel found it to be three or four millimetres higher. In
the adult it is opposite the end of the inferior turbinate bone.
Pharynfireal Tonsil. — ^The pharyngeal tonsil increases after birth, and
by the end of the first year has a length of eighteen millimetres.
Professor Dwight tells me that he failed to satisfy himself of the presence
of anything that could be called a pharyngeal tonsil in the head of an ill-
nourished child of four weeks which he recently divided in the median line.
There is probably much variation. Dr. Dwight has a beautiful specimen
of one in a similar section of the head of a child of three years or less. It
has a length of about twenty millimetres, and narrows most strikingly the
passage from the nose to the lower ])art of the pharynx.
From the tip of the uvula to the top of the epiglottis Braune found the
distance to be twelve millimetres in the median section of an adult female.
In Symington's section of a boy of about six years it is five millimetres. In
a section of a head of three years or less it is not over two millimetres, and in
another of four weeks we find that had the mouth been closed when the
head was frozen, the parts would probably have be(?n in contact. The precise
progress of the changes from the infantile condition is still to be observed.
I may say, however, fn)ra the sections at the Harvard Medical School, from
Symington's plates of children of six and thirteen years, and from other
NORMAL DEVELOPMENT*
67
tneasureiQeDts of childreu, that the chauge in the first two or three years is
very great, and that the pharynx of older childi-en resembles more that of the
adult tluin that of the infant Indeed, at lour weeks we find the tip of the
epiglottis on a level with the low^er part of tlie odontoid proa^s, but, of cx>ur9e,
by oj>eiaug the mouth and depre^jsiug the soft part^ space may be gained.
Hard Palate. — In a child of three years or less the line of the hard
palate strikes alxint the middle ol* the ba^^iHieeipital bone. It would hai-dly
be pi^sible, without pa^^sing the finger roimd the soil [lalate, to feel much
higher than the arch of the atlas. The base of the odontoid process would
be under the mue<:ins meml)rane seen at the back of the throat through the
open mouth. The tip of the epiglottis is at the junction of the odontoid with
the body of tlie axis. I doubt if more than the very ttjp of the third verte-
bra could be satisfactorily explorecL At six and at tliirteen (Symington's
plates) I find that the line of the hard palate has alwut the adult dirwtion,
— tiiat is, it strikes about the top of the atlas or the basilar process near its
begiuidng. In b<:»th the finger could pnjbably examine the vertebrae from
the first to the fourth in-
clusive. The atlas, how- F'o- l*^-
ever, would be reached
with rancli more difficulty
in the tdder than ui the
younger subject, as the
relations of the s<:>ft j)alate
are more nearly those of
the adult.
MoiTTH. — As the in-
fant grows older the mouth
becomes an organ more
adapted for certain uses
beyond that of a mere
means of entry for the
fcMxl to the stomach.
Maxillahy Bones.
— The ossification of the
maxillary bones begins
early, progresses slowly,
and, together wnth the
final formation of the jaw,
LS compk^tc^l at pul>erty.
These skulls (Fig. 16),
one of an infant Ixn-n at
term, the other of a child
three years old, represent the chanirteristic intNmipIote development of the
ramus of the inferior maxillary U*ne in the early weeks and months of life,
and its almost complete development at three years.
Skulls <)howtng development of nimtis at birth and at Ibroe f eaia
W*uTen Mn*eum. Harvartl CnlTeislty.
68 PEDIATRICS.
The chief characteristic, as you see, is the oblique angle which the ramus
makes with the body of the bone at birth, and this becomes more evident
when you compare it with the jaw at three years. You will observe the
much greater proportion of the ramus to the body of the bone at three years,
and the nearer approach to a right angle where they join.
Teeth. — Fleischmann's work on this subject is worthy of especial atten-
tion, as it will elucidate many points of interest when we come to speak
in a later lecture of diseases of the mouth and difficult dentition. His
description of the development of the teeth, and McClellan's description^
which can be found in the first volume of Keating's '^ Cydopeedia of
the Diseases of Children," need hardly be mentioned in detail, but they
provide us with facts which will in a measure explain certain symptoms
of clinical interest during the i)eriod of dentition. The development of
the first set of teeth begins at about the seventh week of intra-uterine life,
and, progressing slowly, is completed about the end of infancy. At birth
the twenty embryo teeth, ten in each jaw, are so enclosed in the alv€K>lar
processes that nothing but the smooth mucous membrane is apparent on
the gums above. Below, they are connected with the branches of the infe-
rior dental nerve (an im[)ortant clinical fact to be remembered) through open-
ings at the bottom of the alveolar processes. When calcification of the neck
of the tooth begins, elongation also takes place, and, as the tooth is enclosed
in bony walls below and on the sides, it gradually grows through the point
of least resistance, namely, the gum, which covers the top of the alveolar
processes. The continued pressure gradually causes atrophy of the mucous
membrane, and the crown of the tooth appears on the edge of the gums.
The various teeth come through the gum at times which are r^ulated
ac(»ording to their development, that is, at times corresjwnding to the calcifi-
cation of their roots and consequent elongation. This process usually takes
place in groups and with considerable regularity in the average normal
infant. Variations both as to the order in which the teeth appear and in
the time of their appearance are so common that it seems hardly practi-
cable to have set rules designating these times. The experience of different
physicians seems U) differ, but all practically are guided by very general
rules.
An infant may be born with one or more teeth, as you see in this infant fburteen
days old, which has just been brought to the clinic to be operated on by Dr. Augustus
Thomdike, who kindly presents the case for your inspection. Tou
Fig. 17. gee that it has an everted intermaxillary bone, on the outer side
C^ of which is the left middle incisor, which evidently came through
^^^^ the gum before the infant was born.
Upper incisor tooth in
Infant at birth, natural The first tooth may appear at any time during the
first year of life, or may be delayed until the second
year without any other apparent vice of development. In like manner^
every kind of variation may be met with in the order in which the teeth ap-
pear, without the slightest evidence of any pathological condition, mental or
NORMAL DEVEU)FMKNT, 69
otherwise, being found either at the time *ir later. It is therefore unnecess-
saiy to alarm the parents by stating that their child is abnormal beeanse it
has not cnt a ttujtli in tJie first year. Wv shutild, liowever, earefnlly watch
these children and l>e sure that their fixjd eontmus the pn>j>er nutritive
elements not only for their age, but also for their individual digi^titm»
The appearancre of the teeth in groups suggestd certain pnu-ticiil divii*-
ions which I shall make ust^ of in later lectures to determine various ques-
tions, such as the best time for weaning^ or lor vaccination. These divisions
ix^nstitute the rfeH//f/ fmd int.etyJenlal periofb. In my individual ex|>erienoe,
the first tooth appears at alxRit the sixth or seventh mouth, though at times
I find it mueli earlier^ as at the fourth month, and later, a^ at the ninth,
tenth, eleventh, or t^elflh month. The first tootli which develops suffi-
ciently to cHjme through tlie gum is in most cases one of the middle lower
inci.sors. The gmups and the dental j^eriods, allowing always lor many
variations, are, as I have noted them, aa fidlows :
TABLE 12.
Temporary Tsct-K First Dentition. TSctnty in Number.
Dtnud Peiioctik Groups of Teeth,
I. 6 tu 8 monttfl 2 middle lower incisors.
II. 8 to 10 months , . 4 upper incisors.
Ill* 12 to 14 months 2 laieral lower inciaora and
4 first molars.
IV. 18 l<> 20 month* ,4 caninea.
V. 28 to S2 month* 4 second molare.
20
I shall now pick out a nuinl>er of infants in the^e various peri<ids who
ha|>|)en to have their tet'th coiTesponding to them, and I should like you to
examine their moutlis. Here are five typical eases which will illustrate
what I have just said,
DlAOBJLM 4.
Caar 12, Case IB*
\
Cask 14.
Case 15.
Five peHoda of development in the Rnst deniltfon.
70 PEDIATRICS.
The second set of teetii b^ins to replace the first at about the sixth year,
and this table will aid you in remembering their order :
TABLE 18.
Permanent Teeth. Second DentUian, Thirty-two in Number.
Yean. Groups.
6 4 flrtt moUn.
7 4 middle incUon.
8 4 lateral incison.
9 4 first bicuspidB.
10 4 second bicuspids.
11 4 canines.
12 4 second molars.
17 to 26 _4 third molars (wisdom teeth).
82
The first four teeth of the second dentition are usually called the sixth-
year molars. They do not replace any of the permanent teeth^ but^ the jaw
having grown so as to provide space back of the temporary teeth^ they ap-
pear back of and next to the second molars. This usually occurs at about
the sixth year.
In the seventh and eighth years the permanent incisors replace those of
the temporary set. In the ninth and tenth years the bicuspids replaoe the
temporary molars. In the eleventh year the permanent canines replace the
temporary, and in the twelfth year the four second molars appear. This
really completes the second dentition of childhood, twenty-eight teeth. The
remaining four molars belong to a period of adult growth. Diagram 5
(page 71) shows very clearly the manner in which the permanent teeth replace
the temporary set between the ages of six and twenty-five years.
THORAX. — Top op Sternum. — Professor Dwight found on examining
two children each ten months old that the top of the sternum was in one
nearly opposite the disk between the first and second dorsal vertebrae, and in
the other a little lower, near the top of the second. In a black child of three
years, whose proportions were strikingly infantile for her age, it was near the
lower border of the first vertebra. In the three-year-old child the subject
for the work on Dwight's " Frozen Sections" it was opposite the lower part
of the second vertebra. In the median section of a boy about six years old
Symington found the top of the sternum a little below the level of die top of
the second dorsal vertebra ; he believes, however, that this was an individual
peculiarity, as in several children of that age he found nearly the adult rela-
tions. From several observations on the living subject Dwight is inclined
to agree with this statement.
Diameters. — The antero-posterior diameter of the interior of the thorax
is to the transverse diameter at three years, according to Dwight's " fVosen
Sections," as one to two, and in a child of from five to six (Symington) the
depth is even relatively greater. The ribs bend much less backward than in
the adult, and the back, as has been said, first becomes rounder and then
NORMAL DEVEIXIPMENT.
71
flatter. At four or five years great progress in growth has beeo made, and
the mfaDtile form of tlie thorax has wholly disappeared. Slight changeS|
however, probably go on for some years.
Diagram 6.
Sl^ht perioda of deTelopment tn the aecond dentltlciii.
OssFFTOATlON. — Towards the eticl of the first year the biiin^x^ntres of
the sternum hav^e grown, and the sternum has gaim^l a gofd deal in stability.
New pomt8 of ossification have probably apjjeared, but still the sternum is
t «»€B6entiaIly cartilaginous, the bone merc^ly (TJiisisting of islands in a si.^a of
'^Ciitilage. At two years of age the raaunbrinm and the second and third
piaoeB are nearly ossified, but their shaf>e is made by their cartilaginous bor-
ders* At three years I have twice seen the manubrium and the second
72 PEDIATRICS.
piece of the sternum presenting in bone their real shape, while the third
piece was still framed in cartilage. Sometimes, however, the prooees of ossi-
fication is more backward. The ossification of the lower part of the sternum
is less advanc^ than the upper imrt. As to its relative size opinions differ.
While it seems to me that it is usually small, I must admit that statistics do
not confirm this view. Probably the individual variation is very great
The ribs being comparatively horizontal, the cartilages rise very little, and
at the lower part of the c^hest in front they are nearly together, making
narrow intercostal spaces, the seventh cartilages often meeting below the
body of the sternum. In the dead body of a young child, especially if
it be emac^iated, it is striking to see how, after the cadaveric rigidity has
passed away, the sternum and cartilages, forming the front of the chesty
fall in at the point where they join the ribs.
Respiration. — At birth there Ls no decided type of respiration for the
two sexes, as I have proved by a number of observations. As the infants,
both male and female, however, grew older and a more equable respiratory
mechanism became established, I found that, as a rule, in the early months
of life the type of respiration was abdominal. This infant (Case 17), nine
months old, presents the irregular respiration of infancy, but yon see the
type is distinctly abdominal.
CHART 2.
AAMA AAmaa AaAm/\
Quick. Pause. Irregular. Pause. Irregular.
Reepiration for one-half minute in a healthy infant nine montha old : awake, but quiet.
Diaphragm. — In a child three years old Dr. Dwight found the dia-
phragm to be opposite the lower part of the eighth vertebra, and in another
child it was at the disk between the eighth and the ninth. Both the chil-
dren were girls. In a boy of five it w^as opposite the middle of the ninths
and in one of six opposite a point in the lower half of the ninth ; in a girl
of six it was opposite a point between the ninth and the tenth^ and in one
of thirteen opposite the lower border of the ninth.
Thymus Gland. — The thymus is most developed in the first two years
of life, but it persists longer than was formerly taught. During its greatest
development it is found in the neck as well as in the thorax, extending
perhaps 2 cm. (f inch) above the sternum, which, you must remember, is no
small part of the surface of a chiId^s nw^k. The thymus extends down the
anterior mediastinum, lying on the pericardium in two long lobes on either
side of the median line. The extent of these lobes is very variable, and the
two are not usually symmetrical. I have seen them, even in an in&nt, 80
developed that the longer nearly reached the lower end of the sternum ; but
it is very uncommon for it to reach the diaphragm. These prolongataons
NORMAL DEVKLOPMEKT,
73
become thinner as they descend. The thymus is a tliiek mass behind tlie first
piece of the sternum, where it rests oo the tt)p of the heart agtiinst the great
vessels concealing the in nominate \'eius, more or leivs oi' tJie j*up:*rior vena
cava and Uie arch i»f the amta, and exti uiling back to the trachea. Lower
down it extendjs on either side into the aogle between the |>ericardiimi and the
hing^, or rather pleura*. Except for the frout view, ohtaineil by n^nioving
the sttTnum, the nize and relation of the tliymus are best jihown by frozen
sections. One, made by Dwight, of a child of three years or les8, at the
Harvard ^fediwil Scbftol, ^iven a most ixnniirkable view of it. The hection in
t|nestioa runs nearly horizontally from the top of the fourth don^al vertebra
t<-» just above the junction of the second c<:>stal cartilage with the sternum.
The <^vity of the thc/rax seems to be divided into three parts, one oa
either aide of tlie lungs and a median one ^x^nijiied by the tliymus, the trans-
vei*se part of the arch of the aorta, w itb the su{:>erior vena cava on its right,
and the trachea and a?so])hagus behind. The area CKX^npied by the thymus is
very nearly ct^ual in that ol' the letl lung. The thymus reaches baek^sard
on the Icll of th<' aorta bcliind the level oi* tlie fnjnt of the spiual cobunn.
There is also what seems to be a piece of it between the vena cava and the
tnu'hea. On the upjicr surface of the same section, at aliout the level of the
sterno-clavicular articulations, it is in front of Ixith innominate veins and
behind the right one^ The lungs are prevented from approachiug each
other so nearly behmd the manubrium m^ tliey do in tlie adult.
Fit), 18,
' Troem flection* child of three yeai^ : EL miirkii right Iuiik; LL iziark^ \q(\ lunf : T mArks thsnnus
gli&iiii : O nmrkfl gullet ; C8 marki Buperior vena cava ; AA tnarki aortic lirth : VA dultJcs vena ntygott;
F m&TkA ttoTDG tliiici which hafipeDed to Ijc in the right chc»t ; BT marks bifurcation of tnichea.
The section of the ehild just described shows that behind the manu-
brium there is much more of the thymus to the left than to the right of
the median line, and its dulness on i^eTcussion must have been evident at
74 PEDIATRICS.
tlie left of the steraum. Below it merges into the cardiac duluess, and
no distinction between them is possible.
The theoretical results of enlargement of the thymus are very serious.
Resting on the anterior and weaker ventricle, which is prolonged upward
into the pulmonary' artery, it may interfere with the pulmonary supply of
blood, and by compressing the innominate veins and the superior cava it
may interrupt the return of venous blood to the lungs. Whether or not
it may compress the thoracic duct is doubtful, but it certainly may press on
the trachea.
The tliymus is said often to persist for several years after puberty, but
observations are not numerous on this point. It seems to disappear from
the neck and from the front of the heart and to remain longest behind the
first piece of the sternum.
For further information on this subject, I shall refer you to Dr. A.
Jacobi's excellent monograph on the Anatomy and Pathology of the
Thymus Gland.
Heart. — It is generally held that in the first year of life the long axis
of the heart is more nearly horizontal than later. The apex is thought by
many to be higher. I am inclined to think tliat this is true in the first
few years, but somewhat later it may be found in the adult position, or, in
cases where the lower part of tlie sternum is backward in development and
the cartilages crowded together, it may Ix^ in a lower space than normal. It
is not unlikely tliat a subsequent cliaugc in these ))ortions of the walls would
correct this. Thus, if in the early condition the aj)ex were at the sixth
intercostal space*, a lengthening out of the lower end of the sternum might
cause such a des«?nt of the riljs as would bring it into the fifth space.
Weigrht. — As shown by Boyd, tlie weiglit of the heart in proportion to
that of the whole Ixxly does not vary much at different ages, so that the rela-
tive labor of tlie heart does not materially differ bct>veen the young subject
and the adult. In the first few years, however, the increase of the weight
of the heart Ls greater than at about the fourth or fifth year, and this increase
is again greater at alx)Ut puberty. These are facts of practical importance
to be remeralx?red wlien we are studying the diseased conditions of the heart.
TABLE 14.
Weights of the Heart during its Development, {Boyd.)
Age. GnmmM.
At birth 20.6
1} years 44.6
8 years 60.2
6i years 72.8
10} yeare 122.6
ITycare 288.7
I should now like you to examine carefully this heart of an infant in the
early weeks of life (Figs. 19 and 20), at a [wriod when the heart and blood-
vessels have completely changed from the foetal type to that of the adult.
NORMAL DEVELOPMENT.
75
It ha8 been prepared by Dr. Franklin Dexter to show the different cavities
and aliso the remains of the fetal couditious. First, looking into the right
auricle (Fi^. 19), you sec the remains of the Eustachian valve, and the
distinctly outlined but cWsed Jorameti ovale, Next^ on turning the heart
around (Fig. 20), you see this small tense csord eonnecting the aorta and the
pulmonary arterj'* Thk is the obliterated duelas arteriomui^ and, bb you see,
it pulls the aorta somewhat out of line, a condition which you wiU tied to
be of considerable significance when we are studying disea^^es of the heart.
Blood-Vessels, — Jacobi, in speaking of the extensive work of Thoma
on this subject, writes as follows :
** According to a number of actual observations made by R, Thoma^ the
post-fcetal growth is relatively smallest in the common carotid, and largest in
the renal and lemoral arteries. Between the^sc two extremes there are found
tlie subclaviau^ acuta, and pulmonary arteries. These are differences which
correspond with the differences in the gro^vth of the several parts of the
body supplied by those bUj<r*d-vessels. In regard to tlie renal artery and the
kidney, it has been found that the transverse section of the fbrmer grows
more rapidly than the volume and weight of the latter. ThuB» it ought to
be expected that c^>ngestive and inflammatory processes in the renal tissue
were almost predestined by this disproportion betw^een the size of the artery
and the amditiou of the tii^ue. Moreover, the resistanoe to the arterial
current offered by the kidney subt^tance depends also upon the reatlinesa
witli which the current is permitteil t<;j pass the ciipillaries. It ha^ Ijeen
found experimentally that within a given time more water pnjjj^jrtionatcly
can be squeezed through them in the adult than in the child. These ana-
tomical differences may therefore be the reason why renal disea^^s are so
much more frequent in infancy and childhood from all eaufies, w^ith the ex-
ception of tliat one which is reserved for the last decades of natural life,
atlien imatous degeneration,'*
Pulmonary Artery, — Professor D wight has found the origm of the
pulmonary artery at ten months to be near the top of the first intcri-ostal
space and at the same age at the level of the seoond costal cartilage. At
three years he fijund it near the lower bortler of the first spaw, also near the
lower edge of tlie second cartilage, and again at alxjut the lower part oi' the
secfjnd space. On the whole, oonsidering the great variations which ixxjur
in the adult, as retxjrded by Gibson and others, it is doubtful if there is
any essential difference at different ages. If we say that in the iuiiaut it is
rather higher than later we have stated about all that is justifiable.
Lungs. — At what age the liuigs reach their full expansion forward has
not lx»en determint^d. It would appear tliat it is not before five or six years,
and it is probably still later. As the ebest ex[>ands laterally the lungs of
course increase, aud the relatively greater size of the heart to the lung in
the infant dej>ends essentially on the size of the lungs. During the first
year of life (according to Northru|)) the alvettlar walls are thick and their
blood-vessels are held loosely. It is not until the fourth or fiith year tl\at
76
PEDIATRICS.
the proportionate adult development between the alveoli and the lMt>ndii
is attained, and the stroma has become dense and binding, restraining
the capillaries as in adult life. In infant life the underlying loose tissue
lining the bronchial tubes gradually binds tlie mucous membrane to the
fibro-muscular wall. From this time it keeps pace in its growth with the
other compact tissues, until in adult life it appears as dense fibrous bands.
During the first two years the air-cells have not attained the proportaonate
capacity which exists in adult life, and the bronchial tree is still laige in
proportion to the dilating and multiplying alveoli. Again the air-^MMB
developed from the terminal bronchi have covered themaelvi^ ^\itll a
continuous layer of flat nucleated epithelium. In its subeequent growth
in adult life it is believed that the expanding alveolus does not increji^ its
number of epithelial cells to cover the more extended wall, bat ^n mew bat
enlarges their size, and, still further, that some of the flattened t^prtheUuni
loses its nuclei and expands to form large, very thin plates, callc'^I rL^pira*
tory epithelium.
Fu). 2L
SlonmL'h, Kfuleeti, and |*aner\''a'^ At 10 months. Nnturul size, ptiett^rlitr view. S uu|rk^ the ti(»k'Vii ; P murks
the iJttiuTeas ; D, the ilutxlenum, Wjiireti Must'ttm, lliin uriJ rnivef>ily.
NORMAL DEVELQPMENT-
n
LECTURE IV.
ABDOMEN, ^ TEMPERATURE. — PULSE. — RESPIRATION. — HEIGHT. —
WEIGHT*— FEET,— BONE MARROW— SKIN,— CORD— FUNCTIONS.
— BLOOD. — LYMPHATIC SYSTEM. — URINE. — INTESTINAL DIS-
CHARGES—INFANTILE SKELETONS.— NORMAL INFANTS.— TOPO-
GRAPHICAL ANATOMY OF THE EARLY PERIODS OF LIFE.
ABDOMEN. — Liver. — The liver is, as I have told vou,
pnjpoitioo-
»
*
ately large at biitli and in early chiklhrHjd, and, as I fihall prt^rtently show
yon on the living Hubjii/t, t*an be Mt l*elow tlie edge t*r the ribs iu the
right hj^x'hondriiim, its iK>rder being ab>ut 1 or 2 cm* (f to | iuch) below
the lower ril>.
GaO-BIadder. — The fiindiL^ of the gaU-bhd(fet% ai^ording to McClellan,
is in relation to the surface of the body about that of the nintli t'Ot^tsl
airtilage near the boitler of the right rectus raus<:'le.
Spleen. — There is nothing e8|iei.nally to l*e noted in the spleen in ehild-
h(3od, as it corresjwHids in its position to that of tJie adult. Aeeonliug to
Fcwter, the spleen gnnvs mpidly in early inianey, but iu proportion to that
of the adult is tRith absolutely and relatively suMiller, It is said that tlie
spk*en when enlarged encroaches more upon the tlioracic cavity tlian in
the adult, owing to the greater resistance offered by the costo-oolic fold
of the peritoneum uj>on whieli it rests* My clinical expierienee, how-
ever, does not espt^^^ially snppjrt this view, bs in many ea^es of eidarged
spleen from varied tiuisegi which I have met iu infants it has always
seemed t<^ me that the alMloiuen was eurniat*he<l upon to a gmater extent
than iu adults, and that both the physical and tlie mtional signs of the
enlarge<i spleen in tlie thorax were relatively insignificant and often difficult
to detect.
Pancreas. — The function and tlie anatomy of thi* pancreas corrf*ijK>nd
very closely to those of the salivary glands. It is situated in front of the
first lumbar vertebra, Ijehind the stomach, and, aeeording to the variations
prodnced by age and the gnrwth of fitlier parts, lies somewhere l3etwe(*n
the undnlicns and the ensiforni cartihige.
The relative position of the spleen and poncreajs to the stomach and
dutKJcnnm is very beautifully sh*>\vn in these organs obtained at the autopsy
of an inlknt ten nioTiths ^ild, which Iat4"ly ditMl in my wards. You set* that
the spleen is behind the mrdiac cud of the stomach, and very near its ex-
tremity (Fig. 21, facing j>age T<» ; organs set^n from behind). You will also
notice how tlie pancreas extends from the spleen (its tail iM^iug iu <dosc apjXH
sition to the latter organ) along the posterior surtac^e of the stomach and
Bomewhat upward to the smaller cnrvatnrCj pairing behind the dmjdeuuiKL
78
PEDIATRICS.
and its head resting in the concavity of the duodenum. The curve of the
duodenum is also clearly shown in the s]x>i*inien.
Kidneys. — The kidneys are lobulated at birth, as I showed you in the
specimen taken from an infant three days old. (Division I., Lecture II.,
Fig. 9, page 44.) This condition continues for a long time and then dis-
appears, the lobulation being represented by the pyramids of Malpighi. A
few years after birth the position and relations of the kidney approximate
those of the adult (McClellan).
Supra-renal Capeules. — ^The supra^rcnal capsules are, as I have t<;>ld
you in Lecture II., relatively large in size, and gradually approach the
adult proportions as the child grows older.
Bladder. — ^^Vlthough small at birtli, tlie bladder soon becomes capable
of great distention.
Symington, from a frozen section which he made in the median plane
through the body of a child seven months old, shows the position of the
bladder, which happened to be dLstended. It takes up, practically, the whole
of tlie lower portion of the abdomen, an observation which at once presents
to our minds the difficulty of making a correct physical examination of the
infantile abdomen during life, unless we are sure that the bladder is empty.
The above fact was strikingly exemplified in this little girl, three yean old (Case 18),
who entered my waids at the Childran's
Case IS. Hospital yesterday. She was sent to the
hospital for an examination in reference
to the advisability of an operation to re-
move an abdominal tumor. On inspecs
tion, a rounded prominence extending
from the pubes to 8 cm. (H inches)
above the umbilicus could be plainly
seen. By palpation the tumor could be
felt extending from the right inguinal
region over to the crest of the left ilium.
The tumor was soft, elastic, and fluc-
tuating. It was evidently not in the
abdominal walls, but intraabdominal.
The child was said to have been ailing
for over a week, and to have grown thin.
She passi?d her urine frequently, but in
small quantities. Nothing abnormal had
been found on an analysis of the urine
made before she entered the hospital.
You see I have marked in black the
outline of the tumor as it appeared on
entnmco.
Suspecting a distended bladder, I
had a catheter introduced, and removed 270 grammes (9 ounces) of urine. The tumor
immediately disappeared, and, as you see, the al)domen is now soft and resonant.
Girl 3 years old. Distended bladder.
A practical lesson to be drawn from this case is, that the bladder should
invariably be carefiilly examined and emptied before diagnosticating or
NORMAL. DEVELOPMENT,
79
operating for abdominal disease. I have seen a dL^tingukhed laparotomist
neglect this precaution in a young child while operating for ap|jendioitii5,
and on o|x*ning the abdominal cavity cut direc"tly through tJie walb of
the bladder. The urine flowing out tliruugh tJie \\'onnd was the first iodi-
cation to him tliat he had failed to appi'eciate that in early life the bladder
is essentially an alxloniinal organ.
You Clin see thai many pecnliarities of the digestive tract may arise from
the causes which I have alix^ady spoken of in Lecture IL Esfiecially to be
noticin:!, however, art^ those ^vhich art> due tu the ditfennit proixntionate stages
of developmeut of tiie ])ai"ts of the gastrcMj-uteric tract at ditferent ages, and
to diUcrcnt^cs in tlieir ]x^ritoneal attachments.
Stomach. — The stomach grows very rapidly, and |jeeuliarities of shape
appear at an early age. 1 have seen a stomach of four and une-half months
which, although small, was relatively broader" than in the adult. The adult
sha[>e» however, is soon acquired. Ho%y jjermauent this may be is as yet
unsettled. Ther€* is no doubt that great diktat inn may l>e induced, and it
is highly probable that where too small quantities of forjd are givrn the
normal stomach will contract. It \b also very likely that certain shafies are
acfjuiiied at a very early peritxl. I have seen in a young child a well*
mmrked antrum pylori^ — that is^ a pouch alw^ve the pylorus, which, in ex-
treme case?, forms almost a separate chamber. It is evident that the clinical
significancie of our anatomical knowledge of the growth of the stomacli in
the first year is very gi-eat. This question of growth is, iii fact, one of the
most important fa*:4ors in the piTiblem of the sulrstitute It^xling of iniauts,
and a lat'k of its thorough comprt^hension often leads to most mifortunate
results.
Capacity. — TheiT^ ha^ been mncli dispute b& to the proper methtKl of
determining the gastric capacity during infancy. All methods of which I
know are o|ih:^u to criticism, l>ut I have found that by tH^mbining all the
methods aud making general detluctions I have arrivetl at very practical
conclusions conctTuing the size of the stomach at different ages. I Iiavc also
flinnd that my results corn:^poud elr>ei4?ly to those of* otliers who have made
c^rt^ful studies of this sul>ject, noUibly Flcischmann of Vienna, and Htilt of
New York. One of the metlirjds which I have employed has Ix-cn a f'liui-
cal one^ which I shall show you, as I hapfwu to have a wet-nurse with a
healthy babv four months old here in the ward.
[Cask 19.] The mother Ik henlthy. uiul ha.^ plenty of milk ii» h&T breftst^. Her milk is
evidently in equilibnunii utid ajj^reen wilb her litiliy, wh*i i^ di^estiug it well and gaiiiitig ftbuut
BOc.c. (1 ounce) & day. Now^ if we wish to detennine tht* gustric cApacity of an infantas
gtomacb at four montlw we can exp**rin3ent with this iiifant. The weisibt of 30 c.c. (I flmd-
uutice) of human milk iji very nearly 30 ^rummeii (1 uuiic*?). If then we iutroduee 30 e,c.
(1 ounee) of milk into ati infant and weigh it immedintely before and immediately ufter tlie
intniducUon, the infant should increa^&e 30 ^nuiime:* (1 uunce) in weight. This methfxi 1 hwve
|vri»ved a number of times to be fairly cnrPH.it, afi ynu niK^ it \a in this especial c««e (Case 19)
within four or tive ^rammea. It is well known amonjyj those who deal in cattle that when
tat cattle lire tmnsported long distances, as fix>in Chicago to New York, tbey are found ta
80 PEDIATRIOS.
have lost materially in weight, pi^rhaps thirty or forty pounds. Now, if these cattle are
allowed to fill their stomachs with water, an increase in their weight will be found oone-
sponding exactly to the weight of the water which they have drunk. I find that this in&nt
(Case 19) weighs before nursing 7080 grammes (16^ pounds). We will now let it nurse
until it evidently is satisfied, that is, practically until it feels that its stoznach is fUU. I then
immediately weigh it again, and find that it has increased to 7146 grammes (16} poundB), a
gain of 1 15 grammes (about 4 ounces). This would, in a general way, denote that the gastric
capacity of this especial infant was 120 c.c. (4 ounces).
Now, if a number of healthy infants of different ages and of average
weights are fed and weighed in this way, we can approximately by oom-
paring the gains in weight which correspond to the same ages determioe
the gastric capacity for each age. I should not, however, consider this by
itself a reliable method for determining the gastric capacity, as it is open
to many objections, which need not be discussed at present One source of
error, for instance, is the variation of the infant's appetite, which may cause
either too great distention or underfilling of its stomach. Another method
which I have used is the actual measurement of the gastric capacity at the
autopsy, with suitable precautions to avoid ovor-distention. Combining these
methods, I have arrived at certain general conclusions, whidi I shall give
you in figures. I have in this way also determined that the stomach grows
very rapidly in the first three months affer birth, grows slowly in the fourth
month, and is then almost quiescent for about two months. It then begins
to grow again until it has reached its adult size. Frolowsky's rules for de-
termining the gastric capacity' of young infants approximate in their results
so closely my own investigations that I liave prei^red from them this table
of infants' stomachs at diflTerent ages and at diflFerent periods of growth.
The tracings of the stomachs are life-size. Frolowsky shows that the activity
of the stomach's growth is very great in the first quarter of the first year,
that it is ver}'^ slight in the second quarter, and that it again shows a moderate
activity in the last part of the year. He represents this activity of the
stomach's growth by the ratio of 1 for the first week to 2J for the fourth
week and 3^ for the eighth week, while it is only 3J for the twelfth week,
3^ for the sixteenth week, and 3f for the twentieth week. As a starting-
point from which to calculate the above proportions I have taken the infants
stomach which I presented to you at my lecture on the Infant at Term as
representing a fair average capacity for this age, 25 to 30 c.c. (|- to 1 ounoe)
(page 45, Fig. 10). ^ '
This, of course, is also intended to represent an infant with the average
birth weight. This table will with its six tracings explain what I have just
said alx>ut the rapid increase in size which the stomach shows at the periods
I have mentioned (Table 15).
KOBMAL DEVELOPMENT.
81
TABLE 16.
Oastric Capaeity in the First Five Months of Life.
I.
Iniknt 3 houn old. Capacity of stomach 25 to 80 c.c. (| to 1 oance).
II.
Inliuit 4 weeks old. Stomach 2^ times larger than I. Capacity 75 c.c (2^ ounces).
82
PEDIATRICS.
Inlant 8 weeka old. 8lomach 8i times larger than I. Capacity, 96 cc. (Si oonoeay.
Infttnt 12 weeks old. Stomach 3} times larger than I. Capacity, 100 cc. (8} (xaMtg^
KOBHAL DEVELOPHKNT.
83
Inlknt 16 weeks old. Stomach 8f times larger than L Capacity, 107 cc (8.66 ounceB).
Intuit 20 weeks dd. Stomach 8| times laiger than L Capacity, 108 cc (8.6 oonces).
84
PEDIATEICS^
In comjMiriiig these measurementd with actual Btomaehs^ the
capacity as given for sixteen auJ twenty weeks b somewhat small. I
consider, however, that they are extremely vahiable tc> b€^in with, a^ it
is always better to err on the side of giving too little ChmI tbaa too much.
As ha8 been admirably iminted out by FIeii?eliniaixn, tlie gastric capacity
is grt^ater at the same a^ in the artificially -fed than in the breast-fed infanL
This obnervation, however, in all [in )l lability itnly empliasizes the impor-
tanee of bearing in mind the normal gastrie eapaeity of the different liges^
and of iLsing this kuowletlgt^ to prevent the overftMxling whieh has produced
Eo notieeable a diffen»nee Ix^twecm the ,sizt^^ of thv sivmaeh in breast-fed and
in artiticially-fed infants.
Since I liave devel<)[Md my methods of .substitute-feeding in eonoection
with milk mcKlitieatitin, I have no ii^ason to suppose that when the infant's
6t4jniach haj^ Ix^en projMiTly managed, as I ean now aeeomplLsh in suhetitute-
feeding, it is any larger than in breast-fed infants.
The cause, however, which pnxluix*.s the most imiibrm individual differ-
ence in the gastric ca|iacity at the same age is the weight of the in taut. I am
inclined from the results of my own oli^r\'ations in a oonsiderable Dumber of
Fio. 22,
BtomMCh of Inftttii 12 motith* old, niUural slae. Ga^lric eftpftclty, 90-10& c,c. Weight, 4289 miunmei^
cases to agrw with Fleisi^limann's stat^'intait, that the greater the weight the
grt^atcr the gastnc capacity. A gCMKl illustration of the correctness of this
rule has lately come under my notice, where (Case 20) a breast-fed infant of
twelve months wnth a stomach (Fig. 22) normal in shape presented a gastric
NORMA.I> DEVELOPMENT.
85
I
capacity of only 90 to 105 c,e. (3 to Si ounces). This capacity corre-
sponded te) its weight, 4289 grammes (9 J pounds^), alx>ut the avei*age normal
weight of ail infant at eight or ten weeks, rather than to its age, which in
the average infant would present a gastric capacify of 240 cubic centimetres
(8 ounces).
I have also had under my care an infant of six weeks whose general
development and weight eorres{>onded &c> closely to those of the normal
average iulkut of twelve weeks that it was sell'-evident tliat the two ounces
of fcKxl which would ordinarily have been the pi-ojMT allowance, sf> Ikr as
the age was conc'crned, wa^ not sufficient, and that its weight indicated a
gastric capacity for an allowance of four ounces, which, in fact^ it ttM>k and
digested with the greatest ease, while with any amount less than the four
ounces it was never satisfied.
It will now, I think, be instnictive for you to examine these stomachs
which i'rom time to time I have obtain wl at autopsies, and see how they aim-
pare with the measurements which I have just given you. Dr. Townsend,
who prepared mast of tliese sjiccnmens, drew my attention to the im|>ortant
fact that ID measuring the gastric eaj>acity it should be done Ijefbit* the
stomach is separated irom its mesenteric attat^hment, as otherwise it is easily
stretchcfl by the tluid introduced, and will then show a grater capacity tlian
would !x* \>ithiu the normal limits during life. I have had some of the
stomachs disteiMlecl Ijeyond their natural size in order to show you how rais-
leatling it would be to dejiend for exact residts on this method of iuveritiga-
tioo. You will therefore find quite a variety of figures repn^^enting the
gastric capacities, hut on the whole they corresjxind m> closely to the rule
already stated that they oorn)borate rather than disagree with the other
methfKls. It is interesting also t^* note the d liferent s]iaj>es which tliese
stomachs represent^ as some of them are very diflereut from the usual clas^si-
cal figures represented in books. So far as I could ascertain, these shajMS
did not occur fn>m any t^ix?*-*ial disease, such as would influence tlie outline
of the stomai'h, as has hapiiened in this s])ecimeii taken from a case of rlia-
chitis. (Page 849, Fig. 108.)
{The illustratioTis represent tlie actual sizes of the stomachs.)
Beginning with the youngest subjfxt, an infant three hours old, you see,
as I have already shown you at a previous leeture (Division I., Lecture II.,
Fig. 10, page 45), that the stomach has the average c^apacity of the new-
bom, 25c.c. (f ounce), althf»ugh the infantas weight was only 2500 grammes
{5k pounds).
Tlie next stomach (Fig. 23, page 80) was taken from an infant two and
one-half days old, and weighing 4000 grammes {Sf pounds). The gastric
capm*ity is 25 c.c. (| ount*e).
This next stomach (Fig. 24, page 86) was taken from an infant five days
old and weigliing 3000 grammes (6f pounds). The gastric capacity is
25 c.c. f g ounce).
This stomach (Fig* 25, page 87) was taken from an infant seven days
M
PfiDIA^TBICS,
old and weighing 27CN) graomieg (6| pounds). Its gastric capacity is 40 cc
(IJ otitic^).
ThfiBC four stDinadis (Fig. 10, page 45, Fig. 23, Fig. 24, Fig. 25), all
takeo from infatite witliia the first week of life, show us at once that we
Fio. 2S.
Stomacb of tnfatit 2% dap old« n&tunl sUse. Outrlc e&pftctty, 25 cc Wcl^t. 4UU0
cannot always depeud on an infant '5 weight for determining its gastric
capacity in the early days of hfe. Thus, the \veight8 of 2500 gramjBeSj
3(XKJ granmiert, and 40(K) grammes all had the i^iune gastric capacity of
25 c,c. Again, the weight of 2100 grammes;! had a greater capacit>', 40 c.c,
FiQ. 24.
Btomicb of iniiuit 6 days old, uatiuul idae. Ga«Crlc capcMzlty, 25 cc. Welgiit, 8000 KituiuiiaB.
than the weights of 3000 and 4000 grammes. We must^ however, aisT
allow that there might \w an ern>r in measuring the gastric capacity.
Do not for a moment think that I am deducing any rnle^ for growth from
NORMAL DEVELOPMENT.
Fi&. 25.
87
Btoitiiich i*f iiiCuit 7 dap oldp natuml size (pufiterlur view,) Gji.*5trtc capacity, 40 c.c. Weight. 2700 gTiuumtsk
this very limited niimljer of ea^B. You will, liowever, understand the sig-
aiiicaue'e of these figureis a little later when we are dii^:u88iiig tlie feeding
Fio. 2G,
8itff>mac!h of ttifani 12 da^ra old, ilb^wnded to hold 81) c.c Natural gaKtHt lapai'lty, 40 c.c
"of the early days of life. This next stomach (Fig. 26) is from an infant
88
PEDIATRKT8.
twelve da>^ old. 1 liave, iiiifortiinatt^ly, li^t the record of its weight
It represents very well, however, the UHiml shajie and position of the
8tj»niar»h in early \\il\ and 1 have hajtl it distended lx*yond the limit
of itri iitJFLuil aipiMity, so a^ to f^how ycm the jrreat elasticity of the vei-
tricular wall-n to whieh I liave ah'eady referrtKl. The gastric capacity
was about 4t) e.c. (IJ oiuioes). As you see it now distended, it holdn 80
CO. (23 oumx^)»
This next speeimen (Fig* 27) shows tlie stomach, duodenuna, spleen, and
pancreas of a well-developed infant five montIi» vid, VS em. (26 inches) long,
Fui, 27.
StooiAcli i>f infiint 5 munths obj ^fpofrterlflr view). Weltfht^ <5flO0 ^nunineA. DIJltenfted l<> hold 225 cc
Nuttiml gmlTiii cApacit}', liU c«,c, S murlw the wpletm ; P th« iiiajct«ft8 ; D the duodenum.
and weigliintr by estimate about 6CMX) grammes (13 {xiunds). Its gastric
capacity was abrnit 120 c,c. {4 ouncx^). I have had it distended so that it
now holds 225 cc. (7} orinccfl).
StomAch of infitiiL T months old (pn^terior ri^w). \Vt;ighl, iyJ^H} ;KrnimniB& (%l% iiuiiiids). Ite gistiie
CApaclty was Aditiii im U.C, (5ouiic'e«i), but It hiu^ been dl^itetided to \m\ twioc^ itKsi«c nnd qow hold<30()
I
NORMAL, DEVELOPMENT.
89
I
I
I
I
I
I
Tins next stomacb (Fig. 29) came from an infant seven months old and
weighing 5500 grammes (12 pounds). Its capacity is 220 c.c. (7 J ounoes).
Tliia stomach (Fig. 30) was taken from an infant nineteen months old
and weighing 6270 grammes (13} pounds). Its capacity is al^out 300 e,c.
(10 ounces).
I wish yon to understand that I do not make any definite deductions from
the last four cases. The stomat^h at nineteen months is especially unreliable
as to its capacity. It was very distensible, and could easily by the mere
weight of the water be made to hold 450 to 600 grammes (15 to 20 ountx^s).
It gives, however, a very iair idea as to how the stomach looks at this age.
This seven-montlis' stomach {Fig. 28, facing jmge 88) in its cajjiicity corre-
sponds to the weight, which is tiiat of an infant of four montlis, while this
other sevcn-mooths' stomach (Fig. 29) seems in its caf>aclty to corres|>oiid
to the infant's age rather than to its weight, which is that of the average
infant at four months.
I have now treated this question of ga«^tric capacity by the more exact
methfKls of weighing and cai-eful calculation, and also by the nsually inexact
metbxl of direct measurement. Both methrKis, however, result in a general
uniformity of figures and give us very fair data by which we can be guided
w^heu we come to the question of infant feeding.
It will be seen that the general principle of activity of growth is well
represented in these figures.
The gastric capacity, however, in the third, fourth, and fifth montlis
may api>ear rather small, and considerable differences will arise in the
measurements of different observers. This, however, only impress^ on u&
tliat we liave not yet solved the problem of gastric capacity by any system
of measurement. When all observers have agi-eed to make uj^ of a mathe-
matically precise and constant pressure in measuring the stomachy we may
possibly arrive at more uniform i-esults. Even then the degree of elasticity
will be found to ditler so greatly in the individual stomach that most diverse
measurements will result
There is no doubt that the value of these calculations lies in making us
recognize evident changes in the activit}" of growth at certain |ieriods ; in
making us allow that great diirerences arise irrespective of age and weight;
in impressing us with tlie fact that the gastric eapaeity has been < iver- rather
than under-estimated, and in eniuieiatmg that more exact clinical ol)S4^rva-
tious should l>e em|>loywl to reinforce our anatomical and jvhysiologiwd data
During the last two and a half years I have been euableil through the
aid tjf a milk ]abt>ratory to adapt exactly to the apparent needs of the
infants under my care, as well as to their agi* and weight, the amounts of fotMl
on which they have seemed to thrive. It will l^e interesting and inxStructive
to compare the following table with the figuiTs and calculations which I
have just shown to you, and thus see if my practical clinical results have
corresponded to my experimental deductions.
The following figures represent tlie average amounts of fix>d taken at
90 PEDIATRICS.
different periods during tlieir first year by three hundred and forty-one infiEUitB.
Tliev were all well and strong, of average weight, and all were thriving and
steadily gaining during tlie year. Tiiey received only stated amountB of
food carefully ordered by prescription at the Milk Laboratoiy, and were
watchctl witli the greatest care to see when they evidently were hungiy enough
to have the total amount of tlieir food increased. Of course the opportonily for
exac^ work is almost unlimited where one has a milk laboratory at his com-
mand, and it has therefore seemed to me that this method of determining the
gastric capacity is an unusually good one, and one which has never thoroughly
been carried out before. Before showing you the table of the general averages^
I will pick out one case to explain the significance of the general figures.
This infant (Case 21) was fed with the greatest care both as to the
quality and as to the quantity of its food. The following figures represent
the amount of food given at each meal from birth to ten months :
TABLE 16.
Amounts of Food in an Especial Que.
Cubic Centl-
^*®- metTOB.
Birth 80
4 weeks 45
8 weeks 60
12 weeks 75
10 weeks 90
20 weeks 182
ThLs case shows the necessity for frequent and great increase of the total
amount in the first four or five montlis, the comparative quiescence of growth
in the sixth, seventh, and eighth months, and the increase again in the ninth
and tenth months. It does not, however, correspond so closely to my pre-
vioiLs results as does this table, where averages taken from the three hundred
and forty-one cases already referred to are given.
TABLE 17.
Three Hundred and Forty-One Infante fed at the Milk Laboratory.
Number of Cases fbr Avenge Amount of Ibod at
Age. each Age.
Birth 45
4 weeks 76
8 weeks 84
12 weeks 97
If) weeks 87
20 weeks 86
6 months 78
7 months 66
8 months 54
9 months 45
10 months 33
11 months 28
In this table the same infant has of course been recorded a number of time* at dif-
ferent ages.
Ounces.
Age.
Cubic Gentle
metres.
OanoaL
1
6 months . . .
.... 160
6
^
7 month! . . .
.... 160
6
2
8 months . . .
.... 160
6
2J
9 months . . .
.... 196
6>
8
10 months . . .
. ... 240
8
4J
C.C
Ounoai
29.4
0.98
70.6
2.86
96.6
8.22
118.8
8.M
187.0
4.67
158.4
6.28
171.8
6.71
186.4
6.18
208.6
6.06
226.2
7.64
288.8
7.89
242.0 .
8.07
KOBMAL DEVELOPMENT.
91
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I
The whole quesstioti of gastric capacity is bo closely connected with the
subject of infant feeding that I shall leave it for the present, and speak of
it imwv in detjiil later, Avlien it will be seen to he of infinite importance in
oitr attempts to regulate the substitute feeding of infants.
Intestine. — Small Intestine. — Daring the first month after birtJi, it
may be reckoned that the small intestine will graw about two feet (about
sixty -one centimetres), and a like rate of growth may usually be recf»rded
at the end of the second month of extra-uterine lite ; but atler that jieriod
it^ development proceeds in a most insular manner. Thus, in a child
of one year the small intestine measured eighteen teet (alx»ut five hundred
and forty-nine centimetres), while in another, aged two yeai'Sj tJie length was
only thirteen feet eight inches (four hundred and seventeen centimetres).
Again, in a child aged six years the small intt^tine was no k^s than twenty-
one feet (aljout six huudretl and forty and five*tenths oentimeti'es) in length,
while in another child, eleven years of age, ite length was fourteen feet
(about four hundred and twenty-se^^en centimetres).
I agree witli Mr. Treves that the great variations which a(>j»ear so early
in the length of the small intestine Ix^ar no relation to the growth of the
chikb They probably dej>end on the diet. Not only the quantity' but the
cjuality of the ftxwj i^ an important factor in the growth of the intestine.
The amount of residue, also, and the more or less irritating qualities of the
ibod, must all have their effect.
As to the internal struetui*e of the small intestine below the duodenum I
can only say that I c<jntirm the view now generally ac<]'e|)ted, that Peyer's
patches are found very early, I have seen them at three days and again at
thiitcf^n days.
In another case, sixteen months old, Peyer'a patches were fouud, and one
of tliera was five inches long.
Large Intestine. ^ — Treves has also ol:)ser\'ed that up to three or even
four montiis the length remains the same, but that nevertheless a remark-
able change occurs. This is that the large intestine grows at the expense
of the sigmoid flexure, which at birth is nearly one-half of the large intes-
tine, while at four months it has assumed about its ]>ermanent proportion.
Treves found the large intestine to measure at one year twH* feet and sLx
inches {about seventy-six centimetres) ; at six years about three feet (about
ninety-one and five-tenths centimetres) ; and at thirteen years alxnit three
feet and six inches (at>out one hundred and seven wntimetres). I find
among my notes the following measurements of the intestine.
TABLE 18. (Dwight.)
Sex. Age. BmjiU Intestine. Luk^ Intestkie^
Girl 18 days, 292,9 cm. 4«.5 cm.
Girl 10 monthi. 670.0 cm. 78.0 cm.
Boy 10 inontbs. 4^5.0 cm. 90.0 cm.
Girl 3 yeaiH. 490.0 cm. 84.0 cm.
92 PEDIATRICS.
Ooecum and Ascending Colon. — In about thirty-five observatioiis on chil-
dren under four years of age, most of them new-bom infantB, the ceecum
was found in about thirty cases to range from the right lumbar r^ion to the
lower part of the iliac fossa. It was very frequently found at the. junction
of the rather vague lumbar and iliac regions. More or less would usually
be found between two parallel horizontal lines, one at the level of the highest
point of the crest of the ilium and the other at its anterior superior spinous
process. In five cases the caecum was either in the right iliac fossa or over
the true pelvis, the fact being that it was so free as to have no fixed habi-
tation. It is comparatively recentiy that the truth has been recognized in
America, England, and France that normally the caecum is at every age
completely invested by the peritoneum, and that the idea that a large part
of the posterior surface rests on areolar tissue without any intervening
serous membrane is baseless, except in rare instances.
In young children the ascending colon difiers in some respects from that
of the adult. Owing to the high position of the caecum, to say nothing of
the relatively greater size of the liver, it is very short There is no ques-
tion that the ascending colon much more frequently has a mesentery than
in the adult, and also that a relatively larger portion of the part above
the caecum is also invested with peritoneum so as to be absolutely fiee.
More than once Dwight has seen the caecum and a large part of the ascend-
ing colon in this condition. As to the question of how frequently more or
less of the back of the caecum may lack its peritoneal covering, in which
case of course it is bound down to the parts beneath it, Dwighf s observar
tions are rather remarkable. Treves in his Hunterian Lectures stated that
in one hundred observations he never found the posterior peritoneal covering
wanting. Tufiier examined one hundred and twenty subjects, adults, chil-
dren, and fcetuses, and found the posterior surface uncovered in nine, all
of whom were old people. I have kept no systematic record of Professor
Dwight's observations on adults, but have the following report of thirty-
seven young children. In thirty-three the caecum was completely invested
with peritoneum. In four children, all new-bom or only a few days old,
the whole or a large part of the back of the caecum was without peritoneum.
Considering that this condition is much more likely to occur in the
adult, and that, so far as we know, no one else has observed it in the infSmt^
I am inclined to think that Dw^if^ht's large number of cases (four out of
thirty-seven) must be considered an accident, such as is liable to happen
where a series of observations Ls small. Professor Dwight believes that the
caecum of the infant and that of the young child are much more movable
than that of the adult, and are also usually situated higher.
Vermiform Appendix. — The length and direction of the vermiform ap-
pendix are very variable. I have found it six and a half centimetres (two
and five-eightlis inches) long in a girl of thirteen days, five and three-tenths
centimetres (two and one-eighth inches) in one of three years, eight centi-
metres (three and one-quarter inches) in one of ten months, and seven and
KORJtAL DEVELOPMENT.
93
^
N
a half ceotiraetres (three inches) in a girl eleven weeks old. The vermi-
form appendix in the first of these cases was m peculiarly plat^ as to
describe a few words? of description. Only a small part was free, the rest
btiing held by a small mest^nterj^ to the cteeiim and the a^wx^ndiug et^lon. It
arose from the posterior side of the caecum, and ran backward to alx>ve the
crest of tlic ilium^ where it entered a little i»eritoneal [xiuch in the nnr wall
of tlie abdomeu, and then, turning on itself, ran forward again. The en-
tranoe to the pouch was guarded l>elow by a semilunar fold of jxritoneum,
with its cavity looking upward. It would apjx'ar from Tre%'^eri\s rcsciirche^
that the ftetal shape of the cfeciim is that of a jx^ueli hanging dnwn fr<un the
|>oint of junction of the small and the large intt^tiue and continued into the
, api>eiidix, which grows symmetrically from the middle. Later, however, an
I irregular growth of one side of the oecuni generally h?aves the origin of the
ap|>endix neiir the end of tlie ileum. Dwight has ibund that this condition
usually prevails in the child. The position and direction of the a|i|)endLX
are most uncertaitL It is, however, I Ixdieve^ as a rule, on the jiosterior side
I of the Cfet*unu Its little mesentery |miss€!S to its iM'giuuing from the ciecum
and is only exceptionally attachetl to the walls of the alxlomen or pelvis.
The ira]>ortanw of the lymphatic glands alx>ut the caecum as pissible
starting-poiuts of iuflaniination is very great. Tuiher states that the lym-
phatii^ of the front of the c«ecum f^tllow the anterior ileo-<]^ecal artery to
empty into two glands which he has found coustiuitly in the snperior ileo-
OBBcal fidtl, and whi<'h are very distinct in the child. The {x>st*^rior glands
are a!sf> fiiund constantly on the jMistcrior and inner wall of the ctecum itself
Ijerjeath the peritoneum. They usually form a group of frt>m three to six.
fSitjmoid Fkxute, — D%vight's observations on the sigmoid flexure in in-
fancy show much divei^ity. In some aLsc^ it is obviously very long, in others
apparently of about the adult projKvrtious. iis he has made awnirate nieasui^>
ments in but few cases, I hf^itate tn make precise statements, but very fre-
quently even at biith there was no evident departuix.- from the normal adidt
proportions. A difficulty in this inquiry, which, however, is in itself an
important |M:*int in anatomy, is to dcr-idc when* the descending c( don ends and
tlie sigmiad flexure Ix^gins. Thus, in a girl of ten months the first impression
wa^ that the latter was not ivlativ(4y longer than in the adult ; but it was
fimnd later that what must W adlttl the descending colon proper was very
short, ending alMive the top of the ci\^t of the ilium. This jKirtion, a little
over an inch in length, had a retro-jxritoneal snrfa«?e. The mesentery then
began, and was attachetl nbliquely across the psoas down to the front of the
cum, where it W^ame the mes^j-reetnuL Thus the greater part of tlic d**-
ading ixdon formtHi one loi>p or series of folds witli the sigmoid flexure ; aud
this is by no means the only time that Frof*?89or Dwight has |¥jinted out tliis
^K arrangement, This loop which I luive just descriUxl was als^^j fiiund to \>e very
^m movable. The greatest brejidth of the mesentery' was four and eight-tenths
^m oentimetres (al>out two inches). In another child of the same age it was seven
^ ceutimetreg (alxiut two and seven-eighths inches). I am inclined to think that
94
PEDIATRIOB.
even in infants, in whom the sigmoid flexure does not, as a role, seem laiige, it
often has a relatively broad meseuter}% allowing free displacement. In two
children of three years the sigmoid flexure did not seem to exceed the adult
proportion.
Descending Colon, — As is well known, the descending colon usually has
no mesenter}% but still one is often found. Lesshaft;, in his observations
made on subjecte of many difl*erent ages, found it once in six times. Dwight,
in rather more than twenty infants, found a mesentery to the desoendiing
colon in about half the cases. It is remarkable that Lesshaft found a mes-
entery less often in young subjects than in others. I find that a great part
of the large intestines in infants is less fixed than in adults. I unfortu-
nately, however, have not had at my command sufficient material to enable
me to say when the mature condition is reached.
TEMPERATURE. — The temperature of the infant at term, although
varying within a slight limit, is usually slightly raised. Very soon, how-
ever, as would be expected from the tax which is immediately made on its
vitality by so many new surroundings, the temperature falls rather below
the normal adult standard. In about a week the normal infant has recov-
ered its equilibrium, and, if its nutriment has also been properly adapted to
its digestive peculiarities, it usually presents the average normal adult tem-
perature, 36.8° C. (98.2° F.).
TABLE 19.
Temperature of In/ant ai Term.
At birth 87.2o C. (W P.)-
Within an hour 86.1°-86.6» C. (97«-96o F.).
In about a week
86.8° C. (98.2« P.).
These figures are the average of a large number, and are subject to great
variations, as is seen on comparing them with a number of obeervatioiis
undertaken at my request by Dr. C. W. Townsend at the Boston Lfjring-in
Hospital :
TABLE 20.
Age.
Iday .
2 days .
5 days .
5 days .
6 days .
7 days.
7 days .
7 days.
Townsend' s Temperature Obaervationa,
Temperature.
87.2° C. (99° F.).
87.8<» C. (99.2° F.).
86.60 C. (98° F.).
87.60 C. (99.5« F.).
87.8«C. (99.PF.).
87.5° C. (99.5° F.).
87.2° C. (99° F.).
87° C. (98.5° F.).
Age.
9 days
9 days
9 days
10 days
18 days
18 days
16 days
20 days
TempentOTO.
87.40 C. (W.4- P.).
87.1* C. (OT.8<> P.).
86.9<» C. (OT.4<» P.).
87.1*0. {W.e9 p.).
87.2« C. (90O p.).
87.80 C. (W.20 P.).
87.80 C. (W.20 P.).
87.8° C. (W-20 P.).
PULSE. — The pulse in uterine life is, as a rule, somewhat higher in girls
than in boys, the former being about 130 to 140, and the latter 120 to 130.
Anything over 130 points towards the female sex, but these fignres aa
»
NORMAL DEVELOPMENT. 95
of distinguishing the sexes before birth are not to be relied upon. At birth
the pulse 80t>n falls somewhat, and, as I have alr^dy told you, may be quite
int»gular. This, as a rule. Is merely what we should ex|.>e(?t would Ix^ the
result of the sudden and great change which has taken pla*:xi in the eireida-
tory mechanism, and of the additional force which the heart is calkxl ujj^ju
to supply when it becomes the et?ntral station from which the blocnl is pro-
pelled. The limgs also are scarcely i-e^y to perform at once their fuuction,
and are often somewhat more of an obstruction than an aid to the blood-
current. The puL?e in early life, especially during the first year, varies very
muehj but, as a ride, allowing tliat the girls i>ulse is usually rather quicker
than the tx>y*s, the following table represents pretty well what you may
expect in males,
TABLE 21.
PuUe- Rate fur Mates,
Agt. pQUft-Beiliperllliiiiteb
Ettrly weeks 120 to 110
Until 2d year . •, , 110
2 to 8 years * .100
6 to 8 years 90
From the eighth ye^r up to puberty' the pulse gradually ac^juires the
adult rate. The pulse in children varies greatly under the many nervous
influences which are continually atfec^tiug it in eaidy Hie.
Dr. Towusend has aim made a record of the pulses taken in the same
infante whose teinjM.Tatui'cs were recx)i'de<l in Table 20. The}% as you see,
do not esp^x'ially corres(K)ud with the geneml averages of Table 21, but are
what you may ex[)ect in the cases which you happen to see at random*
Cliniciilly I have never arrived at very satisfactory results in my obser-
vations on the pulse in infancy. If, however, you care to investigate thl^
subject more thoroughly, I will i-efer you to the excellent work done on the
pulse by Keating and Edwards.
TABLE 22.
H Ag^ Qolfll Cryiag.
m Iday , . 180 168
■ 2 days . . 120 166
■ 6 days 162 164
H 6 days 160
H 6 days .....*«. 162
■ Tdaya 120 154
H 7 daja . 160
H 7 days 152
■ ©days 148
M 0day8 160 180
H 9 days . . , , 166
" 10 days 152
18 days IStt
■ 13 days 168
■ 16 dflvs 168 172
20 days . ............ 168
96 PEDIATRICS.
BBSPIRATION. — ^The respiration, although quicker in early life than
in adults and corresponding somewhat to the pulse, assumes the equilibrium
of a later period of development much earlier than is found to be the case
with the pulse. It varies with changes of temperature and with excitement^
and has its rhythm much more easily aiiected by diseased conditions than in
later life. This table represents fairly well what you will usually meet with
on counting the respirations when a child is quiet.
TABLE 28.
JUspirationa,
Age. BflqjizatSoofl per Mlxratei
At birth 46
Until the 8d year 16 to 40
8 to 6 years 26
I should now like you to notice closely this infant (Case 22) which is
Ijring quietly in the nurse's lap.
It is a male, eight months old, and healthy. In the first place, you see that its type of
respiration is decidedly abdominal. Counting the respirations by the rise and fkU of the
ensiform cartilage, which stands out quite distinctly in this case, I find that they vary from
£0 to 70 in the minute. They are also, as you see, quite irregular, and by making^ with a
pencil an upward stroke for every inspiration, a downward stroke for every ezpirmtion,
and a horizontal line for every pause, you will find somewhat the same lack of rhythm that
appears in the infant at term, which I described to you in this way in a previoua lectuxe
(Lecture II., page 48), and also the rhythm corresponding to that of the in&nt nine months
old which I have already shown to you (Case 17, page 72).
Dr. Townsend has also observed for me the respiration of four caaes at
the Lying-in Hospital, with the following results :
TABLE 24.
1. Age, 1 hour Respirations, 48 to 66. (Awake.)
2. Age, 2 days " 80 to 52. (Asleep.)
3. Age, 8 days ** 24, 82, 44. (Asleep.)
4. Age, 6 days ** 28 to 40. (Crying.)
The respiration in all these cases wa.<^ very irregular, and both abdomi-
nal and thoracic in tyiK?. In the baby two days old the respiration was
chiefly alxlominal.
HEIGHT. — The average height of the male infant at term, I have
already stated, is, according to a large number of measurements made by
Quetelet, Vierordt, and others, alxmt 49.5 cm. (19| inches). These figm!e8
wrrcspond very closely to those wliich I have met with in quite a number of
infants whom I have myself carefully measured. Insufficient nonrishment
and improper food, especially as represented in rhachitic children, seem
to retard the growth, wliile, on the contrary, the various fevers seem to
increase the activity of growth in length, while decreasing the total weightb
In the first three or four months the growth is proportionally rapid to that
in the latter part of the first year. In like manner the activity is greater
in the first month than in the second, and in the second than in the tfairdy
becoming still less in the fourth, fifth, and sixth months.
NORMAL DEVELOPMENT.
97
The average increase for the fir&t month h about 4.5 cm, (If in.).
" *' ** " ** second month is jtUmt iiJ* *'iiu (H in.).
** *♦ •* *' •• thir<l to the tlJltt*nth tnonth ij= about 1 to Locm. (j to J in.).
" " ** ^* *' flret year is about 20 cm. (8 in, ).
*♦ " ** *♦ ** Becond yetir u about 9 cm. (8J in.).
'^ '* " ii n tbiiid j^ear is about 7.4 cm. (3 in.).
** •» ** ** fourth and ttlltb yvar« lA alK*ut ri 4 cm. (2| in.).
» '* " •* '* fifth to the fourteenth )*ear U about 'i cm. (2| in.).
I
I
I
The height Is almnt cloiibltxl in the first six years, and at fourteen years
the final hei^dit has tidnally l>eeLi attained to within ak)nt t*ne-t\veUlh, The
height at ditleix^nt ages will Ix^ shtiwn io eomparison with the weight in
Table 27 (page 104), when we am t^onsideriug the question of weight. The
growth in heigltt seems to \ye most iietive in the spring.
WEIGHT, — We now e)ome Ui the subject of weight in ehildmn, tlie
gtiidy ol* whieh has deser\*edly attraeted considerable interest aiid 8<*ieatific
researeh. In cjiilte a nnmWr t>f ea**es it has b*\m fijuntl that the aii*efnl and
systematie weighing of infants gi%'es ns warning of the aj>pn>aeh of disease
iome days before any other symptoms are evident. Tins point was very
clearly illnstratcxl in a ease whit^li wa^ rinder my eaix* at the Infants* Hos-
pital, and to whieh I shall refer in a later leetnre more in detail (Case 279^
page 627), This infant entered the hospital to have its ftxid regulated.
It was appartHitly [>erfeetly well, l)nt after a few days the daily weighing
showed that it was losing. This los.s of weight continued to loe the only
peri-eptible symptom for a number of days, when it manifeste<:l tx^rtain
nervous phenomena and died a few days later of cen'bmi thromhosh. We
sometimes notice a loss in weight pre<*eding a chronic nutritive disturb-
ance l>y several wc*eks, and if the coming disi^ase is an arute (tne, or is of
unusual severity, the loss is often sudden and gi-eat You will therefore
reatlily nnderstand that the earefnl and systematic weighing of children maj
l»e of considerulde value in preventive mwlicine. Tims, it' we have nt*tieed
that a child has without perceptible caus<^ lt>st weight, we can, by guartli ng
it friini an ex|M>snre which in health would nnt 1m* too great, pivvent it tW>m
having eomplieations such as of digestion or fri>m cold, and render the c*uning
disease milder in its tyjx^ and more readily dealt with. In a ptiiXT on the
Relation between Growtli and Diseast*, by Pn>fess(jr H. P. Bowditch, these
c4ianges in weight am (*s|M'ciaUy dwelt np"*n, and it is a[)pamntly shown that
this metluxl of determining tlie onset of the ilis^^a-^c is more useful in chn>nic
than in acutc^ diseast^ , though even in the latter class it is not im|»ossible
that the warning may be given in time to he of use, and to merit the term
of "danger signal*' wliich has Ix^en given to it by TV. Peny Bolton. Ii<iw-
diteh shows in this interesting table (Table 25} the rate of gniwth of a
girl between two and thrt^* years old, and the relatii*n between gniwtli and
diseafie. The tigiu'cs repi^esent the absidutc weight *if the child obtained by
weighing in tlie cutlinary manner, and then deducting the weight of the
clothes*
98
PEDIATRICS.
TABLE 25.
Datk.
i Age. ill
1880.
September 19
October 8 . .
NovemlHjr 7
l>eceiiiber 5 .
DiHJeinber 12
DweinWr 26
1881.
Januarv' 2 .
Januury 28 .
Januur^' 30 .
Fel>nia*ry 6 .
February 13
February 20
February 27
March 0 . .
March 13 . .
Man'h 20 . .
March 27. .
April 3 . .
April 10 . .
April 17 . .
April 24 . .
Mavl . .
May 8 . . .
May 15 . .
May 22 . .
May 29 . .
107
100
114
118
119
121
Weujiit.
Kilo.
11.40
11.40
11.78
12.25
12.28
11.90
Lbn.
25.08
25.08
25.91
2«.95
27.01
20.18
122
12.15
125
11.80
120
11.05
127
11.5;3
128
11.55
129
11.96
130
11.75
131
11.94
132
12.15
133
12 20
134
12.41
135
11.91
130
11.71
137
11.98
138
12.00
139
12.03
140
12.01
141
12.34
142
12.15
143
12.09
26.73
25 90
25.r»3
25.41
25.41
20.29
25.85
20.20
20.73
26.84
27.30
20.20
25.70
20.35
20.40
20.47
20.42
27.14
20 73
20.00
Enlai^ed cervical glands noticed Februaiy &
Clay-colored dejections Febniary 12-15.
Attack of measles beginning April ft.
Cold in the head beginning about May 22.
An examination of this table shows that the child, having grown rapidly
during the autumn, suddenly, and witliout any manifest cause, began to lose
weight about the middle of December. This loss of weight was irregularly
progressive until February 6, when an enlargement of the cervical lymphatic
glands was nottnl, followed a week later by clay-colored dejections. These
symptoms yielded to appropriate treatment, and the child again gained weight
rapidly until March 27, when a sudden loss of weight occurred, followed by
an attack of measles. A sul)seciuent loss of weight in May seems to have
l)een associated wnth a rather s(»vere cold in the head. We have kere, then,
a case in which a disonlcr of nutrition manifested itself by enlaiged glands
and by clay-<x)lored (lLscharg(»s, but in which these symptoms were preceded
for several weeks by a progressive loss of weight. It seems not unreason-
able to sup|X)se that this loss of weight was the first symptom of a disturb-
ance which aftenvards manifested it.s(4f by more unequivocal signs. Even
in the case of the acute attack of measles it will Ik? noticed that the loss of
weight preceded by at least a week the actual eniption of the disease. You
must not, howTver, supjK)se that loss of weight in a growing child is in every
instance? a precursor of actual disease. The weight of a healthj child is
liable to oscillation within limits which have not Ix^n accurately determined,
but it may sf)metimes amount to ten or fifteen j)er ct^nt. in a week. Children
NORMAL DEVELOPMEKT,
I
I
lose in weight and rt^^ain their loj^ in a wouderlul manner, so easily are they
affected by even slight physical disturbanees, and go great are their recu-
jierative }K)wers. The weight of tK>vs, a8 a rule, m 8<>me\vliat greater than
that of girls at birth, and n^mains greater up to the age of pubeily, whf n
tiie girl mpidly overtakes the bjy, surpasses him, and hecximej? a developed
woman very soon, while the boy does not become a man until some years
after pul>erty. This tat*t you will see exemplified in the table (Table 27,
page 104) which I shall presently show yon, and whieh sliows that the
girls have surpassed the boys in their height at the eleventh year, and
in their weight at the twelfth year, when they are found to l>e taller and
heavier than the boys, vu< is the <'ase alsj in the thirteenth and the l(>ni*teenth
year.
The systeinatit* and fmpient weighing nf infants during the first year of
their lives I wnsider t*i l)e of grt*at im|x>rtan*^e, and fiir movQ useful as a
means for determining their nutritive eomlitinn than any other one method
which we know of. For many yeai^ I have had the infants at the Infants'
Hos]>ital weighed every ilay as regularly as tliey are led, and a glance at tiie
column containing their weight*^ in the various weeks and months givee
information as to their general health, and serves as a guide to tlie changes
whic^h it may be net*essary t*» make in their f()od. The information gained
in this way is i'ar beytnid what tlie most eareinl physical examination tM>uld
disc^lose. The w^eight is, in fact, an index of the nutritive processes to such
an extent that it is repivsentative of the child's well-Wing, while the height
gives us intormation nitlier as to its cellular activity. 1 have already stated
that the normal average weight of cpiite a number of infants at term is for
males 3250 grammes {1} jx>unds), and for females 3150 grammes (7 pounds),
and I have also stated that many individual cases occurred where the weight
was either greater or less than these figures, and yet the infant was healthy.
The inert*ase in weight is in direct proportion to the original weight, and if
the original weight is small the gain is usually cx)rresj>ondingly small. This,
however, is only a general rule, tor at times I met:*t with infants of light
weight whose gains are remarkably large, and ollen surpass tliose of infants
with a heavier initial birth weiglxt. During the first three or four days of
life there is usually a ktss in weight, antl the original weight is in a large
nnmlK^r of cases regained only in the second week. If it is not regained by
tlie third week, we should cousider that if is a warning that the nutrition of
the infant is at fault, and that es|)eeial measures shtiuhl Ix^ taken to increase
its vitality. This initial loss of weight is iL^^ually dt*signated as phifftioimikftL
Wc must not, however, be misle<l by this term, or |jlnce t<K> much ixmfi-
dent^ in it, fi)r, as a rule, this initial loss, which oOen amounts to fn>m 270 to
300 grammi»s (9 to 10 uunees) can Iw jux'ountai fiir oidy partially by natu-
ral physiologiad t^auses, "Ilic additi<)nal loss is evidently path<»h>gical, and
b to be so regai-detl, in oi-dcr that we should (^ndeavor to obviate it, and
tlms prevent im|K»sing an ad4litional tax on the infimt's vitality at a time
when any tax whatever should be regarded as serious. Dr. Townsend has
100 PEDIATRICS.
made some interesting investigations on tliis loss of weight at the Boeton
Lying-in Hospital, which show that the infants of primipane lose about 45
grammes (1^ ounces) more than those of multi|)ara; also, deducting 45
grammes (1^ ounces) as the average loss from removal of the vemix caseosa,
tlie meconium still remainmg, tliat the loss in weight is reduced to 247
grammes (8} r)unc(>s) in the infants of primi|mne, and to 222 grammes (7|
ounces) in those of multipara. The whole k>ss should include the meconium,
which is computed to weigh about 60 to 70 grammes (2 to 2|^ omioes), so that
a loss of from 90 to ]')() grammes (3 t4> i> ounces), which includes also the
urine, on the first day, can, in a ver^' general way, be admitted to be purely
physiological. Dr. Townsend's figures also show that although the infants
of primiparse los<» more and are slower to rt»t»over the loss than are those of
multiimne, yet after the second week they overtake and keep pape Mrith the
latter. The whole (juestion is simply one of nutrition, it being well known
tliat the milk of primi])ane is somewhat longer in acquiring its equilibrium
than that of multi])ane, but that finally it is ecpially nutritious. It was also
found that the presence of the colostrum corpuscles in the milk had some^
thing to do with the k)ss or with the failure to gain. Where the colostrum
persisted the infants lost more than when it s]x>iHlily disappeared. The colos-
trum should normally disappear in the first week. Where its presence is
prolonged into the third wei'k, the infants do not thrive. Townaend cites
three cases at the hospital illustrating this ]K)int : all the mothers seemed
healthy and had plenty of milk.
(1) Multipara — no oobxptruni on third day, — infant's logs 8 ounces.
(2) '* ^•oliMitnnn until ninth day, — infant's loss 16 ounces.
(3) Primipnra— colostnnn until thirteenth day, — infant's loss 14 ounces.
The average loss in five infants of multiparte where the colostrum was
absent by the fifth or sixth day was 10 ounces.
I am indebted to Evetsky and Foster for much valuable information on
this subject, and (juote freely from their writings. The whole nervous sys-
tem of the young child is much more active and excitable than that of the
adult. The brain, for instanw, besides lx»ing fifteen times as large propor-
tionately in the infant as in the adult, incrt»a»^<»s with much greater rapidity
up to the age of wvcn years tlian at any other ix?riod. In connection, prober
bly, with the constructive lal)ors of th(» gmwing tissues is the activity of the
lynijJiatic system. The absorpti<m of oxygen is said to be relatively more
rapid than the pnKluction of carbonic acid, — that is, there is a oontinued
accumulation of c»])ital in the form of oxygen-holding compounds. The
fbixl represents so mu(;h ]x)tential energy, but it must be converted into tissue
before the energy can become vital, and in such conversi(m a large amount
of molecular energy' must be ex])ended. The metabolic activity is more
pronounced in the infant than in the adult, and is exi)ended not so much on
tlie energy required in the external world as for the raj>idly increasing maas
of tissue. Another reason for the presence of mon? active metabolism in
NORMAL DEVEIXjPMENT.
101
I
the infant than in the aduh is the necessity of mjikl molecular hiterehange
to k€K?p up the temj>erature. The infant having? the smaller body, and yet
tlie it'latively lar^r siirfaee (the extent of skhi tliiis \wm^ proportionately
greater), it lost^s more heat prf>])oilioiiately than diK^s the adidtj and tliiis
suflers more easily from changes of tem{>eratiire.
Distnrbanees of the nutritive pmeessos fmm these conditions very easily
arise, and the pnx'ess of assimilation is much more imj^Mirtant than io atlult
Hie, for the ehild's at'tivity implies a greater e*jnsumption of nutriment in
the form of WmkI or tissue. The child^s equilibrium is thus much more
easily distnrlM^d than the adult's, aud this creates a greater susoei>tibinty to
disease aud less jiower to resist external influences. This is well exempli fitnl
by the rule that the younger the individual the greater the mortality. There
are three timis as many deaths in the lirst lialf of the first year as in the
second half, aud a large pr4jp<>rtiou of those dying in the tirst half year die
ill tlic Hi^t mcmtli. Of those dying in the first months death oetuirs in a
larg<' projKirtion in the first week. A tHnisideral>lc nnmlxT of tlie deaths
whieh occur in the early weeks of life, esptrially in the first wet^k, are fnjm
a'^thenia. These fac-ts are very signiHcant in o^nnewtion with the child's loss
of weight in tlu' early days <»f life over that which we liave just descrilz^ed
as Ix'ing physiohigicai. Lack c>f sofHeieut nourishment and an unstable
equilibrium are the factoid in the pnjblem which represent this early loss
of weight. These eonditioos are euhaui'ed by the state of the mother,
who, exhaust*^! by the pn>eess of lalKir, Is not alile to supply a food for her
infant whtcli is adujiti^l to its sensitive and iuctKupletely develojjed digt?s-
tive function.
In addition to these manifest causes for loss of weight, we must ivinsider
tluit the new-lx>rn infant is much more snsc^eptible to external impressions
than when after the first weeks its various fimctions have become adapted to
their new surroundings.
The whtiic system is stimulatt^d to greater activity of tissue interchange
not only by the sudden change of temperature to which the akin is exixisc^:!,
but also by the change fnmi darkness t^* light, and from silence to a greater
or less dt^gRH? of s^umd. This transient ii^rly period of life, tlicrefon^, ig
markt^l by a su[M'raetive metalKilism, insuftieient nourishment, and resulting
asthenic t^intlitions whieh are analogous to star\''ation. This is representecl
as a whole ljy a loss of weight evidently of a pathological character, in ad-
dition to that which I have des4.Til:>ed as physiological. Yon will, therefore,
now nutlerstand vntb what care the newly-born infant should be protei'ted
from ttx> gn»at changes of tern jiera tore, tix) much light, and trM> mneh noise.
The analogy of this statement is iound in the sensiti%'e oi^nimtion and
habits of the lower animals. In this way only e^n the digestive fiinetion
be made to corres|xmd to such an extent, in the early days of life, to the
work which is required of it, as to keep the loss of weight within the
physiological limit, Star\^ation, as is well known, proves fata! primarily
not from tlie amount of ff hkI fiimished being too little for the processes of
102 PEDIATRICS.
disint^ration, but fn)m cxhaiLstion of the nervous system. The endurance
of the starvation is in pro|X)rtion to tlie ca|)ability of resistance of the
nervous tissue. This nervous tissue is so highly sensitive and has such
great functional activity in the infant, proportionately to the adult, that it
needs much more nourishment, and succumbs much more quickly to depriva-
tion fn)m nourishment. Young animals die in a veiy much shorter time
when deprived of food tlian do older ones from tliis cause. It is not sur-
prising, therefore, that when the early period of life is represented only by
hoimj and days, the various disturliances which would be of minor conse-
quence at a later |)eri(Kl of existcni^e should have a decidedly pathological
efTect and produce a markcnl loss in weight beyond the natural physio-
logical loss. The following case, taken from my records of this dags,
exemplifies the practical bi*aring of what I have just said.
Cask 23. — A male infant was Ijorn December 18 at term. It was healthy and vignr-
OUPt and gave no evidence of on^anic disease. The mother, a multipara, strong and healthy,
was twenty-eight years of age. Her other children were living and healthy. On the thiid
day, DecemlK*r 19, the infant had a slight attack of icterus neonatonim, which disappeared
in twenty-four hours. On the fifth day, DwemWr 21 , the weather was very csold and bleak,
but the infant was takon to church and christi*ned. The churt^h was warm and the in&nt
n*a8<jnably w(>ll pn>tcctod fmm ajld, but th(>n* were a large number of people pieoent, and
an unusual amount of nois(.\ The infant, (»n being taken home, immediately he^^an to show
symptoms of asthenia, and on the following day was found to be cyanotic and hreatfaing
rapidly, with a subnormal toni()eratun.* and no apparent organic disease. It died in the
aftf^rnoon. Tlio asthenia seemed to be produoinl by tt>o early exposure to change of tem-
peniture, light, and sound.
As a rule, the avera^ daily gain in the first two months should not
be 1k»1()w twenty granirai^ (two-thinls of an ounce). I have found at the
Infants' Hos])itaI that if the gain is less than this the infimty as a rule, ia
being badly nourisluKl, is sick, or is going to be sick. There are, of oourse,
exceptions to this rule, and J would here also call your attention to the
fact that (>l>s(Tvations of weight including only that of two or three days are
very misleading, and that it is tlie wtiek's weight which gives us "the fidiest
idea of loss or gain. Tlius, I fnM|uentIy find infants showing a daily gain
of only five or ten grammes (one-sixth or one-third ounce), or even losing
fifteen or thirty grammes (one-half or one ounce) on one day, and then gain-
ing one hundreil to one hundi*cd and fitly grammes (three and one-thiid
to five ounfx»s) on the next day. Fnjm this you will readily understand
tliat we should obtain froni one day's ol>servation too low and on the next
day too high an estimate of the nutrition. By the end of the week, how-
ever, the weights usually ecjualize each other, and we have fairly corrvct
figures to guide us. This table (Table 2^5) shows about what would be
exi)ectcd of the average infant as to weight during the first year. Girls, as
a rule, gain less than Ikas, but this is only if they are of lighter weight
The heavy girls make the same large gains as the heavy l)oys, but, as a rule,
their initial weight is smaller than that of the lK>ys, and they therefore make
smaller gains.
NOBaiAl* DEV^ELOPMENT.
loa
TABLE 26.
Qeneral Figurta of Weight.
Weight
^^" GramjneB, Pounils.
At birth 300IJ to 40()0 6.6 to 8.8
From birtb to 6 months . .
Fnjm o months to 12 months
Average Gato per Day.
Gnunm<es. Ouncfs.
20to»0
10 to 20
i t.. 1
iloj
Age.
Weight.
At 1 year »*,500 m.m
AtTyeara , . . . , 19,(MM) 4L80
At 14 years - , . 3H,aM.» 83.60
[The ttliovo figures tir*? on a ba^is of 350() gnitnnias (7.7 pounds) at birth ^ and of a ^iiin
of 30 grammes per day for the first four months and 10 gniinme* ptT tluy fur the last eight
months of the tint year.]
Useliil figures to remember are that the initial wx^ight b doubled at five
months and trt^hktl at fiftoeu mouths; also tlmt the weight ttt une yvivt is
doubled at st'veu years, aud that this weiglit is again doubled at IburttJeu
CHART a
syli^^yi^igigii^liigi tu
* «• S E^ ft tt'i
1__ . — , — ^^^^~. —
lJ __ « ^^ ._; 1 ^1 1 - ^ ^
:~:- r s---:r=:::::
--- ^iiis: - -
: V ^s - --
:^::^ -:!;_: 5, _ _
>" ^s,
::::::i:::s ::::!5-::::
5 s
_
I- " ; 5.
^1
.,^ ^
t ^
^
\
s.
». « - \.
5. - - _ '
>
Jta _
_ _ _ _s_ __
-5^
___:e,
----- - -^
^ ^ _^ ^^ -,_'
__ . -L.--
s^^^ : -Z^
5 .
^ ^ ^
■ "_"" "" : : '. \'.
"5 " ~
,__: \
: :s: : :
:::::::::::^::::: :::
^ s
IS : _3: :
\.^
— — _|_^;__ _,
--,"- - - ^
i:;::::":::::^-:-::
^
3
__ _ r
^-1
-C
^ 3^
1 — ^ ^ ^^
:::::::: : : ::::: _c^
- ^ _l
— -— 1 '
X - -- - -J
::::::-::±::::::::::-'
m D»t« of BblK iaQt 21.
* I laiUil Wight, 4650.
4,5iJ0
7,172
7,176
7,«t»2
7,ttM
8.170
^M'>
i^,fm
8.U12
9,ia6
9,376
H),U2
10.(»12
11.6M
ll.WM
12,544
12,010
ia.tfH
13,370
Jonu 27.
July i.
" IL
** la
Aug. I.
" a
** 16.
*• 22.
** 29,
Stipi. ft.
" 12,
** ll>.
" 26.
Oct S.
" la
•* 17.
*' 24.
*' 'A\.
Not, 14.
" 21.
Dec.aOi
Feb. 20.
*' lf7.
March 5.
A|irilfl^
Apcuaa
Juneia
ek^ix^:p»«»«9i3d*v<
-» >j: 3 ^ li 1: ii L: t^ *^. i^
^ g I PniiiMlu.
104
PEDIATRICS.
years. There are, of course, l)(>th gains aud losses in weight duriug the
year, the welglit ac*ting as an index of the disturbances which arise. Ai^ a
rule, what may \)e ealli>d the line of nutrition rises from the initial weight
in the fir><t week, wwk by week, up to the fifty-seoond week« A uniform
increase is, however, exceptional, on account of the many disturbances, such
as from food, the dental |)eriod.s, weaning, improper hygienic care, and the
contraction of di.si*asi\
Instances of amtinual weekly gains during the first year have occasion-
ally come under my uotkv in both hospital and private practice, and the
chart on the preceding ju&ge (Chart 3) gives the exact weights of a healthv
male infant fed by a wet-nurse for over a year, and will serve as an example
of the idwil line of nutrition.
The infant was gaining so regularly that the weighing was omitted in
several weeks, which fact is unfortunate, as the weights would probably
have shown the same uniform gain. A weekly gain is also shown in this
same chart of a male and a female iniant, brother and sister, nursed by
their mother. The double line represents the boy's weights in the first
tvventy-nine weeks of his life; and the dotted line the girl's weight for
t\i'enty-one weeks.
The question of weight is so intimately connected with that of feeding
that I shall reserve showing you the charts recording the daily weights of
the infants which for the past ton years I have had an opportunity fw
studying at tlie Infants' Hospital, until we Ix'gin to investigate the general
principk^s of nutrition. I have prepared this table (Table 27) to show you
how at a glance you c»an determine tlie average normal height and wei^t
of boys and girls from birth to fourtet^n years.
TABLE 27.
Average Heights and WeigliU from Birth (n Ficr Vears^ atid of Boston School BojfS and
Girifi^ irresjtrcfire of Sationalify^ frotn Fire fn Fttftrteeti VearB,
Boys.
Ueifirht.
WeiRht.
CentimetreK.
Incheti.
Kilogrammeft.
PotintlK.
4^87
1 19.75
3.25
7.15
61.87
1 24.75
0.50
14.30
7«.82
. 29.53
9.54
20.98
84.55
. 33.82
13.80
j 30.30
92.0.-)
37.00
15.90
34.98
98.27
39.31
17.27
; 37 99
103.92
1 41.57
18 04
41.00
109.37
4.3.75
20.49
45.07
114.35
45.74
22.20
; 48.97
119.40
47.70
24.40
' 53.81
124.22
49 09
20.87
59.00
129.20
51 t)S
2f».02
05.10
133.82
53.83
31.84
70.04
137.77
5.5 11
34.89
70.75
143 (r2
. 57 21
38 49
84.07
149.70
! 59.88
1
42.95
94.49
A4iE.
GiRLB.
Height
Weight.
Ceiitlmetrefu
Inches.
KUogimmineL
FiomidL
Birth.
48.12
19.26
8.16
6.98
5 nionthft.
59.12
28.26
680
18 86
1 veur.
74.17
29.67
9.00
19.80
2 voare.
82.35
82.94
18.81
29.28
3 years.
JK).77
86.81
16.07
88.16
4 v<'ars.
97.00
88.80
16.68
86.86
5 veart*.
103.22
41.29
17.W
89.67
0 vears.
108.37
43.86
10.68
48.18
7 voars.
113 80
45.62
21.60
47.80
8 voarfi.
118.95
47.58
28.44
61.66
9 years.
123 42
49.37
26.01
67.00
10 vears.
128.35
51.84
28.29
62 28
11 vi'ars.
133.55
53.42
81.28
68 70
12 vears.
139.70
55.88
86.68
78.16
13 v<'ars.
145.40
58.16
40.21
88.46
14 years.
149.85
59.94
44.66
96.28
NORMAL DEVELOPMENT.
105
I
Tlie figures for biilh, for five rmiatlis, and for onv year R^|>rt^eiit my
investigation!?, eorubined with the figures wliieli I have already rihowii you.
The figiirt*s ff>r the ^^tx'fuid and thinl yeai's aiv takeu fruiii a stTie^s of investi-
gations matle by Dr. (ieoi^e W. Peekhum, of Milwankt'e, in the Report of
the Wi8*x)nsin State Board of Health for 1882. The figures for tlie fourth
year are appn^xiniate averages taken from ehildren of tliret* and five years,
BA uo reliable figures tx>n"cs ponding to theotliei'^ in the table eon Id lie found.
The figures from the fifth year to the fonrtivuth year were taken fmm Pro-
fessor H* P. Bowditeh^s artiele on the Growth of ('hildrt*n, in the Twenty-
8eiYind Annual Report of the State Boai'd of* Health of Ma-^sm^husetts.
They represent the averag*.' figureg of a large number of .sehrMjl-eliildren.
lu the preoediug tiible the weights at birth, and in the first, ^^eeond, and
thirtl yeai-s, were taken without cloth iiig. Tlie ordinary sch(x>l-elothes were
worn in the weighhig from ^\X' to fborteeu }'wirs,
FEET. — 1 have ab'eady referred in Lecture II. to Dane's work ou the
Infant's fiK>t at term, and I will now tell yf»u what he has to say on it*
ilevelopment, as it is s<3mething which eauiiot bc^ obtained fn>m any other
sourt^\
During the first year of life the nmseolar tone is steadily impmving and
the foot slionhl sliow a well-markal arch. In fat babies there may l>e a large
adipo.se pad lbrine<l under the internal arch, such that ou taking an im|iriut
of the sole its internal bt>rder may a|>|>ear straight. Even here when the
<^aniphor-smoked pafwr is us<m1 theiT will Ix* a distinct shading, shitwing that
the pressure is much less tiiau in true fiat-toot, as is so well shown ixi this
baby with flat-fU>t (Leeture II,, Fig. 14, page 50),
In sickly cln'ldrtm, or in castas where for any rea.son the mnsc^ular develoiv
meut IS int€»rfcred with, the foot will remain in a lax ctmdition, t>r even of
itself fall r>utwardly int4> the valgus position. The sexes are alike. Out of
eighty-five eases, tldrty-five were found to sh*nv erjually good arches on lioth
feet; in thiii:y-tw<i the right fiH>t wjis Ix^ttcr fiirmed and in sixteen the left,
while !^n*eu showed a broken-down or badly-fbrniHl a audition of the aix^h.
Fmm the time the ehiUl begins to walk there is a dLstinct brt^aking down
of the internal arch, which in most eases is wholly lost, the two i4H4 suffering
ef|nally. For the next year and a half tlie fct^t ivinain ijnite flat, yet during
this fKriixl isolated tracings apjM*ar in which the arch is never lost. It is
interesting to note that sui'h an* always girls, and therefore presmnably lighter
ehildren.
During the third year the arch is slowly rebuilt, one foot irapmving before
the other, and the fcmalc*s cf)nsiflcrably in advance of the maleV. Wlien the
fourth year has Ux^u well enten^d upm, the fwt have reaeh«^l nearly the adult
condition, the two feet are alike, and there is no tlitference bc»tween the sexes.
At the sixth year the adult ty|ie of foot has pmctically hoim attaintxl.
The following tracings rcpn'st^nt the avcnige from a series of five hundix^ and
tH-enty children. Fig. 31 rt^presc^nt*? female feet from one week to eight years,
and Fig. 32 tracings of male feet from two weeks to eight years (page 106).
108 PEDIATRICS.
offer the most rational explanation for tliis condition. This author saystliat
it h dif!i(*nlt to av<iitl ass<K'iatin^ the ic*teriis in some way M'ith a disturbaoce
of the heiuitic ein'uhition, (iwiiifr to tlie transfer of its chief blood-s*uppIv
from the unihilieal vi>in. Tills is es|HH'ially to In: Hcen when ^ve consider the
very evident conpstlon and oHlfnia of the liver, ho well described by Weber,
which oecni's in (usts in wlii(*h the (*ireulation thnmgh the umbilical ooid k
int4Trn])t<'<I Ix'ton* the n^])iratorv movements, by tlieir efiect on the right
feiide of the lieart, afford an adetpiate eom|M>nsation.
The vess<*Is In the hiUis of the liver an' snrnamded by a dense layer of
eonniH'tivo tissue, whl<'h Is cf»ntinue<l into the or^n along the branches of
the |K>rtal vein. In <':m»s when* then* is venous obiitniction in the liver in
eonsequencv of delayeil hlrth this tissue is the seat of much cedoma. A
hn»ad layer of ^ray pnlpy tissue enclt>ses the vessels and is also seen amund
the uml)ili(*al vein in its diaphrafrmatic* ]M)rtl<»n, extending also to the gall-
bladder. Tlie nilen)seo]>i<' apjH'sirances <if this tissue are those of cedenia
with more or less abundant aceuuudation of n>und cells in the intetstioes.
That this swelling of the tis<u(» must ^'ompn'ss the bile-ducts is suffidentlT
obvi<»us, and ]tin*h-llirs<']ifeld luis found that not only under these circum-
stances an^ the blltMlucts dlstcudc<l, but then' may U* a |K)sitiv« difficult}' id
s<|ueezing the bih* <»ut of the pill-bladdcr into the duodenum, while in the
latter then* is a maulfi'st deficiency of bile. In (U'^^s where death occurs on
the first day of life, a lH»jrinuinjr i<'t4Tus may Ik* distinctly detected, and
Bin*h-Hlrschfeld has n']N)rt<*d csisc^s demc»iistniting this condition, and has
also ol>ser\'<Kl the ^nulual incn*iL^' of the jauudut* where life had continued
lon^T. Bin*h-nirs<>htM<l has also shown that the presence of the bile^-acids
may always iMMlcmonstnitctl in the |MTiranlial fluitl in fatal eases where this
icterus neonatorum was pnsciit, when»as they (*annot be found in other chil-
dn'u who do not pn-s^'ut a jaundiced condition. This may be r^arded as
stn»n^ evidence in favor of the hepatop'uic origin of idenis neonatorum,
I shall sj)eak of the graver forms of icterus in a later k»eture.
This explanation of the <*aus<' t»f ict<Tus neonatorum must not, however,
l)e n'ganhnl as <'ouclusive ; for Cohnhciui has in a number of auto|Kiies
made on this class of ca^'s failKl to sul>stantiat<' the conditions described bv
Bin*h-Hirs<'hlcld.
The (jnlinarv bathinjr <»f the infant's skin is all that is necessary' in
these cases of irUru^ ymnuifonun, an<l I have never seen any indicati^in
for es|)ecial tn'Sitnx'nt of this <'on(litic»n lK>yon<l ^niit care in establishing
the wpiilibrium Ix'twcen the flMxl and the di^stion.
Erythkma XKoNA'muT'M. — At bii-th the skin is exceedingly sensitive
to external influences, and in every case shows variations in color according
to th(^ depn^e of this s<*nsitivcn<ss, au<l t<» the jrreatcr or less amount of irri-
tation, whether from temjK'ratun' or fn»m mechanical causes, to which it is
exjiostJ.
The delicate layers of epithelium an* ciimmonly thrown off to such a
degree a« almost to n^presi^'ut a physiological desquamation, and it is often
NftunAln^tn
•^
R.
HMtufi\ Si:
Vet low 60 ^n Mif roKk
%Hm4i^\ S.I*
NtSriAlorum
NORMAL DEVELOPMENT.
109
I
ei*al weeks before the normal infantile c^>ndlitioii of the skin m reaehect
In quite a number of eai^eii? thin natural condition becomes inteiL^ified, and
we find a unifnrm rnlnt^-? of the whoh^ skin, wliieh nsually appears in the
first two or three days uf life. In a eonsiderabk* numIxT of eases thii!? by per-
SBinic condition ol' the skin gmdiially fades away m about a week, and ia
replaced by the normal pink color whieh I have already shown you {Cm^ 2,
Front Lspieee). With many others^ however, this red t*olor may te eompli-
cated by the ieterie wndition which I have jiLst shown you (Phite II.), or it
may change with many intermediate shades of red and yellow into a pro-
nounced idcniH nronalonim. These inlant^^, whieh are res)_)e<.'tively five» six,
and eight days tM (Ca^^es 25, 2(j, and 27)^ show very beantilully the t^uubi-
nation of these two physiological tHinditions, while the infant Ui whirh I
shall now call your esjR^ial attention represents a typical case of an uucom-
plieattHl eriithemti jwonaforum (Plate II., facing page 108).
This iafiint (Cii8<* 28), a femiilef wa* born ye«terdAy. It weighed 3000 g^raiumes (ubout
6} pounds). It is now twent^'-fuur hours old, and ita wci|?ht b the mm& as at birth. It
hegun to turn rw3 wbtm it was Iwt^nty hout^ oMt and h now^ as you sec, of a dull hut pro-
nounof^l red color nil over iU face, head, thorax, and oxtrt'mities* Its temperature and rt?»-
piAtions are normal. The int^ojoium ha* come awny in natural amount. It ha* begun to
Ptltmef ftnd seeing perfectly well.
There are usually no mn.Htitutional symptoms in these eases. Where the
hyperemia is verj^ intense a j^light deHrjuamatiou is at times noticed* It is
well, then:*fi>re, for you to study this rather iK-^'uliar nKi tinge of the skin in
eomparijion with the redness of simple erythema, ec*i?enui, erysijx^las^ and
scarlet iever, which I shall show you at a later lecture, and wiiieh, owing to
the dit!ercnt degree of sensitiveness of the individual skin, may at times
simidate erythcnm ncK>natornm as well as cat^i other. This piKsiliility of
errt>r must l>e aetx^pted, sint^e these other diseases have l>een known to apjH'ar
at so early a i>erio4l t>f life, altlniut^h it is unusual tor them to do so. In
one instance at least, to my knowledge, m ease of s^^arlet fever, whirh ulti-
mately prove<i fatal to another ehild in tiie family, was cxtusideii'd by the
attending physieian, when he first saw it, to lie a (*ase of eri/thenia neonalot^um
in the see*md week of life, and vet eventually he aduiitt*Hl it to \w the s<iniTe
of inft»etit>n of the other niemlK^i's of the family and of the death of one
of them.
The applimtion of a simple jiowder made U|) from this prescription,
Prkscbiption 1.
Metric. Apothecary,
QmawA.
a Pulv. sind oxidi ..**.. aOj Bfc Pulv. zinci oxidi. , Ji;
Fulv. amyli tnt , 120 | Pulv umvli irit Jiv.
M. M *
with the use of water without soap on the skin, using enough only for elean-
liness, until the redness has disappeared, is generally all the treatment that is
neoessary id these cases. *
PLATE III.
A. Intertrigo.
B. Seborrhoea capitis of infants.
C. Amoeba coll. Section of mesocolon. (Leitz oil immcnion ^, oculftr No, 8.)
Napkins.
1. Detritus of uric acid infarction (otain on napkin during early days of life).
2. Meconium.
8. Color of feces resulting fh>m good human breast-milk.
4^ (t t( (( (I ii (t (t
5. Crystals of uric acid and urate of ammonium (hedgehog orystalfl) taken fW>m 10.
6. Subi^titute feeding. Fat, 2 per cent. ; milk-sugar, 5 p<>r cent. ; protelds, 1 percent.
7. " ** ** 3 " '♦ ti " " 1 •»
8. ** *' ^^ 4 '^ "7 ** " 1 •(
9. << << *t 4 *' *' 7 *' *^ 1 "
10. Di'tritUB of uric acid infarction in excess.
11. Bile-sUiin on napkin.
12. Color of fieoefl after bismuth 3 grains every two hours for six doflee.
14. " •' ** *' was omitted for twenty-four houn.
15. Color on napkin commonly seen, but in this case excessive in amount and patho-
logical from uric ac^d.
16. Color of " clay-coloHKl" fte<*08.
17. Color of the chuiigi^ in milk-fed (breast or otherwise) infant's fbces just before or
just utter th(\v are passed (not necessarily pathological).
18. Pathological color seen in Case 424, page 888.
19. ** " ** Case 425, page 888.
112
NORMAL DEVELOPMENT* 113
little or none passed. The function of the kidney begins quite early in foetal
life, and the bladder lia^ been found to be full uf urine at birth. The urine
which Lh first pat^s*^! Is usually dark and thick, but it s<»«m beet>me8of a light
yellow color, and is generally slightly acid in it^ remlion. Its ^jKHjilie gravity
(101(3 at birth) falk in two or thrt^ days to 1003, and by alx*nt the tilleenth
day Is limud to Ix* 1006. By the end of the first week and throughout
ehildhiHid the amount of urine passed iu tweuty-ibiir hours Is relatively
greater than in adult life, Tim iu early infancy may be due to the pre-
pouderauw of li(|ni*l fcnnl, Imi is iu (lart the result of the infant's more
active rnetal"M>lisn), tor the urea is also tbund Ui be proportionately increased.
According to Foster, the presence of uric and oxalic atnd in unusual quan-
tities is a tWqueut characteristic of the urine o( children. It is also suited
that the phosj>bates an^ deficient, Ixnng i^'taiued iu the b>dy for the purpose
of buildhig iq> the osseous system. The itric aeld infarction^ which I have
already refen-ed to, aud evidences of* which may last for two or tiux^ weeks,
o<»nsistsof urate of ammouium (hwlgehog crystals), amorphous urates mixed
with uric a<"id crystals, and some epithelial cells (Plate TIL 5, facing jrnge
112), The variations in the amount of urine which has l^ecn computed to
be passed during the early days of infancy and ciuldhootl are very great, as
the amount iu all pi\) Liability dejiends very largely on the quantity of liquid
ingested* It is well, however, for you to have some general idea of the
normal total amount of the urine at different ages w^hen you b^in to study
the tlLseased conditions of the kidney.
The difficulties in actrurately meajsuring the amount of urine excreted by
very young infants are sucfi that fctw positive statements eau in} made as to
the quantity. It is sufficient to say that it Ls about ninety grammes (three
ounces) a day for the first few days, and then rises in amount very rapidly.
Rietz states that during the first flnir days of life the urine contains
more or less albumin, aud that this disaf>j>ears at alxiut the seventh or eighth
day. It also frequently hap|x^us that tlie first urine that is pas^sed is cloudy.
The follnwiug tables (Tables 28 and 29) give approximate figures for
infancy aud childha:>d :
TABLE 28.
Age. Totul Urine tn 24 hooK
2i rannths . , . . , 25<M10 c,e. (8i-l3| ounew) (Folbk).
5 months . , t^H^i e.c. (38 ounce*) (C»merfer).
TABLE 29. {Scbabanowa,)
AgB, ToCaI UiinB in 24 hotiis.
2- 5 years 760 c.c. (25 ouncw).
5- 9 yean liMS c.c. (34^ ounces),
10-18 yean 1430 c,c, (47 ounoea)*
It 19 oft^n convenient to know how much urine is excreted for each kilo-
gramme of body-weight* The following .table (Tabic 30) represents the
re^idtB of some careful work which has been done on this subject :
8
J
114 PEDIATRICS.
TABLE 80. (Vierordt, in Gerhardt's Handbach )
Number of cc
Number Ayentice Body- Total Amoant of Uilne ex-
Yean, of Wciyht,in of Urine in 2i cfetad fbr each
CiMs. kilogs. houw, In cc. klloy. of body*
welglit.
8>6, boys 4 18.82 748 68.08
8-6, girls 4 14.78 708 48.00
6, boy 1 16.6 1209 7aOO
7, boy 1 22.42 1066 47.06
11, boy 1 24.0 1816 76.64
18. boy 1 82.09 766 28.12
Adulte — 63.0 1700 to 1800 28.00
Urine of Adolescence. — It is well to bear in mind, in oonnection
with the conditions of the kidney which exist during the period of develop-
menty what has been termed the urine of adokacence. At puberty there
appears to be a disturbance of the equilibrium of the renal circulation oc-
curring so frequently, and presenting so ' distinctively the characteristics
of a simple hypencmia, that we are justified in looking upon it as a physio-
logical rather than as a pathological condition.
This physiological congestion of the kidney is probably closely con-
nected with the development and increased activity of the uterine circulation
in the female, and with the pn)static and genital blood-supply in the male.
The importanc^e not only of* knowing that such a condition exists at puberty,
but also of l)eariug it in mind when we arc called to treat children who are on
the border-line between childhood and adolescence, is too little recognized,
and this want of recognition oflcn leads to imfortunate mistakes. Xumerous
instances of the truth of tills statement must arise in the practice of eveir
physician : so that I need refer only to one of a number of cases of this
kind which have come under my notice.
Case 29. — A girl, thirteen years old, was brought to me for advice with the following
history. She had always been some what delicate, but had never had any special disease,
and was considored to be fairly healthy, until she was twelve years old. She then b^an to
grow very fu>jt in height without a corresponding development in weight and g^nen&l mus-
cular Htrc;ngth. When she wok twelve and a half years old the catamenia appeared, and
werfi accompanied }yy jjovertj pain. This was in Noveinlnir. In December, six weeks later,
the catamenia again upp<.>ar(Hl, and wen^ accompanieil by considerable pain and general pros-
tration. The child at this time hoiked jmh' and thin, had very little appetite, and was easily
fatip;ued. A physician was ccMi-ulti'd. who pn?scribi'd stn»nj» food, such as meat, a tonic,
and j^'innasium exercise. This advin^ was followiil implicitly, and the child was made to
exercise esjK*cially the musch's cinineettMl with the aUlomcn and pelvis three or four times
a week at the gymnasium, and by daily home (>xercisi*, such as lying on the back and raising
the legs. Under this treatment the child rapidly grew worse, and the catamenia did not
return in January. The j)hysician then exiimiiHHl the child carefully, with negative results
until the following analysis of the urine wjis made (Analysis 1) :
ANALYSIS 1.
Mnn-A 19.
Speciflc gravity 1086.
Reaction Acid.
Albumin 0.06 per cent.
Epithelial and hyaline casts w«.*re fi»und.
NOBlfAL DEVELOPMENT. 115
The child at this time was thirteen yean old. The physician now hecame much
ahumed, and informed the parents that their child had a form of Bright 's disease. This
statement completely demoralized the whole family, carrying with it as it did to their
minds the impression of a fatal issue of the disease. The father, who was just starting on
an important husiness trip involving much money, was so distressed that his business was
entirely thrown aside, as he wished to remain near his child. Under these circumstances
further advice was sought for, and the case was placed in my hands. A careful physical
examination revealed nothing abnormal about the child beyond overgrowth, with a result-
ing anaemic condition. The urine was sent to Professor £. S. Wood for expert analysis,
with the following result :
ANALYSIS 2. (Wood.)
March SI.
Color Nonnal.
Keaction Acid.
UrophsBin Normal.
Indoxyl Normal.
Urea Increased.
Uric acid Increased.
Albumin Very slight trace.
Sugar Absent.
Bile-pigments Absent.
Specific gravity 1028.
Chlorides Normal.
Earthy phosphates Normal.
Alkaline phosphates Slightly diminished.
Sediment Excess of mucus — a little vagi-
nal epithelium — an occasional
hyaline granular and epithe-
lial cast — an excess of renal
epithelium — an occasional
blood-globule.
Total amount in 24 hours 960 c.c. (a little less than 2
pints).
I was enabled from this report to tell the parents that the examination showed simply
a slight renal hypersemia, ^e very small trace of albumin and the very few casts all point-
ing towards that condition and against any serious renal disease. The parents' minds were
much relieved, but no new treatment was instituted, and, as the child was weak and languid
and did not appear to be improving, I decided to have another urine analysis made before
giving any fUrther advice.
The next analysis showed the following conditions :
ANALYSIS 3. (Wood.)
April 4-
Color Normal.
Reaction Acid.
Urophsein Nonnal.
Indoxyl Increased.
Urea Increased.
Uric acid Much increased.
Albumin Very slight trace.
Sugar Absent.
Bile-pigments Absent
Specific gravity 1027.
Chlorides Normal.
Earthy phosphates Increased.
116 PEDIATRIOB.
Alkaline ph^Mphates Normal.
Sediment Much calcic ozaUtte — much
vaginal epithelium and uric
acid cryitals — ezceaa of renml
epithelium — a few blood-
globuldt — an oocaaional hya-
line and granular oaBt of
small diameter with renal
cells and blood adherent.
Thitt analysis showed thi* urine to Ite so concentrated that the indications for treatment
were very evident.
The child was not allowed to go to school or to the gymnasium. She was made to n»t
in bed for several hours twii^e a day. Her diet was largely milk in considerable quantity,
meat especiiilly being withheld. She was also made to drink fkvshly distilled water, 250 c.c.
(ablaut eight ounces) once in six hours. She was allowed to take a slight amount of exei^
cise out of drM>rs, but to a ver}' liniitiHl degree.
This treatment, so radically dilTerent from what she had previously received, was insti-
tuted on the trround that while there was no organic disease of the kidneys, yet the hyper-
a?mic cimdition wuk im> pn>nounced as to show that the renal tubules were being kept in a
condition of ohn»nic irritation to a considerable degree. This irritation was so prominent a
factor in the girl's generally debilitatcnl condition that it became for the tinne being of
primary inii)ortance. The causes for the irritatii>n were very evident. The catamenia were
just being establi>hed ; accompanying this was the irregular and varying congestion of the
pelvic organs originating with the uterus and ovaries, and extending to the kidneys. In
addition to this was the adolescent condition so common in children growing too rapidly
for their general nutrition. The girl had b«>en made to exercise the very muscles whiiM
exercise would naturally tend to inoreaiie (Mjlvic congestion, and was fed largely on meat,
which would not tend to lessen the renal congestion. The indications for treatment were
evidently rest for the (M^lvic organs and dilution of the irritating concentrated urine which
was pa^ising through the n»nal tubules.
Tnder thi^ course of treatment the child began slowly to improve. She became lest
ameinic ; her a}>}M>tiU' increased, and was l(>ss capricious ; she began to gain in weight,
to sleep well, and to have more >trength. On April 11 another analysis was made by
Prt)fe6Sor AVikxI, with the following re*sult :
ANALYSIS 4. (Wood.)
April 11.
Color Normal.
Reaction Slightly acid.
Uropha?in Diminished.
Indoxyl Nonnal.
Urea Slightly diminished.
Uric acid •. . Increased.
Albumin Very slight trace.
Sugar Absent.
Bile-pigments Absent.
Specific gravity 1015.
Chlorides Normal.
Earthy phospbatt'S Nonnal.
Alkaline plutsphatcs Diminished.
Sediment Excess of mucus and renal oaUa
— f(>w blood-globules ^ one
hyaline cast detected (alter a
seareh of more than an hour)
— vaginal epithelium.
I
^^F • NORMAL DEVELOPMENT. 117
TbiB analysis showed such marked imprnviftm«nl that it was evident that wc were
dealing with au exaggerated physiological rathttr than with a puthologictil condition, and
that our treatment was a wbe ono. 1 think it niay be of interest to you to follow the
gradual improvement which took place later, and whieh resulted in eornplute recovt^ry in
about one year frt>m the time when the albumin and general renal irritation were first
noticed. This improvement is shown in the folh^wing table :
TABLE 8L
AnalyKla, May 2. May 6. taMt
Albumin Slight trace. Slight trace. Veiy sl^ht lnoe.
Specific gravity . , . . 1008 108S 1018
The sediment was F*+ry similar in uU th^e analyses, and considted of mucus and of
vaginal epithelium^ n little seetuulary calcic oxalate, and an occasional hyaliue cast und
blcMfd-glnbule.
A final analyiis (Analysia 6), nuidc January 29, enabled me to give the following satis-
factory report^ namely, that there was no evidence of any renal disturbance whatever, and
that the urine was nonnal in every way.
ANALYSIS 6. {Wood.)
January f9.
Color Normal*
Reiw^tion Acid.
Uroplucin ,-...,,• , Normal.
Iiiduxyl . * • Normal.
Urea . , , Normal.
Uric acid Normal.
Albumin Absent.
Sugar ...♦..,,,...,..-,.,.... Absent.
Bile-pigment» Absent
Sjjecific gravity . . 1020.
Chloride* Normal.
Earthy phofiphates ..*.,,.♦.. N«»rmftL
Alkalin*^ phosphates Normal.
Sediment . , ... Vaginal epithelium
and rnueu*,
INTESTINAL DISCHARGES. — The contents of the int<-stioe amtiuue
to be niixt>d with ma-ojiium for tliree ar four days or a week, the longer
time Ix^ing when the infant is weak and does not nurse well. After this
time tlu* infimtik^ di^ehargt^, wliich have a ehanieteristic appearance a8 dis-
tinguished from tJiose of tlie okler etiikl, appear. It h e.siK?eially necessary
for you to familiarize yourselves witli their ehanieteristicB, as they are an
important guide to the pro|>er feeding of the infant nnd are nn index show-
lag whether the iSxnl is pro}K*rly digt^tetl and assimilated. When the nutri-
ment is milk, with the j>erct*ntaf^ of its different element* corresjxuKling to
what 18 normally found in gofwl averiig*' human milk, the di-seharge^ are of
a golck'n yelhiw eolor, smooth^ uuturmed, of mtHlium eon^sLstejiey, showing a
large projx>rtit>Q of water, and sometimes changing on exposure to the air to
a grtienish yellow. They as a rule contain nnde<^omfX)st»d hile-pigment and
bile-salt^, wldle tlie older ehikrs and the adult's diseliarges do not amtain the
hile undeeomiK>sed. The amount of ffecal dis^'harge in the first day of life
is about forty-five grammes (one and one-half ounces), and increases in the
118 PEDIATRICS.
following days to fifty grammes (one and two-thirds ounoeB). It consists of
mucus, fat, epithelial n^mains, and a slight amount of albuminoid material.
In early infauc}' tlu^rc^ are from two to four discharges daily. As the child
grows older there are two and finally one in the twenty-four hours. They
do not lose their yellow a)lor until amylaceous or albuminoid food is given,
when the different nhades of bro\\Ti Ix^n to appear ; they are not formed
until something besides milk is swallowed. Starting at birth with the sterile
meconium, infection by the mouth and rectum quickly occurs, and in a short
time almost any form of liacteria may be found in the dischaiges, but chiefly
8u<'h putrefying forms as Proteus vulgaris (Jefiries). With the suckling of
tlie infant and the substitution of the refuse of the milk and the secretion
of the digestive tm(*t for the meconium, a sharp transition occnra. Instead
of the generally distributed forms, causing decomposition, only two kinds
of Imcilli are now regularly found, the Bacillus lactis aerogenes and Brieger'fl
bacillus, the first chiefly in the up|)er ])arts of the intestine, the aeoond in the
lower part^ When the infant begins to take a mixed diet, quite a number of
forms of Imcilli apix'ar, among them the Stri^ptococcus coli gracilis, the putre-
fying green fluorescing, a tetrad coccus, ami several kinds of yeast. Hie
color of the infantile intestinal dis(*harges when the nutriment is milk alcHie^
whether human or animal, seems to de{)end somewhat on the peroentage of
fat, as you will see by examming these napkins with dischaiges on
prcKhuxil by milk of varying perc(»ntages (Plate III., 3, 4, 6, 7, 8, 0, :
page 112). The considenition of the iivcal discharges of the infimt is 80
closely conncH*t<Hl with th(> subject of infant feeding that I shall leave any-
thing further which I have t<> say about it until we begin to consider timft
iniiK»rtaiit branch of our nicilic-al studies.
We have now, gc»ntlemen, studicnl the princijial anatomical and physio-
logical facts ct>iic<'niing infants and childrcMi which will be of ptaotioal use
in aiding us to diagnosticate and treat their dist^ases. Before beginning the
study of these di.s^aws I should like to pn»sent for your inspeotimi some
ac^tual illustrations of normal infants and children. I have explained and
shown to you in a g(»neral way the normal condition of the external portionB
of the Ixxiy, and also what it contains.
INFANTILE SKELETONS. — Ft may aid you to remember wlnt I
hav(» said if you will also first examine these two skeletons. One (f%. 33)
is tlie .sk(»leton of an infant at term. The other (Fig. 34) is the skelehm of
an infant at ninet<»t»n months.
You see in the younjrer subject tlu* iar^» head in proportion to the smsll
thorax, and the lack of develoi)mcnt of the face in comparison with llie
head, which is very evidently due to the rudimentary development of llie
jaws. You will also notice the widely oj)en anterior fontanelle. On ezamin-
injr closely the sternum you will s<*e tliat it is not in one piece, as in the adult,
Imt that the centrc^s of ossification witli the* inter\'ening cartilaginoos eon-
necrtions, which I have already descril)ed in a previous lecture (Lecture
III., page 71), are well marked. You will also notice what I have not
Infimt at Umhi, Mhowtng Iaiv«-^ heiul, L < lulaiji al VJ tnoritii^, fehimInK l&r^a hew\, ffmuJl
rtor ^onteiieilB. frnuLll thonkx, etuiiljii^m a ...r anterior fonUnene* ottiiicaUou of sternum, tilted
Dum. tilted pehii, uid bow-legi. pelvlii, luid str»%ht legs.
I Warren Mtneum, Harvard Utilvenitj.
NORMAL DEVEIX)PMENT.
119
I
I
referred to before in s|>eakjng of the pelvis, how it b tilted forward, as com-
pared with the adult's, and how small and conti'acted it looks. You will
observe that the legs are not straight, as in the older child^ but show decided
brnving of the tibia and fibula. This ehanieteristie wndition of the legs m
intra-oterine life is pi-esent at birth and eoutiuu*^ Kir .sjuie months, the bones
usually becoming straight by the time that the ^>eririd of walking has been.
reiiehe^L In thb skeleti^n of an infant nineteen months old, you seetliat the
legs have develo|)ed natiu-ally in tlieir growth and ai'o straight The pelvis
still tilts st>mewhat, but is evidently less contracted, or rather has begun to
enlarge. Tlie tin >rax has broadened in wmparis«ju witli the head, and the
cartilaginoas sternum has lx*eome to a large degi-ee Ixme. The head is still
large proportionately to the face, although the jaws have develo{>ed consider-
ably Iwond what L^ seen at birth. The anterior fi>ntanelle Ls, as you see,
cjuite small in comparison with the tbntauelle itf the new-born infant.
These are the chief ehanyteristies of the iufaut*s and child's skeleton,
and yon will now appnviate this series of infants and eliildn^u which I have
carefully s€'lceteil to inipn^ss u|M:>n you tlie ag€\s at wliich the various stages
of physical development shcuild naturally be found.
NORMALLY DEVELOPED INFANTS. — You must not consider
this exliil)itioii nf healthy infants too trivial for your closc*st study. I
bi^lieve that one of the greatest drawliaeks to the jjrojjer appret^iatitm of the
kind ijf knowledge which is needed t^i examine children sua'cssfnlly and in-
telligently when tliey are sick, is the lack o( |>recLse facts contx^rning healthy
children. To know at a glance whether it is normal for a child not to sit
alone or not to stand alime, — in understand its childish actions, whetlier in
creeping or in walking, — these are data ^^Iiieh will l>e of infinite use to you in
your nursery practice, I thei-efbre dn nut hesitate to ocrup}' a ceitaiu amount
of time in showing you these inftuits whose physil^al develo|)meDt and
strength represent about what you will meet in a large number of average
individuals at these especial ages.
I
This infant, ft few boui« citd (Case SO), is, as you see^ absolutely tmahlf. to sit up or to
iioUl its htad up. The swollen condition of the faee which \& so frevjuently *etMi during the
iikrly hours of life after a prolonjied labor is wt?ll exeroplified here^ and will pat« away
nHttirally by to-morrow. When the he^d ia not hujipftrtcd, it fallri in any direction on the
thffmx. You must^ of course, Impress upon the nurse ihiU care j*hould be taken U> supprjrt
the head gcfntly as well a^ the back in Hftinsj and carrying the irifunt at thiP age, and until
the inuscles have dt?veloped loadt-gree which will n.'uder it possible for the infant to mipport
its own bead, or until, uiv h etJU more in)p<^^trtant t** rememl>er, it has learned to co-ordinate
sufficiently to make use of these muecle!*. The time when the infant begina to sustain its
fiwn head varies eonsiderahly, certain individuals being' d<?cidedly precocious in this n?j?pect,
while others, without showing any sign of disea;^e, are much later in sustjiininp their bends
than is the case with the average infant. From two to three monihA h alxtut the time when
the normal infant, according to my experience, $\iMain.^ itn head without aA^ii^tance, although
this ie usually done tn a very vacillnling way up to the fourth or fifth month.
ThiR infant (Case 31) is two and one-httlf months old. It ii apparently num^ally
deveiopod a« to weight* height^ and general grf)wth, and, although it oanuot sit alouet and
haa to have it* back supported^ it holds up it« head quite steadily.
120 PEDIATRICS.
We liave now arrived at a ix^ricxl of growth when the infant can be put
on the floor without haviug to Ix; held by the nurse. This is usually from
the Heveidh to the ninth moiUh,
The nurse bus just unilni4t«cd thi(« infant and plactnl it on the floor (Case 82), so that you
can fic>c it from all |K>intc> of view. The infant is eitfht nwjiihit old| and U normally devel-
o{>cd. Slie. a8 you »w, sits alone pfrfccUy iceilf and can be allowed to amuae herself on the
floor without fear of b«T fullinj; over.
The next infant whieb I phull havo bnmji;bt in to show you is a little more advanced in
itri physical devfh>]>nient, iu« it is ten months old. While the one at eight monUiB (Caae 82)
can sit very well, you s(>e that it cannot as yet move alnrnt the floor, and in Ikct doei not
attempt to do so ; but watch how this active infant, ten tmmths old (Case 88), aa aoon aa yon
place it on the floor, turns over on its hands and knees and moves across the floor, imdMr
awkwardly, ]K>rhap, and not ver}' fast, but it cert^dnly can be said to ereqv. It la natnnl
for the average infant of from ten to twelve months to move about in this way. ^le loco-
motion of infants at this a,(;e, however, is m»t always on their hands and kneea. Many
individuals never cntep, but their first cfforti) in prou^rcssion are represented by litliiig on
the floor and dragging themselves along with one leg.
Now wo will set* what this next infant, which is twdve tncntha old
(Case 34, facing page 119), can do when we place it beside the othen.
This infant has arrived at a peritxl of development 'when it is strong enoiig'h to pall
itself up and stand hj/ a chair, and you stv that it immediately performs thia featy and li
evidently very pn)ud of the accompli^hment.
Finally, here is another infant, fifteen months old (Case 85, facing page 119)| *»»^
nonnully dtfveloped, as you will notice if you carcfiiUy examine it. The head pvopoi^
tionati'ly to the adult's is still large. The thorax is well formed, with the natuiml cuirei of
the back, and the legs an? straight. It can walk very well, and although it is rather aTBBO
to perfonning for your benefit and is crying, still you see that it can go across the floor to ill
mother |)erfectly well witliout faHing. The agt; at which th<* average in&ntwalka of ooniM
varieii, und many infanU never attem))t to cnM>p, but iK'gin to walk before they are twelfe
months old. The average infant, however, walks fn)m the twelfth to the fifteenth \
TOPOGRAPHICAL ANATOMY OP THE EARLY PERIODS OF
LIFE. — I have aln\idy spoken of tlic ini|X)rtance, for purpoBes of diagnosifl^
of recognizing the fact that the organs differ in the space which they occupy
in the IkhIv according to the stage of development of the child. "Well-
marked perifxlis are thns shown to exist by physical examination as well as
by anat<^mical research, and tlic results of these different methods of inves-
tigation are found to corrosfx^nd. 1 have always found that a careful
ainsideration of the pericKl of development is of the first importance when
beginning to make a diagnosis of disease, especially of the heart and lungs.
The large size of the liver in infants and the comparatively greater propor-
tionate size of the lieaii: to the lung in the middle years of childhood are
striking instances of the truth of this stiitenicnt, and should warn us that
more than ordinary c»arc should be employ(Hl in diagnosticating a pneumonia
of the right lower lobe Iwhind in infancy, or a dilated heart in childhood.
Three |XTimls of growth are of es|x?cial signifiamce in this connection :
1. The development of the orgaiLs in the first year, especially in the first
half of the year. 2. A jxTiod occ^urring during the fourth, fifth, sixth.
NORMAL DEVELOPMENT.
121
eeventh, ^d perhaps eighth and ninth, yeaxs*
hood.
3* The later years of child-
To represent the first period I haye taken this infant {Csise S6), seven roonthi old and
normally developed^ and I have outlined in bUick the printipHl points both in front and
behind which will be useful for you to remember when nmkirig u phv'^ieal ejtamination at
this age.
Case 30.
»
I
Nomial infant sov en Qiontiu old.
First look nt him in fri>nt. The phiin dark lines have fir>l lowed the lower mar^n
of the rilw and the outline of the enHifonn eartiliige and inanubriuin. To the left of the
lower part of the left parasterniil lino you will notice a email curved line. This repre^enta
the absolute dulne^s of the heart. The rtdtitive dulness is very Hlightf and indeed ahnofit
imperceptible even on lii;:ht percussion over the sternum. Thii? area of diilne«€ can altuofit
be covered by the end of the fln|jjer used tor p*reufiaion» It is bounded by the fourth rib or
tbinl int<3r»pace above, and ie jUi<t within the imiinmiiry line. ThcR? is ver\- fair rc*oiianc«
under the whole leiiejth vf the sternum. The interru|>ted lines represent the upper and
lower iMirdera of the liver. There is not much to say nlM>ut the upper line, but the lower
one in interesting and instructive kb illufitratin^ the lari^e ^ize of the liver in early infancy,
and you aee how little of the stomachy which is here reprej*ented by a dotted line between
the edge of the liver and the left border of the riba, is to be reached by percussion. The
stomach »«, of course, in this infant, empty. When full, it come« out much further under
tbe ^p3 of the liver This ^^eneriil idea of its position, however, is very imjxirtiiot when
wo come to ctmsider cages of impmper feeding wheiv we have to det4?miine whether we have
a dilated stomach U* deal with. The broad bhick line jiwt above the level of the umbilictw
122
PEDIATRICS.
marks the transTeTM colon, which in infuncy has u n^lutively low position. The
which u marked hy a black oirelef sUndfi^ aa you see, hije:ti in the iibdunieiit near tlie ant
0uperor epine of the ilium. I have also outlined the uppiT fti»^ce of the gti-Tfiuui aiid ir
cated the clavicle and llr»t rib. On looking at tbU infant* hack you will &ts^s that 1 ha
marked the lower bordt^rs of the thoraXi tbu kidofivi^, and the lower borders of the luu
The left kidney h decidedly higher than the right at this iig«. While the lower border ^
the lung on the left come* down iim far as the tenth rib, the corre»|>onding border of the i
lung, owing to the Urge mzQ of the liver, det;cendi} only as far hjs the ninth rib*
I shall DOW show you a child in the seermd jieriod of growth (Case
In this middle jx'riod of i^hildhtxid tlie heart has developed more rapidly
pi\fjK>rtioiiatc'ly than tlie lungs, and takes up niore spaee in the anterior
|ic_irtioii of thf thunix.
Cask 87.
^
l^'volopment atdx years.
This btty^ six years old^ and prr>p#rly develojved ffrr \m nge^ pn^sents certain points i
lnt*?i**t which dJiter from the infant and the adult, and which should be careftilly taken inl
acw>unt when we are making a physical examination wt this age. You see I have fir
marked the mitnubrium, indicating the clftvicles, the first and second ribs, the en*ifu
cartilage, and the lower borders of the theirax. The area of cardiac dulnesti is far grt?at(
than in tliis infrint (C's-^e 30). Thid dulne«« should, so far as tbf stenium h concerned,
deterniined by light percussion directly over the flteniuni frt^m above drswnward. In ihij
way we can detect the lOmnge in the percussion note over the lower part of the sternum
NORMAL DEVELOPMEKT.
123
I
I
I
I
better than by percussing ttom the lung to the Bteraum, since the former is so much more
refrLtuunt thjit the sounds are more difficult to diatingubh and are often mialeading. The
upper resonant part of the sternum, on the other hand, present* an excellent opportunity
for comparUon, and brings out the delicate ahadei of Bound which are needed in getting
the relative dulness. Thifi relative dulnesa, however, is usually pronounced under the
lower part of the sternum in this period of development, and you hear as I percu&s to the
left how it shades off into the absolute dulness of the precordia, Abaolutt dulness under
the sternum, unless depending on pathological conditions, h rare even at this age, when
it is also rare not to have thi^ pbyi^iological relative dulne^s. In thiB period the dulness
of the heart extends higher in the lct\ parasternal line than at any other time of life.
The lower border of the third rib usually marks the upper b«»r(lKr of the absolute dutness,
which extends also to the left parasternal line and keepd well within the munirnary line*
The relative dulness, on the other hand, reaches a£ high as the lower brtrder of the second
rib. It then pa^^es to the right under the upper third of the sternum^ descends obliquely
to the fovirth right costal cartilage, and then keeps closely to the right parasternal line.
To the left it extends well out to and perhaps a little over the mammary Une* The
area of dulness in this special boy I have outlined where as I percuiiBed his precordia you
heard a marked absolute dulness between the matumary and left pnrni^ternal line« gradually
ehading intt» the marked relative dulness of the lower third of the sternum. You will notice
that this is a far different result of percus«ion from thut which is found in the adult, and
in this infant (Case SO), where, m I have shown you, there is no dulness under the sternum,
and the absolute dulness rises only as high as the fourth costal curtilage in the left para-
flternal linSi and the relative dulness only to the third interspace. The relative dulness also
extends only as far as the mammary line. The impulse of the heart is usually found a
little higher in infant* and in young children^ irrespective of these perit:>ds, than in older
children and in adults.
You will next notice that a much i«mftller space is oocupieil at this 8ge by the liver than
in infancy. This I have indicated by the double line, which n^es as hitrh as the fifth rib in
the mammary line, and to the attachment of the sixth or seventh right costal cartilage to
the sternum. The dotted line of the stomach, on the other haiidT ocfupies, as you see, a
much larger space than in the infant. The line of the transverse colon stands projjortion-
ately higher, the eiecum rather lower. On examining the back, you see the lower border of
the right lung is still a trifle higher than that of the left, and conu^s to about the upper bonier
of the tenth rib, while on the left side it extends to the lower border of the same rib. At
this age the liver has diininished in size relatively tft such an extent that the difference of the
poiiitiou of the lower borders of the lung is but slight.
The kidneys are about on a level on both sides, I have also indicated as landmarks for
your study the first and twelfth dorsal vertebnr. Ton «ee that this child is passing through
tnitisitional stages of physical dovelopment, and is gradually apjiroachlng the adult type
of perfected growth.
This perfected growth, so far as the topogfmphy of the organs is con-
cerned, is reac!h€*d m the lust years of ehildhorwl and at alxjut the age of
puberty. The organs of the child seem at this age, although they have not
yet aeqiiirtHl their complete gn)wth, U> pi^esent for purp>ses of fiei'cnssiyn
the outlines which we are accustomed to see in the adult, with the exoeptiom
possiijly of the |>osition of the e^etnim.
This normiiUy developed boy (Ciipe li8, page 124), twelve years «>f aire, illustrates re-
markably well the relative tupugraphical correspondence of later childhood and luiult life.
I have, aa in the boy of six yeai^ (Case S7), outlined the nianubnum, clavicle, first
and second ribs» ensiforni cartilage, and the lower borders of the thomi. The curved line
passing up the left parasternal line to the fourth rib and keeping within the mammary line
marks the absolute dulnesi* of the heart, arid correspondft to the to|.K»gniphy of the adult's
bttait. The upper line of the liver ii^ you will notice, found to be about at the level of the
134
PEBIATR1C8*
fifth rib in the mamrtmry linei and does not extend beneuth the lower border of the libi^
but U just belitw the tipof ih«? eru^iform ciurtilago. The dotted line trpresentfr the stomack
The spleen has its iip|>er l»ofder iit the ninth rib» and itfi lower jK>rtion com€» down mm tkr u
the lower border of the eleventh rib. The ciecum yuu will notice is mar kcnl in the upper
Cask 88*
1
Noniul deretopment at twelve yeani.
part of the right groin. The tmngverse colon is about midway between the stomach and
the umbilicus. Looking at this same boy from behind^ you will see that I hiive marked hit
kidneys tind the lower bopdera of bk lungs in about the same relative position aa occurs
the adult. I have aim Indicated the Urst und twelfth dorsal verfcebnei
H
4
These representatives of the normal development of im|K)rtant perirjda i
of life have not only been carefully mapiK?cl out by myself by percu8sioi[^|
and in acoordanoe with the aiiatomi(*aI kuowlefljj;*^ whieh we possess on th^l
subject, but have ako Ix-en verified by Pnifessur I) wight, who has examine
each child carefully and has satisfied himself that my marking is cx)t
I shall at present say nothing moi-e alMiut thesi^ various stages of develop
mcnt, the knowledge of whi(*h I hojie you have now mastered suffirientlv
utilize in coniiectioo with tlie sulyect^ to which I shall next direct jrot
attention.
DIVISION III
HYGIENE OF THE NURSERY.
LECTURE V,
THE NURSERY.'-INTERTRIGO.— SEBORRHCEA CAPITIS OF INFANTS.
—CLOTHING—FEET AND SHOES.— SLEEP.— OUT-DOOR AIR— NUR-
SERY-MAIDS.—SCHOOL.— IMPORTANCE OF CORRECTING DEFECTS
OF POSTURE.— VACCINATION.
^
We have studied the infant at term with regard to itiS normal anatomy
and physiology. We have also examined it at different pt?riod^i of its growth
up to the age of piilifTty»
I must now, lx^fi>re undertaking to explain and to t^idow to you the
various diseases of early lile, impress ujion you the imi>ortance of a knowl-
edge of the eare of the infant and ehild in health. I am aeeiMomixl to
place what I have to say on this sul>jcrt under tlie title of *' Hygiene of the
Nursery." It is essentially in tlie nursery^ that we should study the healthy
ehUd, as the nurs<_^ry is its home, wliere it dn^h niont at enm} and l>ehiivt»s in
the most natural manner. The general liygiene c>f the child is reprt^senlt^tl
in its nursery, and we shonid therefore by our knowledge and adviee so
direet these (|uestious of* iuirsery hygiene as to give this sensitive, easily
impressionable young human lieing the best oppvrtunity to develop into a
heiilthy and vig^.i foils adult
NURSERY. — We cannot, of eonrse, in every ease proeure for the ehild
the surroundings wfiieli arc^ liest i5ir it, but we ran at least impress on the
parent what these surroimdings should b.% anfl how iinj>i)rtant they are for the
general health of the ehikL The nursery' should \ye high from the ground and
out of reaeh of the dampness which arista towanls the latter jiartof the day.
Sun and Windows* — It should have a smmy ex[>osnre ami large win-
dows high enough from the fl(M>r to av*>id having the younger ehildren eon-
tin ually pressing their faces against the ^lass to k«ik i>ut, and thus freijnently
catching c^jld from the little currents of air wfiieh j>enetrate most window-
casing. The mothers often overlook this simple manner of catching oild,
and wonder how their children, wlu> are so closely watched, tniuld have con-
tracted the catarrhal cc»nditions which you will be summoned to treat.
126
126
PEDIATRICS.
Fio
Papers and Carpets. — In my opinion it is much better not to have a
paper on the walls or a carpet on the floor. Young children are very sos-
ceptible to inhalation poisons, and to organisms of all kinds. Many a case
of amemia, naso-pharyngeal catarrh, and stomatitis ulcerosa has in my expe-
rience apparently arisen from arsenic in tlie paper. Dust also, with its mul-
titude of organisms, which with the most careful sweeping it is impossible
to get rid of, is another source of irritation to the respiratory tract. I shall
speak of arsenic in the wall-paper later, but here merely state^ in support of
what I have just said, that very mmute amounts of arsenic appear to affect
young children, and that the {)aper itself is a receptacle for micro-orgaiusDis
which are difKcult to eradicate.
Picture-Mouldings. — It is advisable not to have any picture-mould-
ings on the walls, as tliey are a place for dirt to gather which it is impos-
sible to remove proi)erly.
Fixx)R. — There should be as few cracks as possible in the floor, and it
should l)e smooth, so as to be easily cleansed. The floor, however, shomd
not be highly polished, for children frequently fall while playing, and some-
times quite severe accidents cKXJur in tliis way. I have known of one little
boy four years old (Case 39) who broke his arm by simply slipping and
falling on the floor. It is too
oflen the case that blows and
resulting injuries are over-
looked because it is thou^t
that all children naturally fill
and strike their heads. This
little boy, two years old (Case
40), fell on his nursery floor
six months ago. Nothing
esi)ecial was noticed at the
time, but one week later a swelling appeared on the right frontal bone, and
latrr three small ulcers were noticed in the same locality. The child was
brought t4) the liospital, and Dr. Augustus Thomdike examined and re-
moved this sequestrum, GJ cm. (2f inches) long, exfoliated from the ri^t
frontal bone and ext<mdin^ from the temple and line of the hair backwaid|
including a little of the sagittal suture.
Walls and Ceiling. — I prefer the floor, the walls, and the ceiling to
he painted. Not only can they then be frequently washed and scrubbed,
but when the (jhild hapix»ns to have any of the contagious diseases, the
whole rcK)ra can so easily be disinfected that it saves much trouble and
ex{x»nse.
RuciS. — A rug is desirable in the middle of the room. It should never
be an antique ; in fact, it is iK'tter to have new, simple carpet rugs. The
rug should not l>e too larg(» nor too heavy to be frequently taken out into the
ojien air and thoroughly l)eaten.
Bed. — The child's bed should be iron, painted so that it can be caiefully
SequcHtrum IVom fh^ntal ^M)ne. natural edze. Child two yean
old.
HYGIENE OP THE NURSERY.
127
cleansed by wiping, and its sides, as the child grows older, should always be
kept high enough, by some simple contrivance, to prevent the child from
climbing over them. As few hangings and nseless cuiiains, with which the
mother is asually so desirous of draping the bed, should lie usc*d as |x»asible.
Pillow and Mattrese, — The pillow and mattress should be of hair, and
the latter shcmld Ix* pn»tcct<xl by a rublx^r t^hcet and ain^l thomughly every
day. Especial preimutious should be taken that tlie child does not kick
off the clothes at night. It is well for the nurse's bed not to be close to
that of the child. This entails a little extra trouble on the nurse's part, but
her bi-eath is not a healthy pabulum for the child's lungs, which recjuire
tresh, pure air of their own.
CiXkSErrs AND Drawers. — ^The child should have its own closet and
its own drawers. The nurse's belongings ought to Ix^ kept in a separate
room. The closets aud drawers shuuld l>e clcauscd at least once a week.
Furniture. — There should lie sutScient fiirniture in tlie room for com-
foil, but stutlkl furniture should l>e avoided. As little as jKvssible tliat is
complicated or cuml>ersome should be kept in the child's nursery,
CuHTAiNS, — Only simple muslin curtains, which can be washed, should
^ hB nsfHJ at the windows,
Hkating AND Ventilation, — The heating and ventilation of the
nursery are of great importance. The child recjuires pure, warm air. Tlie
temperature of the nMini Ciui vary somewhat aectirdiug to the climate, but, as
a rule, the average should l>e from 18.8^ t<j 21.1° C. (60"' to 70^' F.). The
open wood fire is Ix^st b<:»th tor the character of the heat which it gives, and
for its value ns a means for promoting ventilation.
Draughts. — ^We must take into consideration the current of air in
the nursery, so that the mother, understauding the atmospheric a>nditions
which surround her child, can give the simple directions, which she has
learned from us, to tlie nurse* This is by ur> means an uime*?essarv pra-au-
tion, for oue of the worst cases of rheumatisui iu the hip-joint« (Case 41 ^ Divi-
si*m XVIII,, Letvturc LIIL, pi^ 1085) which has oome under ray notice
was that of a child two yeai*s old wht) was a!li>we<l to sit on the floor with its
l>at*k to the open d(H>r, and directly iu a Hire with the open firt^place. The
direction of the currents of air between the dtx^rs, windows, aud of>en fire|)lac5e
is admirably and scientitically dt*sf'ril>tMJ by Mr. John Pickeriug Putnam in
his vahiable work entitled *^ The (Jjxhi FiiTplace," and 1 have representctl
the direc-tion of the e»old-air current in a picture (Fig. 36, page 131) which
I shall prc^*ntly show you. If the child is much on the Hiwr, a shcH^t
cau easily l>e placxnl over the cracks of the dtHvr ; and plain white slieets are
always tlie l>est articles for screens or |>orti^res.
Window Ventti^ator.s, — A plain pie^^-e of wood the width of the
window, about 10 cm. (4 inches) high, and made to fit closely to the
window-sill, is the best ventilator, but is rarely ueeiletl where a w<xk1 fii^e
IS burnuig in the room. The up|)er sash can also l3e lowered for a few
indieB if more air is needed.
128 PEDIATRICS.
Toys. — Remember that a child puts everything that it gets hold of
into its mouth, so be careful not to allow it to have toys with oolors that
can be soaked oif by its saliva, which would perhaps poiaon it. Toys also
which are made of woollen materials or of feathers should be avoided, as
jmrticjles easily a)nie oiF them.
S(:ali->). — The weight of the infant is so important, as I have told yon
in a pn.»viou8 lecture (Division II., Lecture IV., page 97), that I consider
projKTly adjusted scales an im{X)rtant {)art of tlie nursery equipment
The scales which are usually pn>vided are, as a rule, very inadequate for
the minute and daily weighing, the results of which are at times of such
great assistant* to the physician in the management of the - infant's food.
Never hang an infant in anytliing on a hook to weigh it. Such weights are
usually, from the continual kicking of the infant, quite incorrect. Do not
think that the kit<?hen grtKvr}' scale is good enough for the infant. We cao
afford to have incorrect and approximate grocery weights, but cannot afford
to apply these methods to the growing infant, with its unstable equilibrium.
The scales should l)e of a small but solid platform variety, which can be
placed on a firm table by the tub where the infant is to be bathed, for use
beibre the bath. Here are the scales wliich I am in the habit of using.
(Fig. 36, platform scales on table, page 131.)
These sc»ak« weigh from four or five grammes (one drachm) up to ninety
kilogrammes (two hundred i>ounds). A basket, with a small soft blanket
lining it, is phiccHi on the platf<)rm of the scale, and the naked infant is
weighed in the basket. The scale Ls balanced, and the infant immediatelv
taken out of the ba.sket without stopping to read the weight, so as not to
exjK)se it t<x) long while uncovered. When the infant has been dressed the
scale c^u Ix? n^ad, and the balance-weight minus the weight of the basket
and blanket (which can, of course, always be a constant quantity) gives
us the exact weight. Weighing with the clothes on I have found a very
unsatisfactory procedure.
BATHING. — The question of the bath is one which you will frequently
be asked about, and is indeed of a go<xl deal of im{X)rtanoe in the early
months of life. Unless there is some definite oontra-indication, I think that
an infant should Ixi bathed every morning. The contra-indications are if
the skin or nails turn blue, or if the infant seems in any way to show symp-
toms of weakness or lowered vitality after bathing, such as are represented
by cold extremities and nose, or an unusually quickened respiration. In
these ca.ses si)onging, merely sufficient for cleanliness, is to be substituted for
the bath. The bathing should l)e done with celerity, the tub being placed
on the side of the firej)la(i» oi)[X)sitc from the window, and fronting the
latter, so as to avoid dnuights and insure a good light, care being fatlran
at the same time to i)n)twt the infant's eyes from a strong light. I will
now descrilje to you the manner in which I j>refer the details of the bath ta
be carried out. The nurse sits with her face to the light and has the in&nt
on her lap, wni|)|)ed up in a warm blanket, with its feet towards the fireplaoe,
I
HYGIENE OF THE NURSERY. 129
and its head in such a pc^sition as regards the window as to avoid having
too much light in its eyes.
Temperaturk of Bath* — The water should vary in its teQi|)enitore
somewhat witli tlie a^e of the iniant, but should never be so cold as to cause
blneness or ccjld extremities. We must also be careful not to have the
water too hot, as this has sometimes proved to lx» injurious. Each infant,
however, must have the tcm[>erature of its bath adiipte^l to its own vitality.
Thi8 table will, in a general way, guide you in determioing which tempera-
ture at each age yon had Ix-tter Ix^in with.
TABLE 32.
Ttmperatiire of the Bath for Different A^»*
Age. .Centigrade. Fahrenheit
At birth Sfl.6<» ^S"
During first three or four weeks » 86* ^*
One to six HKintha 84*» »S.2<*
From six to twolve months 82,2* 90®
Twelv*:? to tw€?nty*four months . Z0° 8G<*
Then j^dually reduce in summer to , . 26,6® 80**
In the third or fourth year^ if posaibli% reduce to 28.8*' 7S**
The nui^^t* first washes the fkee in eleiir water, keeping the body and
limbs wrappetl up iu a warm blanket. She t^hoold gently elean??e the w^eCj
the corners of the e_ves, and the external ern^. The nose is espeeially imiK^r-
tant, for the intkut's vitality is easily affix-ted by tx-c^hidefl uares. The face
in then wipetl with a sc»it towel. The nurse should then soap, wash off, and
dry tlie !^^alp* Tlie sponge aud water in the other division of the bathiug
basin are then lused for soaping the bxly and extremities. EsjKfial care
should be paid to the iolds of the neck, theaxilke, groius, genitals, and anus.
The temi>t'rature nV the water in the basin and bath shr^uld be tested from
time to time with the bath thermometer until the wasliing lis over. The
proper warmth of the water is to be kej^t by adding when necessary a little
hot or cold water from nins within easy reach.
Tub. — Tlie tub, which is preierably made of rubl>cT hung on a simple
W(K>den frame and sufficiently higli to prevent nw^lk'j^i^ st*K>ping on the part
of tiie ntirse, is plat^xl, ii8 I have nrrangeil this rrKim to show you (Fig. 3G),
on the nurse's left, at a e<mvenient distance from her chair.
Basin. — In front of the nurse is the double wa^liing basin, which, n^
you see, m merely a china bai>in divided into two er) m part men ts, and fitted
to a wicker stand, also sntficiently high to prevent the nurse frtmi sto<iping
as she uses it^ To the right of the nuiMe is the table, witli the scales on one
end and the toilet basket on the end towartb her.
Soap. — The soap should be white castile, or any kind which is free from
irritating elements.
Sponges, — There should be two sponges : one goes in one side of tlie
washing basin, and is for the hcatl and face ; the other is to be tised in tlie
opposite side of the basin, and is for the body and extremities. The body
9
130 PEDIATRICS.
and limbs having been thoroughly and (quickly soaped, the nurse should
gently lower tliu infant into the elear water in the bath, being careful not
to frighten it or drop it. ThLs is not an unnecessary warning. I have
known infants, even in the hands of ordinarily careful mothers, to be
drop|)e<l fmin the bath or scales, with a resulting permanent injury of the
spine or hi|). Af\er allowing the infant to kick and splash for a few seconds,
it Is taken lyai'k into the nursi^'s lap and eareiully dried with a warm soft
towel. Never soap and wash the infant in the bath, but always on the lap.
Powder. — When the skin Is perfectly soft, clear, and in a normal con-
dition, no p)wder l< needed. Where tlierc is any slight irritation, which, at
times, is liable to occur wIhmi the skin has not been kept sufficiently dry, and
specially if there is a diH^ided redness in the folds of the skin, as of the
net^k, axillte, or groins, this )K)wder can be applied, for ivhieh jrou can write
the following prescription :
Prkscription 2.
Mtiric. Apoiheeary.
Oramma.
K Pulv. zinoi oxidi 7|5 B Pulv. sinci ozidi ^i;
Pulv. amyli trit SO ; 0 Pulv. amyli trit. Jil
M. ' M.
No perfume of any kind should be added to the powder. The infant
should be sweet and pure in itsc^lf, without accessory odors. In addition
to this room arranged to show these various details of nursery routine,
I have had this diagrammatic picture of the nursery drawn for you to illus-
trate what I have just said in regard to ventilation and bathing (Fig. 36,
I>age 131).
You 8et> the simple woixlen ventilator under the lower sash of the win-
dow, and th(» arn^ws marking the entrance of tlie cold-air current. Where
tUs current Ls too strong it can be tcmj)ereti by pinning a towel across the
oix?ning l)etwe(ni the upper and the lower sash. The cold-air current passes
from the window at a j>oint near the floor directly across the room to the
o])en fireplace. This should at (mce suggest to the mother that parts of the
room, on ati^ount of these currents of air which from doors and Mrindows
pass over the floor to the fin»])lace, should Ix^ avoided not only for bathing
but also for playing on the fl(K>r.
A high/e/ifte- covering the entire ojK^ning of the flreplaoe, and fastened
so that the older child in playing cannot pull it down, is an important part
of the nursery- efiuii)ment. It answers two purposes,— one to prevent the
si>arks fn>m flying out on the child, the other to prevent the child finom
falling into the fire. Serious accidents have happened from a lack of
pn)p(»r precaution regarding this apparently self-evident necessity. The
hot air from the fire rmliatcs in all di^^ctions, as is shown by the arrows.
There should \)q a rack for the towels, which should be kept warm in
front of the fire while the infant is Ixung bathiKl.
The clothes should in like manner Iw neatly spread out on another
rack, ready to be put on as soon as the infant has been dried.
132 PEDIATRICS.
The bath thermometer is represented at one end of the tub ; it is usuallr
guarded from breaking by a wooden frame, which also allows it to float in
the water, and the nurse is thus enabled to see at a glance that the bath-
water Ls remaining at the pro{x;r temperature!
CiiOCK. — There sliould be a good clock in every nursery.
There are two amditions of the skin that quite commonly occur in
infanti^, es{XK;ially in their first year, which, although they are abnormal,
usually come from lack of sufficient care in the nurses, and can therefore be
spoken of here mther than among the {)athological conditions of the skin,
which I sluiU mention later. One is intertrigo, the other the sebonrhaa
capitis of infaiiin,
INTBRTRIGK).— The former, intertrigo, is merely an exaggerated hy-
percemic condition of the skin, usually of an erythematous type and occurrii^
in the folds of the skin. This infant (Case 42, Plate III. A, facing page
112) represents very well this condition in the groins. Napkins soaked
in urine and allowed to remain for some time without being <dianged are •
frequent cause of this condition.
Keeping the skin clean and dry and applying the powder will, as a role,
soon cure this intertrigo. At times, however, it becomes much more intense
and runs into a pn)nounced eczema, which is a much more difficult lesion
of the skin to d(»al with and requires si)ecial treatment such as I shall
describe when showing you cases of eczema in a later lecture (Division
IX., Lecture XXI., page 470).
SEBORRHCEA CAPITIS OF INFANTS.— The second conditku,
which also can well 1k> descrilKtl in this connection, is represented by
This infant (Case 48, Plate III. B), two month8 old, which I shall now show you. It
hiis, as you see, n collection of crustii of a brownish-yellow color on the top of its bead.
TJie.se crusts are especially tliick over the anterior fontunelle. This condition is called the
schftrrhffii capitis nf in/ants, and you will often be a^kcd whether it is safe to remove it. It
should never be allowed in collect, and when present it should be gently and gimdiiallj
reniov<.*d by first soaking it witli warm sweet oil to loi.)sen the crusts, and then washing it
off with soap and warm water. A little simple ointment should be applied to keep the
scalp at this point soft and thus prevent the reaccumulation of the crusts. The whole snip
of the infant should be perfectly clean. Seborrhuea capitis is simply a tendency to om^
production by the sebaceous glands of their .secretion, which, mixed with dirt, produces t2ii&
conditi«»n.
CLOTHING. — It is very imp)rtont that those who care for the infimt
should not only (Jothe it i)roperly but should understand why one method
of clothing is lx»ttcr than another. Tlie surface of the infimi's body b
greater in proj)ortion to its entire weight than is the case in the older and
hence larger human being. Greater surface means that there is a greater
opportunity for radiation, and hence that the smaller subject will cool off
more quickly, other conditions Ix'ing cijual, than the larger one. We theic*
fore see at once that much cave should l>e given to tlie question of warmth in
the infant. Any ex|X)sure of the b(xly or limbs in either infants or childreo
is unwise. A very im jx>rtant factor in the problem of growth in the in&nt
HYGIENE OF THE NURSERY.
133
I
ig perfect freedom of motion for its legs aod arms and for the respimtory
and alxiominal muscles. It shfujld also be thoroughly understood that
pressure on any portion of the Ixdy or liinl>s must prf>duee evil results,
by dispkunng organs which should be allowed to have entire freedom of
|x>siti(m in their I'espective cavities.
Too little warmth will do harm, by preventing the prt)|M^r metalmlism of
the tissues and thus reducing the animal heaL Too great warmth, on the
other hand, by eaa^mg inequalities in the circulation, will in like manner he
detrimental to the child*s gnjwth and vigor. Clothes which bind any part
of the inlimt tightly cannot but pres.^ out of theii* natural position %vhatever
happens to \)e l^eutmth the }K)int of pressure, whether it l>e the liver, the in-
ines, or the toes. The clothes, then, must evidently be warm and lo4>se,
we must l>ear in mind that loose clothes are warmer tlian tight ones,
from the very fact that they do not interfei^ with the natunil activity of the
circulation, and that they give freer play to all the muscles which pnxluce
the normal warmth arising fiY>m exen^ise. We must rememlier that the
only way in whicli tlie intant ain obtain the exercise so much needed for
proper grow^tli, and w^hich is m easily obtained by the older child in running
alxiut, is by continually moving its legs and arms and thus accelerating the
muscular action of its thorax and alxlomen.
An important item in the projxT management of the infant in its nursery
is that it should be irritated as little a^ |Mjssible by unnt^x'ssary delay in
dressing it after its bath, Uselt»ss stitches, buttons, and articles of clothing
should be dispensed with, and a method ailopted which, while ctimbining the
necessities of dre?^s which I have just sjxiken of, wuU allow the dressing t<j be
finishctl Ix'fore it has time to annoy the infant,
AnrJOJiiXAL Band. — There is no necessity' for using beyond the first
two or three weeks the usual flannel l*and supjxpsed to be so indispensable
by the average nurse. Herniie, wliether umbilical or inguinab cannot be*
obviatetl, and in fajct may he pnxlucetl, by undue alMhmiinal pressure.
This form of abdominal band (Fig. 37 A), which is made of light soft
flannel, ran be snux^tlily a]>plitil over the di'essing of the cuixl and kept in
place with m<xJerate pressure by means of safrty-pins.
The band can soon ^K^ rcjihiced by a somew^hat elastic knitted garment
(Fig. 37 E, A), half liaud and lialf shirt, with shoulder-straps of the same
material to hold it in phu-e, and a tab in front to fasten it with a salety-pin
to the napkin {Fig. 37 E, B)*
This shirt t^an be made of soft wool or silk, or, as I have recently fouod,
can l>e knittcnl in any fcirm or size frf>ra half ccjtton and half silk.
This knit material can also b)e ust^l fr)r these <>thcr undershirts which I
have here to show yon (Fig, 37 B and Fig. 38 F, page 137). Garments
made in this way are the l^est that I have ever seen. They are warm, myft^
and delicate, have no seams, can l)e washixl without shrinking, and rt*tain
their elasticity" much better than those made from the other materials which
I have mentioned.
134
PEDIATBIGB.
"?
Pio. 87.
{Long Clothea.)
A
— :??■ — t
r%.
'^'
'i/^
^ A
FUimel band lor early weeks.
DroB.
A, knit band ; B, napkin ; C; stocJdiiy.
HYGIENE OF THE NUKSEBY,
135
Napkiks, — This napkin (Fig. 37 E, B» page 134) L^ folded and ikstened
with satety-pinri as ia customary for keeping it in place. ' The usual na[>kin
is very cumbersome and heavy, besides being expensive. It can be replaced
by mils of .soil al)st>rbent gauze, which absorb the urine from the skin, an
importaut quality iu Ciisc'S where the skin is easily irritated. These napkins
can simply be cut from the roll, w^hieh is kept iu the nursery, and, when
removed from the infant after a moAx-uieut of the h*n\els, cau Im? burned,
thus avoiding the trials resulting from the objections of the nnrse or the laun-
dress to washing the napkins. If, however, the mother preiei^ the regular
old-tkshioned napkin, small squares of this gauze cimbe placed in the middle
of the uapkiu, and this will in great measure obviate the moiH? disagreeable
part of the napkin-wash iug, as the s*juare of gauze will hcJd most of the
movement aud can at once be burned.
The infant while in long clothes nwxl not have any furtlier coyering for
its legs, and uveii have m^thing on its teet. There is no particular objection
to little knit socks if the mother w^ishes to use them.
After the tuirse htis put on the l:Miud and tlie napkin there ai-e left three
garments which are usually the clothes needed to wuiiplete the infant's out-
fit of io7ig clothes.
Tliest' garments are the shirt (Fig. 37 B, page 134), the petticoat (Fig.
37 C), and tljc dress (l^ig. 37 D).
Shirt {Fig. 37 B). — The shirt is a garment with long sleeves aud high
neck, cut almost as long iis the outside white slip or di-ess. Unless it is
knitted, as I have licfore described, it is well t*i have it made of some soft,
fine, all-woid material, with the si-ams fiuinhed on the outside to prevent
irritation of the skin. It is made to button in the back. A fresh garment
of this kind is also sutlicicut for the iulaut's dress at night, exix^jit during tJie
eiirly ww'ks of life.
PETricx^AT (Fig. 37 C). — A flannel sliirt cut all iu one jneoe, as the
shirt is, made of fine flannel with no sItH.*ves aud with low ncx k, represcuts
the pettictmt. It should lie made large enough to gf) over the shirt, should
be of the same length a«^ the dms<, and should also be uiade to button in the
back. Tlie taste of the mother ran Ix* ^^[ratititHl by any reas4>nal>lc degn\^ of
emlirfiidcry which she may wish to init on this second garment, but the shirt
should he jicrfectly plain.
DkE-Ss (Fig. 37 I>). — The outer garment should be made of some soft
white material, such as nains*x>k, should l>e large enough to go over the shirt
and pt^tticoat, sliuuld nut Ijc stan'lic*!, und is usually alwut one yard long
from the nwk to the Imttom of tiic skirt. It should Imve high neck ainl
long slet>v<:^, aud should Initton Ix^liiud.
The advantage t»f this t^jstumc is that it is loose but warm* and that the
three pieces which constitute it tiiu be put on together, the infant having to
be tnrne^l over only once before the clothes ai-e buttoned. The uther methods
of clothing usually necessitate turning the baby over several times in the
process of dreeing.
136 PEDIATRICS.
Before the infant has had its bath, these three articles of dress are to be
arranged one inside* of the other, ready to be slipped on all three at onoe.
This can be done with great celerity, and the dressing prooesB can thus be
gone tlirough without the usual accompaniment of irritated cries which are
so frequently heard in the nurserj', and which are to be dq>reeated.
When the infant is old enough to have its long clothes changed to short
ones, which is at about the time when it leanis to creep, the under-gannent can
be replaced by a knitted or fine all-wool undershirt with high neck and long
sleeves (Fig. 38 F, \mgc 137) made short, with an additional white petticoat
in winter if desired. The infant should now also have its feet and legs
covered witli long white wool stockings, which are kept in position by being
pinned to the napkin (Fig. 37 K, B, page 134). When the child begins to
walk, soil kid shoes should be used with the soles adapted to the natural
curvt»s of its leet, as I have explained in a previous lecture (Division II.,
Lecture IV., page 105), and as I shall presently show you (page 139).
Sto("KIN(;s. — A word more in regard to the stockings may not be out
of place, and is esiKXjially nettled in n»feronce to the older child in its third,
fourth, and fifth yc^ars. It is a mistake to think that if we keep the feet
and alxlonuMi warm the legs can be left uni^overed with impunity. Short
8to(*kings and Imre legs, in my opinion, should be abolished, as a prolific
source of catarrhal c^onditions. The argument is a poor one that certain
child ivn have Ixyen known to grow up well and strong with uncovered legs,
or even that our ancestors were in the habit of depriving their children of
suitable coverings for their necks and arms as well as legs, while they tliem-
selves were warmly clotlH^l from head to fiH)t. Our ancestors did and said
many things which, to us, <^)nvict them of gixrat ignorance. I have said
that the stcK'kings should Ix* white. This is to insure freedom from poison-
ous dyes, which at timers seriously aifeirt the delicate skin of the young child.
Colored st<K;kings an* a soun*e of great gratifiimtion to lazy nurses and to
those who wish to lessen the size of their laundry.
There are three garments which are usually put over the shirt and are
considcnnl to complete the short clothes. These are the flannel petticoat, the
white jK'tticoat, and the dress, and they are to be made large enough to fit
one ov(T the other and thus to Ixj put on all at once.
Flannkl Petticx)at (Fig. 38 (}, page 137). — The inner garment
next to tlie shirt has a flannel skirt, a cotton waist, low neck, no sleeves,
and is fastened with buttons in tlie back.
\\'inTE PETrK-OAT (Fig. 38 II, page 137). — Next to the flanael petti-
coat (x)mc^ a garment with a skirt of some soft white material, with a cotton
waist, low neck, no sleevf»s, and also buttoned in the Ixick.
Drf^sS (Fig. 38 I, page 137). — Finally, over all the other garments
comes the dress, which is made with high neck and long sleeves, and is
buttoned behind.
Nigiit-Dress (Fig. 38 J, page 138).— A regular nightr-draea can
now be used, made of soft flaimel, with high neck and long sleeves^ ^f|^
HVGIIINE OP THE KURSERY.
137
8b in
FIjuuiel petticoaL
VihiUi petUcuttl.
138
PEDIATRICB.
buttouwl l)ohind. An extra ji^arment can in cold weather be worn under the
night-drcris if deemed advisable for the especial child.
FEET. — I Lave aln^dy sicken somewhat at length about the instep,
and how im]Kjrtant it Ls to guard it from the usual injudicioiis treatment
which it receives. In young children, although the foot may be well formed,
it is very weak, so that the arch is easily broken down. The pad of fat to
which I have previously referred (Division I., Ijccture II., Fig. 13, page 50)
is a physiological protci^tion against such breaking down. Children should
not Ikj allownl to walk until some time after tliey are ready to do so, alwavs
allowing, of cr)ursc?, that if they insist on walking they can seldom be re-
stniined from doing so. As they get older, long walks with their parents
should, if iK>ssil)le, lx» forbidden, for it is thnmgh these long walks that the
evils which I have just endeavored to explain to you are brought about. The
child will get exercise* enough at its play, and in doing so will not overtax
the arch of its foot, or use its fcH?t l)eyond the decree which nature intended.
Children should not ]ye told to turn the t<K»s out too much, as this pnts the
an^h in a jK)sition where the nmscles give it least support. The average
dancing-school master is a fair exami)le of what over-zealous ignorance oom-
bincKl with the resi)ected traditions of the past can do to children's feet.
SHOES. — Children's sh(K?s should Ik' rights and lefts, like those of adnlts^
as the present style of straight shoe gives no support to the arch during %
HYGIENE OF THE NURSERY.
139
very important period of its f^wth ; this, moreover, also tends to push the
great toe towards the median line of the foot, and so to cause enfeebling of
the muscles which have so much to do with the proper elasticity of the feet.
We should, therefore, have shoes properly adapted to the child's foot, —
shoes that will at once be comfortable and leave the feet free to develop and
fiilfil all their fnnctions. The children's shoes as we find them in the stores
have the two sides of each shoe symmetrical and equidistant from the
Pio. 89.
Cass 44. (Natural size, 1} years.)
Unsuitable shape for sole of child's shoe.
Suitable shape for sole of child's thoe.
middle line ; the right and left are told only from the arrangement of tlie
buttons, and are frequently worn interchangeably. Now, the foot has no
such median line on each side of which the parts are equally disposed;
and its two edges are very diiferent, as a glance at the soles of this one-
and-a-half-year-old child's feet wall show (Case 44, Fig. 39).
We must note especially that the phalanges of the great toe do not naturally point
towards the outer border of the foot : such a position , common as it is in the adult, must be
considered as an acquired deformity which started, in all probability, with the first pair of
leather boots.
140 PEDIATRICS.
I will now show you how contrary to all anatomical rules are the shoes
which are usually sold for young children. Dr. Dane, to whom I am in-
debted for all these valuable suggestions concerning children's feet and shoes,
has made a tracing of this child's foot to show how the lines of the sole
ought to run, in order to be adapted to the anatomical oonditions. The
dotted line around the lefl-hand tracing shows the shape of the shoe that was
provided for the child's foot at the shoe-store.
That this matter of forcing the first toe out of its normal position may
bring with it very serious couseiiucnces is easily sho^n : as it inclines against
tlie terminal phalanx of the second toe, it often crowds it backward, and
finally makes it the distressing " hammer toe," which may even require a
surgical o[X'ration for its relief. On the inside of the foot, as soon as the
axis of the first toe is bent, we begin to find a bulging out of the metatarso-
phalangeal joint, whi(;li in later years, fosti»rt»d by pair after pair of tight and
ill-fitting boots, is capable of giving tlie most exquisite pain. Still more
subtle in its working than this is tlie tn)uble that often comes from disabling
the gn^t too from ix^rforming its full function. The elasticity of our step
dej)ends larg(»ly uiK)n our i)ower to press down firmly with the great toe and
then raise the weight of the Ixxly over it as a support ; when this is lost by
crippling the toe with ill-shaiXHl boots, the muscles not only of the first digit
but of many adjacent groups lx»gin to atropliy. This soon leaves the inter-
nal arc4i of the foot without sufficient supjwrt, and the long series of woes
in(*ident to " flat-fin )t" is started u|K)n. Therefore, for one and all of these
reasons, let us demand that children's feet shall have at least the chance to
develop proi)erly in well-fitting anatomical sluws.
SLEEP. — Infants and young children varj' much as to the amount of
slec]) which they need and take* during the day. At first they sleep almost
continuously, espvially if they hap]Km to be somewhat premature. In a
few w<*eks, howevcT, th(»y Ix^in to have regular |)criods of rest, consisting of
several hours' sh^c]), at first twi(xj in the day, and later once. The more sleep
they can 1k» iiiduced to take in the twenty-four hours, the better. As they
grow older tlic amount of Aivp which they take grows less, but in the first
four or five years of life it is well to try to indu(*e the child to rest quietly
on its ]ml fijr at least an liour during the day.
WHEN TO GO OUT OP THE HOUSE.— If the infant happens to
b<* lx:>rn in the winter months and the wcjither is at all severe, it is better to
keep it in a well- ventilated nursery, such as I have already described, fhsm
to run the risk of its vitality iK'iug lowentl by exjx>snre to cold. I believe
that infants in our Northern climate an; exiK)sed to cold far more than they
ought t<^) 1k^, and that they need fresh, warm, dry air, rather tlian the cold
and often damp air of our winter months. AVhen they are l)orn in a milder
climate, or at a warmer si^asou of the year, they (»an after tlie first few weeks
be taken out in their carriages often twice a day. When the infant is five or
six months old I am in the habit of giving the following directions to the
mother jis to when she shall stmd it out. I exjilain to her that it
HYGIENE OF THE NUKSERY,
141
macli differenc?e whether the air is damp or dry, and what the rate of the
wind may hapj3en to be, as does the number of degi-ees indicated on tht- ther-
mometjer. If the sim ia shining, the air dry, and tliert* is no wind, the infant
can witJiout liarm gt) out for an bom* in the middle of tlie day even at a
temperature of —6.6** to —3.8° C. (20*=^ to 25^ F.)> WTiere, on the contrary,
the air is damp, or the nite of the wind is j^ix?at, it is better for the infant to
remain in its nui-sery, and, at any mte, not to go out, if* tlie teDijMTatmt? m
Ijelow 0^ C. {32° F.). The practice of allowing the infant to sleep in the
o|X*n air in its carriage in every kind of weather is, I believe, a bad one;
but on the days when it is projKn* ttir it to go out, 8uch ns I have already
dci^cribed, it can without barm sleep in the open air. The nurse should be
directed to prr^ttx^t the infant's eyes from the direct rays of tlie sun^ and
not to allow a strong wind to blow in its face.
Where the weather litis l)een Um severe or damp for the infant to go out
in its carriage for some time, it is advisable to have it dressed warmly and
wheeled up and down in its nursery with the window ojien for fifteen or
twenty minutes. To avoid too nviieli draught, blanket^; can lie plmxxl over
the cracks of the doom and the open fireplace while tlie infant is breathing
the frt:^ii air. The ro<im l>eing far abjve the gruurrd, tlie dampness is
avoidt^l, and even a cxiiisiderable velocity of the w ind outside the house will
in this way he unable to affect the air of the room, and will not make too
strong a dmiight
Not only should an injudicimLs administration of tnild air Iji* avnidi'd, but
extreme c*are also should be taken in hot weather that the child is notexp>st*d
to too great direct heat from tlie sun, and it should never be kept in a hot
atmosphere where cun*ents of frrsb air t^anuot have access.
NURSERY-MAIDS.— The id(»a tliat the child should be taken care of
by an old, experienced nurse is a vicious one. The exjierienee of nurses, as a
rule, is that of ignorant^e rather than of intelligence. Every mother, as she
is presumably more intelligt^nt tiian the nurse whom she employs, and is
surely more interested in the welfare of her child, should personally super-
vise and unhesitatingly investigate nW that the nursi- d^HAs to the child. The
nurse's ideas m to wliat is nei^dctl for the child's hygienic siu'roundiugs, f(>od,
and clothing can well be dis[>cnsed with. The mother, learning from the
physician what is best ft»r her child, should give her dinx'tions to tlie nurse
and see that these directions an* strictly earrieil out. A nui'se between the
ages of thirty and ihrty is preferable to one who is younger or older. She
should be neat, healthy, strong, cheerfnl, gentle, and patient. She should be
willing to refer small details of the nnrser}' niutine to the mother, as well
as those which ap[x*ar of greater im|w>rtanc^. The chief attivibutes of a good
child's nurse, in my opinion, are a desire to obey implicitly the orders which
the peoeives from her mistress, and a tem|>erament in harmony with the sen-
aitive nervous organization of her charge.
MOUTH. — I shall ask you to join me in entering a protest against the
in which the nurse, and in fact almost every one who comes near the
way
142 PEDIATRICH.
infant, put their fingers into its mouth on all occasions. It would seem as
though the infant's mouth ^vas considered by those who ought to know better
as something wliich was es|)ecially made to be felt. Infants are much more
likely to have various diseases in their mouths than are adults, and probably
one reason for this is that dirt of all kinds is constantly being introduced
into them. The fingers should always be thoroughly washed before entei^
iug the infant's mouth, and yet unwashed fingers are continually feeling the
baby's gums to as(*ertain if a tooth can be found.
The nurse sliould be instructed that she is never to kiss the infimt on its
mouth, or allow any one else to. The germs of disease can well be transmitted
in this w^ay. It is {tartly through ignorance of its doing harm, and partly
through timidity on the part of the mother in prohibiting it, that a stop is not
at once put to this bad habit of nurses and friends, and it is the physician's du^
to warn mothers on this apparently trivial but really important question.
In a later lecture, when speaking of tuberculosis (Caae 263, page 603),
I shall report to you a particular instance where the child was, in all prob-
ability, infected by its nurse.
SCHOOL. — I have not a great deal to say about schools. I think, how-
ever, that much ignorance of the child's nervous organization is shown, by
those wlio should Ixst know how to care for it, at a period of life when its
hygienic surn>uudings, both mental and physical, are extremely important
No one system is good for all children. I am sure that I have seen the
kindergarten system do harm to a number of children, although it seems to
suit others. Each child should be gauged for itself, and not be forced into
any general system, even if that system has proved to be good for the manv.
Jso time Ls lost, in my opinion, in sending children to school at a somewhat
later age than Ls usually 8upiK)sed to he necessary. I am continually having
to take little children out of school who are fretful and have loss of appetite.
Neither parents nor teat^her seem to appreciate that the little, actively growing
bniin is overtaxwl by too great stimulation and Ls protesting against 8u<£
treatment by th(»se gc^neral symptoms. Many a child is being dosed with
tonics who merc^ly n(«eds rest fn)m school. The jiarents should keep the most
rigid supcTvisiou over their children while at school, and notice from their be-
havior whether they are montully tired. This suixjrvision should not be left
to the teachers alone, however interested they may be in their little pupils.
It seems hartlly n(X'(»ssary to stiite that the siJiool-room should be well ven-
tilated, and that at stated intervals during the school hours the windows
should Ih» thrown ojk'u and the atmosphere of the room completely changed.
This should not, however, \ye. done with the children in the room. Atten-
tion should Ik? paid not only to what the children eat at lunch, but to how
and where the lunch is eaten. A child really needs nothing but diy bread
betwecm its mc^ls, so far as its nutrition and digestion are concerned.
DEFECTS OF POSTURE.— How can we l)etter appreciate the im-
portance of following nature as closely as ix)ssible in its methods of de-
veloping young human Ixjings so as to jjerft^ct their various functions to the
HYOtEJJE OF THE NURSERY.
143
I
fullest extent, than by examming carefully this group of mal formed children
which I have brtmght here t*j shciw you? (Cases 45, 46, 47, 48, and 4tK)
Back. — The extreme flexibility and slow development of the spine
clearly point out. to us that nature intends to leave its funetion in abeyance
and bring it into use slowly. If the young infant is allowed to Rit or stand
at too early an age, the superincumbent weight of the large head tends at
once to exaggerate the physiological curves of the spine to a p>int where they
may become pathological. As I have already told you in my lecture on
Development^ during the first year of lift* the strength of the spinal (X)lumn
is slowly increasing* Not before the seventh or eighth month has it ac-
quired suiBcient rigidity to warrant the child's being allowed to sit up.
Artificial methiKls, thci^efure, of making tlu* young infant assume a sitting
posture at a peritKl of development when the spine sin mid \}e com]mratively
straight should be deprecated. I have met with numei-ons instances where
both parents and nurses were anxious to have the infants, at a very early
age, sit for quite a long time strap|>ed in t-'mall chairs. In like manner the
same infants were encouraged to stand and walk lung befoi-e the apparatus
for locomotion was ready for use. We may ask, how many of these indi-
viduals developed a spinal curvature in later childhood ? Possibly the risk
in a perfectly healthy child may Ix* small We otk^n, however, in early
infancy, cannot determine which individual may become rhachitic, and
where rhai^hitis is prcs4*nt the tendency to abui>rmal curvature is well known.
We should, then, in our advict^ as to the projxr physical management
of the early years of life, l>e guided by our knowledge of the normal
average develoi>mcut. Free play tor the infantas legs, when lying on ita
back in bed, sliould be a j>oint to Ix^ notic*eil aiwl considered, since we know
that pressing down the legs causes strain and curvature in the lower spine.
Knowing the great lateral flexibility of the infant's spine, we should advise
the nurse not to hold the infant continually on one side. Symmetry of de-
velopment aud tree optMUiunity tor natural movement should \ye our aim in
the management of the infant from the very earliest {leriod of its existence.
Our koowleilge of the giY^at flexibility of the grcuving spine provides us at
once with a most valuable means for treating lateral curvature in ehildlimid,
and we are continually seeing the benefit of encouraging the promotion of
elasticity by moderate pressure and lK*ndi ng. A case which is now under
obser\'atinn in my service at the Infants* Hospital Iw'auti fully illustrates the
truth of what has just been said.
A feeble, rbnchitic child (CaAe 45), nineteen raonths old, wii« presented for treatment
with a mnrkL*d Intt^nil curvature in the doreal repiun, the convexity being towards the tight^
combined with dtwided rcjlation^ following the type? of the wor^t adult csi&ei.
The condition ^eerneii to be pun?ly the n'*ult of hubit, the putient hHving been msde,
whfii vt'ry young, to sit up beyond the limit of endumnce of the stiU undeveloped bones
and ligaments. The trentment instituted by Dt, K, W* Lovett» who took charge of the
cme, wtus based entirely t»n the elasticity of the spine, *n*i congisted eiioply of manipulation
and recumbency, resulting in a very great degree of improvement both as to the curvature
and the twisting.
144
PEDIATRICS,
Dr. Lovett also telLs mv that in the surgical out-patient clinic at the
Children's Hospital thf improptr treatment of the yoimg sufcyect's spine, m
in infante, for in!*tanc*e, where they are carried altogether on oue aiide, k
well recognized as an iiniiniitant factor in the etiology of rotary lateral
curvature. I have ^^een in this clinic a number of examples of this claagy
and have been much im[)ressed with the impoiiant relation which anatonucd
knowki.lge Ix^ars to clinical [inijihylaxis, diagncisis, ami trc*atiiieiit.
If you will bear in mind what I told you in speakinja: of the osBifieatson
of the ditferent jKirts of the spinal c«3lumn, you will readily underf^tand that
so long as an infant eau V>e made happy in the prone position, whether in its
nursery or in its carriage, it will l>e better for it to be kept in this poshioa,
always pnitecting the eyes when out in tJie open air fmra the strong light,
and the iiioe fmni the wind. During the first year when it begins to sit up
in its carriage ite back should t>e carefully supported by a pillow.
Cask i([.
p.wf .1^..,- .piiini t urvHtUfe from t^iuliig Um^i s^xm.
I have here to show \uu an infant (Case 46) who is u IHting example of the bum
which Clin be dont^ by enc^mragiiig elnldren to sit up before thoir spinal columnB mj^ suffi-
ciently strong* This infant, *ix montbii old, has been made to uit in a chair for houn ata
tiiue» fi trapped in a position which allow«?d it to use iU arras^ hut such aa to render it im-
povible to fall buck and rest itself You see the exaggerated i'UTve of its back, which co^
respondi to that which would \m seen normally at birth. Such a cun e I have alf^dT
ihown you in Diag^mm 11.^ Curve 1. If this infant hud not been made to sit until it bai
developed sufficiently to acquire the physioloEriwil curve (Diaiernim IT., Curve 2), it wottU
not at this age ahow any spinal cur^^ature. It hiu*, however, l.hrouj2;h improper treatment
reacquired the poetenor curvature (Diagram II. , Curve* 1) of the early hours of lift^
UVOIENE OF THE NURSERY. 146
As the child grows older, weak undeveloijed mu&cles have a tendency to
allow lateral and posterior ciir\^ature8 to be pn:>dueecL Habit, of eour^, lias
much to do with these faulty positions of later childhood.
Cabe 47.
Lateral curvature of the spioe. Child four auc) one-half jeara old.
This little ^\t\ (Caee 47) ^ aped four and on^half years, show* a lateral ciirvatUT^, not
from dlticnuie of the ^pine^ but one which h uBUtill3' expluined u» a rei^ult of »u{H'nTiciitiibent
weij^fbt eoDiing upon muaclea which are unable to support it properly.
You will notice, on looking at her from behind, the curve which the line of the «^pinal
column take* to the right in the dorsal region, so different from the jitmight line of the
nomiiilly developed boy which 1 showed you in my lecture on Norma! Development (Di-
viBion n,, Xreeture IV., page 124, Case 88), On looking at this eame child in frtrnt, you will
notice how the right shoulder ie higher than the left and how the whole thorax h in a di«-
tc»rt**d fKidtion. These defbrmities are always more readily recognixt^ by ktoking ul the
child in fn»nt and preferably acroas the room, as the outline of the ehe«t and bip§ is much
roorv cleurly dettned on the anterior aspect of the Ixxiy than on the posterior. Posteriorly
you will in cases even of the ^lightciit liitenil eur%'ature at once notice the diflerenee in the
level of the tips of the scapulie. Thi» child atoope, and has what Is commonly called
found shoulders.
This should teach you that in any case of round shoulders lateral
mature should be thought of and carefully eliminated.
10
146
PEDIATKIC8.
Faulty attitudes in sitting mul htauding play a great r6te in producing
these curvature. We raiist, howeverj ackiiowled^ that such spinal eiirva-
tiuvrt have bcx'n diffeitnitly ex|>laimtM:I on t\\v ^nnmd that they are ilie result
of a lai*k of dL'vrlo[uiM'nt of all i\w tissiit^ up m »»ne side of the* spine. Other
explanations have vAm Ix^n given ; but in certain individual cases it is iinp:>&-
sible to fiirnndate any iTasoiialile canst* for the curvature.
Legs. — At birth the iufaut'.s lcg8 are curved ratlier than straight, a^ I
have ali^eady de^crilied to you ( Lecture IV., page 1 18), wheji I showed you the
infaiit Hkeletoris at birth and at uinctt^^n inouilis. The natural tendency of
the grt>wth of the legs* iw to bc<*otuc strai^lit, but if the child Ls exi«>urag«l
to stand and walk t«x) ho<iu, eisjKvially if the bjues have not been prop-rly
nourished, the weight of the ht^l and trunk bei^imes too great to be sup-
jKiftetl by the leg^, whii-h curve out wai**! in the form of an elli{>se^ a condition
which in ealted " how-leys,''
Case 48.
ti - w-lt tr^ < lii |4 1 Ihan.' ami nne-luiir yaifs old.
Thi? Httle boy {Case 48)^ three und one-half yt^ll^^ old^ hfts, m I learn, been encouraged
by hi^ parenU Im stand and wwlk befnit? he whs w year oM.
Ilk iiourbbment hius also been nitlier iinperfectt but ht^ is not rhaebitlc. You see tft
the retiultof this conribimition uT rirciitiiAin rices » dr^idc^l huwinj^of both le^. He \& \mtim
treated in my ward for fiieiul 4X';i<*iiui. which iittNiunts for his mther stftrtlirig head-^ean I
ibaU describe hini as a cjise of eczema in u Inter lecture.
HYGIENE OP THE NTKSERY.
147
The deformity called *' knock-knee," in which the leg at the knee, bends
in rather than bows out, may occur from simple weakness^ but is so rare
except when rhaehitis is present that it is Ix'tter
to 8|ieak of it in e<jauection with that disease. ^^^ ^^■
Finally, I should like you to examine carefully
this girl's back (Case 49).
She is fourteen years old^, and present*, as you see, a
typical ease of br>w-leg8 and of laterul curvature.
These conditkmH are not the repre^entalivefi i»f disea^*:^ of
the bone exieting now, but are the rt'sult of improper nu-
trition catismg the bones to become softened (rbaehitic) aiid
eaaily bent They are ako the outcome of laclv of care to
correct^ by prt>per gymnflstic exemies, weak musclt* and
bad positions of the trunk. When we consider that such
condition's as we see m iniarked in ibis girl could have been
w -aliviatt'd by proper treatment at an earlier p*.*riod of ehild-
'%ood, when they were l>eginnirig, we can readily understand
the irrifvijrtanee of cart^ful medical euperviBion in preventing
the acquisition of various deformities.
VACCINATION,— It is now pretty well ac-
ceptetl thruughout the world that the intnxhictitm
of the vaccine virue into the circidation pruteeta
the individual tiYjm variola. The physician in
general practice, however, is so often (|uestiouecl as
to the advantages in oonti*ai*t with the dangci^ of
vaccination, that it i.^ particularly advisable in
regaril to infants and childi'cn to kncnv a few facte,
especially concerning primary inoculations. Ac-
cording to the careful investigations of McC'ollom
on the hist*>rv of variola and vact*ioatiuo, wmpid-
sory vaccination was susjK^ndcd in Zurich, Switzcr*
land, in obedience to popular clamor, in 188-1 The
deatiis fn>m variola, out of one thousand dcatks
from idl causes, for the |>revious two years and tliat year had been, — in
1881, 7; in 1882, 0; and in 1883, 8. After cctmpulsory vaccination had
bc^n done away with, the deatlm i-ose in 1884 to 1L45, in 1885 to 52,
and in the first eight months of 1886 to 85 per 1000,
In tills connection it is of interest to 'note that during the epidcnuc of
variola in Prague in 1888, 76.57 j)er cent, of tlie unvaceinated died, wliilc
only 10.58 per cent, of the vaccinated suctnimlx'd to the disease.
In Boston from 1721 ti> 171^2, a pt'rind of scventy-<jne years, tJiere were
three very severe and fatal epidemics of variola, or one in about every twenty-
three years. From 1792 to 1892, a |>t*ri4M3 (if one hundred years, there
had been only one severe epidemic* <>f this disi'iLse, and even this could not
be compared in severity with those in the laat century'. The protective power
of vaccination is the only possible explanation of this eoni|mrative immu-
Sptnal curvatUTe And bow-
legs. Girl Bged fourteen yeais.
Rhachitw and Ijick of ear© in
earlier childhood.
148 PEDIATRICS.
nity from variola during the last hundred years. In the past ten years the
percentage of deaths among the unvaocinated at the Boston Small-Pox Hos-
pital has been 75, while that of the vaccinated has been only 3 per oent In
the ])ast twelve years no person who has been sucoessfuUy vaccinated within
five years has died of variola, and those who have been attacked by variola
have had the disease in a very mild form.
Dr. Barry, in his report of an epidemic of variola at Sheffield, £ngland,
during 1887 and 1888, gives a verj' clear idea of the relative frequency of
deaths occurring in the vaccinated and in the unvaocinated. I have arranged
a table (Table 32 a) which illustrates his results very well, and shows the pei^
centagos of those who, living in houses invaded by variola, were attacked by
the disciise, and also liow many of* tlu'se died. It also gives the percentages
for all ages, for under ten years and for over ten years.
TABLE 82a.
Indiriduah living in Houses invatled by Variola.
(1) (2) (8)
Vaccinated.
Unvaccinatcd.
All Ages. Orer 10 Yean. Under 10 Yean.
f Attacked . . 28.0 per cent. 28.1 per cent. 7.8 per cent.
Xvuid .... 1.1 " 1.4 ** 0.1 "
1 Attacked . . 75.0 *' 68.0 " 89.9 ««
I Died .... 87.2 " 87.1 ** 88.1 "
The low percentage of children as shown ui eolumn (3) is very striking
in comparison with (M)himn (2), which represents older individuals and enun-
ciat(« the imiMjrtauce of revac<»ination, A glance at the table at once im-
pres.sc»s u|H>n us the significant of the difference in the number of deaths
bc»twccn th(» vaccinate<l and the unvacscinated. We can hardly imaf^ne anv
other exphuiation for this gn^at difference in the mortality rate than the sup-
|X)siti()n that the vaccine virus is highly pn)tective against variola. Still
mon* striking are the actual figures recorded as representing very large num-
bers of cases of variola. Thcs(^ figures show that among the vaociiiatedy nine^
teen individuals out of twenty recovered, while of the unvaocinated, fifty
individuals out of one hundred diwl. It is not held by the advocates of
vaccination that one vaccination will protect for a lifetime. On the oontraiy,
revaccination is just as imiK^rtant as the primary operation. One attack of
variola does not always protec»t an individual from a second invasion, and
more should not be ex[)ectod from the operation of vaccination.
• Dr. Josef Korosi, Direc^tor of the Buda-Pesth Statistical Bureaa, has lately
published the statistics of 112,000 ol)ser\'ations made with referenoe to tl^
dc^leterious after-effects of vaccination. As a result of these observatioDB,
the author concludes that, even if any slight increase of mortality can be
chargcnl to vaccination in cei*tain sjiecified diseases, there should be placed to
its credit a saving of life at least thnn? hundred times as great. Korosi
stands at the head of living statistical authorities upon vaccination ; henoe
his conclusions are entitled to great res|)ect. He attaches to vaccination a
greater preventive power than U) any other known means or appliance in the
whole field of medicine.
HYGIENE OP THE NURSERY.
149
I
I
I
Variola has been comrauDieated to the cow by direct implantation of the
virus. The efibrts to actTimplkh this were numerous and at tii*st uut^atis-
factory. The iii^t successfnl iuoeulatioii of tliiri nature was at Berlin, in
1801, Since then many ob^^Tvationt^ have bet-^n made in this diiwtiun, and
the cx>nclu8ions of those who have careftilly studied the subjeet and are there-
fore qualified to judge are that :
1. Variola is inoculable on the bovine species when the method of oper-
ation m gooil aod when the viras is taken at the pr<t|)er time.
2. Inoculation of the calf with variola forms a valuable source, in a new
direetlon, tor obtaining animal vaeeine. Tbij^ is of great practical vahie not
only for tlie vaccine institutions of Euro{K% but alsc* for those of wanner
dimateSf where variola is frequently endemic and where vaccine mildly
deteriorates*
3. Variola inoeulat^ii on the calf is transformed after several transmis-
sions into vaeiiue by its pa.ssage thraugh this anioiab Dr. Fif^cher, Diix"c-
tor of tlie Vitelline Institute at Karlsruhe, in Germany^ perftjrmed at alK>ut
the time when Korosi was investigating thk subject a series of similar
exj>eriments, and he arrivtnl at practically the same couclnsions. These
experiments, according to McfJollom, refute the argument of ignorant theo-
rizers, that the va(N:*iue disease cannot protect against variola t)ecause there
is no c(«iiuM-'iio[i Ix^twecu these two disi^ii^es, Finally, I am antFiorize<J by
Dr. John H. lliCoIlom, the city physician of Boston, to state that no death
from varitila ha-^ iMYnirred during the hist ten years liere in Boston of a child
who had been vaccinated before it was five years old. Witii tliesc facts
before us, I shall not disi'uss further the merits and demerits of vaccination,
but shall take It for gnmttxl that it is well to vartnuate the y^iung infant*
The time at wliich this should be done is, I think, of c<msiderable im|K>rtanee»
The infant should be vaccinated early, befon* it begins to be expisiHrl to the
danger of contagion tmm sources outside of its home. We must, however,
remember how low h its vitality' at birth, ami liow readily this vitality is
affected by what would be considered triHing ct>n<litii>ns for the older <'hild
or for the adult. A time should be (*lioseu wlieii the infant is not subject
to tlie other dLsturbiug conditions which naturally arise in the first two years
of life, such as weaning aud tlie irritation of the tiental ]»eri(>tls. If it is
fiiund uRi^ssary to vaeirinate the infant after the sixth or seventli mouth, or
liefore the twentieth, it should l)e done in an intenJcntal nither tiian in a
dental f>crioil, aud not at the time when its tbiid is l>ciug ehangi'd, or when
it is suffering from either slight catarrhal conditions or some definite dis^-ase.
I prefer to vacc^iiiate tlie infant wlicn it is four or ^ve months old, — that
Ls just l>t»fore the jM-ritKl when the fii-st t^ioth apf>ears. At this age it has
usually l>ee<>me ai'distonuHl to its food, its digi'stion is in equilibrium, and its
vitality is much alxive what it was in the early weeks of its life. By the
fifth month als4j it will usually have developed the outwanl symptoms of
syphilis if it has inheritetl that dist^ase from its parents. You will thus not
be so likely to be blauK^l lor havmg luoc'ulated with something Ix^'^ides the
1» FE'11TE>Sl
\wf\zjr -."ir^i-- ■■iyc - ••^** iai<«ifi ir aAer iMiimuia^ m ike carter veek? of
:.:- & -;• r-cJ-Jtif -3 r«-<>ro* -c* -lii Af<tnr. Tliie lAixitte riniK can be inno-
4 vvri \:*^. L'.T :^-: ..:' ur- *••:;. t;^ q^ :*>e ^kia. and anm^Jiiig Kp the &iMy
',i •sjr ;:.;. -i lir. r :iir*^i-. 'jirl i=jiii> <aa l* raonaaaed jas« below the
k.:j^ -:. ::>- --vr ->> -. : \zjr 'j^y. t« • fc- v- &v--»i faaTinr a scar oo the arm. to
T«:-!r. V. ::>.- ^-jL'.y ■■^'^^^ I iii. i.v>^...cr«l m- raccinaae boys oo tbe outer
'j'l- ■ • r:^ -J'^-' i-*^^ ^V>-^^ :ijr vb'r.iiar».<i t? pcfibniied npoo the k«
'^r r:^ i.-r/.. -*- -L' 'il-l f.r< Lr^.-iirv if ii>r j^r^m who k lo tmke can? of the
'.:i:si:r. > r.^z^i-TjirA-^i • r i-n-Li>v«L If ibe narsie. for inscance. is righi-
fjjirA'^l. -:>- -A iil ur^.-^IIy L ^i izir infuit •.« her left annu and in this cage.
t:>- ;:.:is::.r'-r rljfi: arr:. '.*-'!:^ T.TTirl- ilk nui^. h i? becaer for the vaocim-
tA-'.-i V. •>- '..rj :h- i-:t ^nii. Tii^ i.n»>^r^ fk>Gld be le^aaed where the nurse
I- .* :*'.V£.vi*'>l. a.vi iri :h> 'U-^. z'^r the -^mr nea?«:iD. it i? betaer to vacciiiase
o.'i vv- HrfTr.t arrfi -.r I^j. The i-na ^f \-inxA which I huve been aocn^tomed
t// >w-. ^:yi lAfii' h I •i.n.i.W the h^st. U taken ti«>in cows rather than fiwn
h-:.'i;s:. r>-::jjr.. It .h*«uH ri^r \>rk- oane-nilly prepared by those who hare
rn;a0i*- '4, -^-H-fitiri'- <-Ay **\ thr -ubW-t, and, if p:«^ible, od fiums which are
ntA*-T rrrav- -fj|¥-r\-i-i"n.
I -hail no 'A -}j"W y..u th*- d^-taiL^ of vai?i'ination «iieh as I have fimnd in
r/iy j/ni/ti':*: b, U.. th«: Jj^t. It ha* l^»-n prvtri- well proved by oarefbl ob-
i!#rv;iri',rj of lar^f*- nuriiU:!^ i.f j.riniari- vaci-i nation* that those nho in later
lifi- "^fjTrji/t vnri'.la hav<- thf ili-#-a-*.- iu a 1*^* severe form whef« in their
j#rir/j;fr. v:i/*iriari'.rj- th*-y havf- U^n imioulatcd in three plaoea at onoe
T'A^u* r Ui'AU in xw*. *aiA in twn plao^ at ••noe rather than in one. The gen-
t-r.il '■'.fj-ritriti'.riJil 'li-triHiainr- aU» ilne^ imt a]»])ear to be greater irheie die
ifi'/'«ii;jtiorj }i;t-! U-»-ri in two iir tliH'** plao-s rather than in one. The evi-
t\t\iif th'-n-fon- -*-< rn- to U- in favnr «if in<M*uIatin£r in two or three plaoK
in jiflfn;jrv vii/*ination«. A v^ry *mall surfatv is amply siiffi<!ient for the
(irojj^r irjtPi'Jii'-tion i.f tli#- vim-. Till* ]Niinteil ivor\- qaiU (Plate IV.) »
'liJirj."-*!. Jir Villi -4-#'. with vim-, ami lan U* ii.s«l directly for removing the
"j»if|i'liinn, for ^'XjHi-inj; th«- -inalh-r hhMiil-ves>4'ls, and for introducing the
vim-. I jinfi-r not to u-^- any nion- instniment-s than posfiibley in order to
avoid fh" j»'»--ih]i- intPHJii<tit»n of ^inn' fim-iirn sulk«tance which might inters
fin- Aith th'r natural iiHir-*- i»f tlie vaf<ine vims and cause onneoeasaiy
inflanjnjation.
f wjII fi'.w vji/r-inut*. U-f'»r'- v-.n ihi-. infant i('u-f ■V>), a jjirl. four and one-half months
o|ii ;i/.ij I t,;i%i- « h'l-.i-n JI-. till- |iiw<r f'lr th*- ifitpHiiiftion f»f the virus this point Just below
Hi' Vut*' >,\, thi- \i-\X ii-tr. I tir-t wnOi my hmnl-. v«-ri- thonnii^hly. I then wet the
' i.il t,\ ;i Im hiv-li'.il.'l /;iiiin t'.wi-I in wuIit tii:it ha- ju-t \ti^i\ boiled. The skin is then
fli'.f.,ijr'hly ruhlii'l with \\n- h'>t wtifi-r, miiiI imt <lri«-tl. This proc«.'dure acoomplishes two
|.ijr|»'»i ■■ Tin- flr-t i- to niMovwr :ill ^lirt or •xtninfr-iU.- inatt<>r from the spot where we
firi- ii\,t,\i\. \f «TX|»i/-<- ili<- hl'ifi<l-v('..i-|., Hiifl tliii- l«-H-n the duufrer of septic . mbaoT|ition.
'I III- ii'.rt'l i-. t'f n-iiiovff the <xti'nial hiy^-r nt' th«' epithelium, which has been softened
h\ ilii- h"i w;iier, iifMl ihij-. n-nii'T ili«i !-uhse<|Hi.nt M-mtohini: less painftil and shorter in
ii iliiititi'in I flow nuike u -i-rie- of whort i-eniteln- ji!»out one-half centimetre (mbont
one rmirth inr)i) li.ntr. foiiror five in number, uml in two sots, one crossing the other, until
HYGIENE OP THE NURSEBY.
151
I
I
I
the epitbetium U fiufficientlj removed to show that the blood-^Teiaels are exposed^ but
not to a dt*gree that bleeding should tak^ place, for hi the latter case the virus may be pre*
vented frtno gaining an introductioti to the generul circuladun. (Plate IV.) The point
of the quill should now be dipped into water which haa beta freshly boiled (sterilized). The
flat part of the *jmil which is charged with the vitub is then thoruugblv rubl^ed into the
Wound. The akin should be protected for four or five minuter from contact with anything;
aftt*r tbb the infant can be bathed or go out as usual. In some caae« I have waited until
the .scratch has dried ^ and then have covered it with a small piece of aseptic cotton which I
sealed at the edges with colkniion. After three or four days this cotton can be removed^
and* unless the aubfiequent lesion is broken^ this measure h an additional safegtiard against
infection from extraneous matter in the first few days.
Having now shown you the details of tlie vamnation of ilih infant, I
will also show yon a iiunilx^r of cai^ea at ditleiTiit jieriods of the evoltJtion
of the vaccine vims. (Plate I V, shows the ditfl^i-ent stages as they occnrred
in one carefnlly observed case seen by the artist and myself even" day*)
This infant (Case 51) was vacdnated^i^ c^y« ago. Nothing especial was noticed until
yesterday, when a little red pupule appeared over the side of the vaccinQtion, and ti>-day
you see at the end of the vacei nation scratch a n>und clear vesicle, while at the other end
there happens to be left a little brown crust. (Flute IV.)
This next child (Case 52) was vaccinated eiffht days ago. You see an irregular-shaped
lesion about J cm. (J Inch) long, and 1 cm. (J inch) wide, somewhat depressed in the middle,
and with a clear vesicular border. (Plate IV.)
Here is a case (Case 53) which was vaccinated fm dat/x ago. You see that the lesion
of the last case (Case 52) has now increased in length to 2 cm. ({ inch) long, and to a little
over 1 cm. (J inch) wide, but we now have an erythematous condition of the skin forming
an ai'eola with a diameter of about 2 cm. (| inch), in the middle of which is the lesion just
described. This areola is u light shade of red, and on its outer border are, as you t*ee,
irregularly distributed little light n^d macular (Plate IV.)
Thin next child (CiL*e 54) wa# vaccinated tti*elvc dat/s ago, and you see very nearly the
aame appearances as have c^ccurred in the last caae, except that the areola is very much more
Intense in it^ red color, and has grown to the size of a circle 8 cm* (I J inchess) in diameter.
Some of the little maculie have become vesicles. (Plate IV.)
This child (Case 55) was vaccinated sixteen daya ago, and in place of the vesicular
lesion with its depressed centre you see that a crust ha* formed with a narrow line of rednest
around it, and on the outer border of thi.* areola the redness is gradually becoming fainter
and shading off into the normal akin, (Plate IV.)
Finally, hern is a child that wa^ vaccinated nineteen days ago (Case 56)» The crust
is smaller than in the one which I buv** ju.«t shown you at sixteen days, the redneas has
diftflp}>eared, and where the areola was most prcinounced there is slight desquamation.
(Plate IV,)
This child and Its nurse (Cases 67 and 58) present one of the usual appearances of the
viicci nation scar at ofif year and twenty^ne years, (Plate IV.)
or course tveij case of vaccination does not present exactly the same
apiH'nnina:»s. The lesions may diifer iji sha|i4^ and size, and one iiidividnal
may l»e atfk^tixl more inti?nsely by the virus than another ; one may have
aecijmpanying severe cf>astitnticmal symptoms and another have none. The
cJiain of lymphatics may Ix^ atlt ftixl iis tar as the axilla or the ^roin.
As a nile, the folio win^t disi'ri[>ti«Hi represents pr^itty well the iLsual
course of the disease. Ai\cr the viwcination, the skin shows nothing new
imtil the thii*d, fourth, or even fifth day, when a small red i>oint apptmrs.
This soon becomes a papule ; by the next day a vesicle is develofjcd ; about
152 PEDIATRICS.
the sixth day this vesicle usually Iwoomes umliilicated, and is surronnded by
a faint red zone. By the eighth day the vesicle is fully developed, and by
the ninth day the red zone inere&^es rapidly and the vesicle soon becromes a
pustule. By the eleventh or twelfth day a cnist is formed, and this crust
falls fn>m alx>ut the fourte(*nth to the twenty-first day, in some cases an ulcer
being lefl which heals by another cnist being formed, in others the skin
remaining intact. From the eighth to the twelfUi day there may be a slii;ht
amount of fever and eoatcni tongue, with some loss of appetite, and the
glands of the axilla or groin may become enlarged and tender. The scar,
though perha]>s not typical, can usually be n^^ognized by its small depres-
sions (pits) and its Un^iition.
In a certain number of ca»«es, instead of this regular progression of the
va(*<Mne di.st*ase with it«« chanM-teristic development in a single lesion of the
skin, the virus apjx»ars to give rise to the original disease oow-pox (vaccinia).
Vaccinia is characttTizc<l by the appearance of papules, vesieleSy and pustules
of diticrent sizes in differiMit {mrts of the body and limbs as ^well as on the
face, and running a definite ctjurse. I happen to have a case of this kind to
show you (Case 59).
This little pri, two years old, was vaccinated ten days ago. You see the characteristic
lesion of vaccination on the arm. You will notice, however, on the side of the no«e, on
the forehead, behind one of thi* ears, and on tlic che8t, a number of papules, umbilicated
vesicles, and a few pustules. Tliese lesions evidently represent something more than the
usual course of a vaccination. It is. in fact, a case of vaccinia (cow-pox). The consti-
tutional symptoms an^ not pronounced in thi^ case, and there is no doubt that the child will
make a rapid recMiviTy.
Vaccinia is in my ex|MTicnw a rare disease ; its lesions when following
vaccination apin-ar at al)<)ut the fiith day after the inoculation* At the end
of lour days, however, minute vesicles can Ix^ seen with a magnifying glass.
In some castas, instead of the healiiiji: of the scratch in a few days, or the
formation of the vesicle of a suwessful vaccination, irregular excre«icenoes
of a fungus-like character may a|)|)ear. These in all probability have no
connection with the true vaccine virus, and are not protective. In addition
to tlie rather ran' cases of vaccinia to which I have just alluded, varioos
efflorescence's at times apjH'iu* (»n the skin, not only in the neighborhood of
the vaccination lesion, hut also in other parts of the body. They mnv be
present on the fourth or fifth day, or even later, in the second week, and are
pnibably causf<l by some reflex connection with the vaccination lesion. They
vary considerably in form, but are usually i-epresented by a multiple or
l)apular erythema or an urtii^u'ia. It should lx> rcmembered, where an un-
va(^'inated child has lx»en exi)osed to varir^la, tliat if you vaccinate it within
fortvH'i^ht hours it will probably 1k^ prot^i-tcil, and if within five or six days
the variola i)ois<m will l>c so nuKlified as to prcKlucx) only a mild form of the
disease. Following the advice of Dr. Mcrollom, if such a case were pre-
seut<»<l to me I should vaccinate tlic child in two places. I should then wait
for forty-eight hours and n.'|K*at the vacrination in a third place.
DIVISION IV.
FEEDING.
LECTURE VI.
THE GENERAL PRINCIPLES UNDERLYING ALL METHODS OF
INFANT FEEDING.
f
Just as tlie hi^hc^t aim of meiliciil art Bhould b^ dii'eetal to the proviuoe
of preventive medicine, m tbe highest aiul must prartit:^! branch of pre-
ventive medicine should t^nsLat of the study of the best means for Btartiog
young human beings in life. They should l^e presM^rvod from the jierils
which 8um)nnd the early hours of their exL^tence, and 1m* given .strength
and vigor to resist the attacks which must inevitably be made f>n their
vitality, and wliirli are greater and more dangerous in inverse proportion to
their age. With thertc objeets in view, the preventive medicine iif early life
beccimea pre-eminently the intelligent management of the nutriment which
enables yonng human heings to breathe and grow and live. In fact, it is
a proi>er or an irapn:jj)er nutriment which makes or mars the pertection of
the coming generations, Tlie fcetling of infants Ls then, the subject of all
others which should interest and incite t4> researeh all who are working in
the domain of petliatri<:*s. The subject is a great one, and is worthy of the
attention of the greatest minds of the jige. The resjMjnsibility of dis(*ossing
so serious a question is a grave one. It should be taken up carefully. It
should be dealt with bn>adly. We uuist acknowledge for the present that in
the status of imling, as it has existed up to the last few years, the average
human breast-fed infant was more likely to live, other conditions Ijeing
the same, tlian the infant which ^vas fol by any other metJiod. But wc nnist
remember that the latest investigations of this subject show very clearly that
it is not tinman milk as a whole whieli is pre-eminently good, bnt that it is
a varied eoml>iuatifm of the different clcmentj^ of the milk which makes it
the best foixl during the first year of life. It is our province to stufly and
make use of these elemeut:? of the ilml, whicli wcr* once somewhat myste-
rious, but which arc now nipidly l)ec^>ming known through the work of
patient and careful investigatoi^.
15S
154 PEDIATBIGB.
lu reviewing the immense amount of literature which has aocumuhted
on the subject of fec>(Iing, we find that the superiority of human nulk to all
other kinds of infant food in the early months of life is acknowle^ed so
generally tliat it has become an axiom. On the other hand, the opinions
expressed regarding artificial feeding in the past are so diverse and so
o])])(>sed to one another that it is evident that much which has in former
years txH'u taught must be unlearned, or rather admitted to be untroe, before
we can cx|)ect to make any decided progress in this most difficult subject
In our endeavor to copy nature we may hope that, as our knowledge
iiu;n*ases, more and more light will be thrown upon those points whicJi are
now obscurcil by ignorance. It Ls, indeed, of the first importance that ve
should recognize our ignorance, and, watching every advance which science
is making in this subjc>(^, be ready to sweep aside preconceived ideas whicb
<lo not rest u|><)n established facts, and thus by wise ioonoclasm build our
knowledge on a surer basis.
The great numl)er of artificial foods used by physicians according to the
fashion of the day only pn)ves that artificial feeding has never arrived at that
stati' of ])erfc(*tion where it (M)uld coni{)ete with human breast feeding. The
difficulty in approaching the study of the subject has been that phjrsiciaDS as
a class have regiinled it t4)o purely from a clinical stand-point. We know,
for instance^ how <>asily we may ix^ misled by the apparently good efiects of a
mcHlicameiit wliere periia|>s on further investigation, or in the light of some
new dis(^)very, we learn that the improvement in the case was due not to
the drug, but nithor to circumstiiuccs entirely apart from it. The same
rule a])pIios CM|ually well to the (*asc of many foods and methods of feeding.
To state concisi'ly what I have already referred to, we should, in study-
ing the form of nutriment whi(!li shall be suitable for an especial period
of life, uianifestly Ix; guideil by what nature has taught us throughout
many ages. The research(\s of science at present, especially in the subject
of infant feeding, ar(» wisely diitH'h'd towards learning to read the truths
which nature pn^scnts to us. Great }m>gress has been made in reading
these trutlis. What we an* also endeavoring to do is to copy them, and in
regard to human milk a great advance; has been made in our knowledge as
to what we are to wpy from it.
The tee<ling problem is one which is hedged about with many difficul-
ties on account of the gn^at diversity of individual circumstances and idio-
svncntsi(»s. Certain infants thrive on i)eculiar mixtiu'es which are not
a(laj)t(xl to infants as a cLoss. Many will not thrive on that food which
natnR» has provided ft)r them, and the well-lx'ing of an infant will depend
nuich nj>on the circumstances by wliicjh it is surnjunded, such as afflumce or
I)ovcrty, muntry or city life. The constituents of the nutriment which natore
has ])rovided for the offspring of all mammals in the early period of their
existence is essentially animal and never veg(»table. Human beings in the
first tw(*lve months of life are carnivora. It is therefore evident that an
animal food, entirely and freshly derived from animal and not v^etable
FEEDING.
155
I
sources, has been proved to be the mitriinent on which the greatest number
of human btdngs live and the leant number die.
MAMMARY GLAND.— In regartl to the early months of life, a
knowledge of the changes whii-h take plat.-e in the mammary gland from
many causes is of vital impoitauce and mnst l3e kept in view. The methods
of mtKlifying the milk in the mammarv gland, however limiteil in their
800|>e, .should be cai'efylly investigated and adapted to the individual iuiliiit
aecxii'ding to its age and size and general physical condition. The mam-
mary gland, in its perfect state^ uninfluenced by disease or nervous disturb-
ance, or by the impro|)er living of its owner, is a beautitully adapted pieoe
of mecliaoism constructed fur the elaboration and se€!*etion of an auimal
food. When in ecjuilibrinm it represents the highest type of a living machine
adapte<l tor a special purpose, — oiechan it-ally, physiologically, and economic
inlly* When from any cause this sensitive machinery is tho wn out of
equilibrium, its product is at once changed, sometimes slightly, but again to
such au extent that the most disastrous consapiences may follow wht'n it is
taken by the young ct^^nsumer. The breasts of all mammals are ekibonit(irs
and priKlucers, They are not storehouses tor preserving sustenance until it
18 needed. They are dclicatc*ly CTmstruete<l mills, turning out, when demand
is made for it, a pn>duet whit^h has l>een dirt^'tly fornn^l within thtir walls
trom material %vhieh has been brought through their portals from various
parts of the economy. The breast is a compound racemose gland, lined
widi glandular epithelium, which fivrms sugar, fat, and |*roteids, and these
are mixed with water and salts irom the likwjd. The epithelial wlls are so
finely organized, and so sensitive with their minute nerve connections, that
changes of atmosphere, changes in fi3<xl, the emoti<^>ns, tatigne, sickness, the
catiimenia, prt^nancy, and many other influences, thmw their met^hanism
out of e<|uilibriimi most readily, and change essentially the propf>rtions of
their fini,shc<l pHwluet. Then again this delicate mwhanism adapts itself
to the quantity of its pnKluet, ehilj43rating a smaller or a greater supply,
aeeonling to the demand actually made ujxjn it by the consumer. The
same breast will eitlier aupj)ly the projxT amount of milk demanded for
the retpurements of the average age or a greater amount for the same age
in case of a greater gtistric capacity. Again, this maeliiuer\" is regulated
as to the time which it takes to produce the average focxl required for the
difterent ages, a shorter interval of feeding l>eing ntnxlfHl for the younger
infant and a longer one for the older. This tact is made evident by the de-
ciilt^l qualitative changes which result when the gland is called upon to pro-
duce its pn^lur^t at inipri>|M'r intervals. Thus, a pmlongeil interval lessens
the solid constituents in tlicir pn»|Ktrtion t<> tJie water, while a shortened in-
terval, by exciting the epitlielial cells t*! frerpieut work, over-stimulates tiem,
with tlie result of incn*asing the si^lids in their projiortiou to the water. In
fact, tm» long intervals produce a pnwhict tiMi dilute, while tixj sh<:»rt inter-
vals prrKluce a jirofluct tfx) coneentratiHl. The analyses of large numbers of
gpecimens of humai^ milk at different jieriods of lactation show ns that ^svi
156 PEDIATRICS.
only do the constituents vary from month to month, and even fit)m day to
day, but that this variation takes place as much in the early as in the later
periods of lactation. We are not warranted, therefore, in assuming that tbe
milk grows stronger as its age increases, provided that it still remains in
normal equilibrium. The mammar}' gland acts both as a secretory and as
an excretory organ, so that it cannot be classed as a metabolic tissue in the
limited meaning which we now attach to these words. Yet the metabolic
phenomena (Foster) giving rise to the secretion of milk are so marked, so
distinct, and have so many analogies with the metabolism which we meet in
adi|)ose tissue, that we must look u{K)n the mamma chiefly as a secretory
organ. This, however, is only within certain limits, for we know that at
times foreign elements may be excreted from the gland. This at onoe
suggests the interesting question as to when the mammary gland is most
likely to have what we might call its normal secretory function inter-
fered with and to assume temporarily the function of an excretory organ.
This seems to occur both before the gland has attained its equipoise, as
during the colostrum {lericxl, and later when any of the above-mentioned
influences occur which ailect tlie general mechanism of the gland. In
these instances we find the colostrum reappearing in the milk. There-
fore in the beginning of lactation, during lactation when normal metabo-
lism is interfered with, and as lactation draws to a dose, we have analo-
gous conditions in which the mummary gland instead of being a normal
secretory organ bocomt^s abnormal and more or less an excretory- organ.
During these periods of abnormal ^land excretion we must remember that
drugs can be eliminated by the milk more freely than when the gland is in
e<iuij)<)isc. We assume, therefore, that the mamma during that early period
of lactation, which essentially represents a condition of lack of equipoise, has
a double fun(;tion, partly secretory, j)artly excretory. The greater tiie excre-
torj' function of the glaud is at any time in proportion to the secretory, the
more abnormal will l)e the finishtKl })roduct; while the nearer the gland
aj)proa(!hes to a purely secretory organ, the more i)erfect and normal will
Ik* its j)nKluct. The mechanism of the mammar}' gland is therefore in its
most jierfect condition after the colostrum period has ceased, and at a time
when the gtmeral organism, lx)th physical and mental, is freed from causes
detrimental to a perfect nictalK)lisin.
General principles an* vital in their ini|X)rtance when we come to study
the subject of feeding in all its phases, whether the nutriment to be pro-
vided for the infant is to (^)mo diii^ctly from its mother, a wet-nurse, or
an animal, or indin^'tly from the pnMluct of the mammary gland. These
principles are, (1) That nature* throughout all ages has clearly indicated by
means of natural selection what the source* of sup})ly should be ; that is,
that the mother should during some early pcTicKl of its life supply food for
her offspring from her mammary glands. (2) That where, owing to dis-
ease, over-civilization, or any causers whi<;h prevent the offspring from
receiving its sustenance directly from the maternal mammas, some nutri-
FEEDING. 157
ment must be substituted which will correspond as closely as possible to
the natural food-supply. (3) That this substitution can be obtained most
exactly through the product of the mammary gland of another woman.
(4) That, owing to the strong analogy between human beings and all ani-
mals which suckle their young, we should in our study of copying good
human milk make use not only of what we have learned from human
beings, but also of what is known of lactation as it occurs in animals.
This entails acquiring a knowledge of the investigations and experience
of those who have studied conmiercially the breeding of animals and their
food, and the production and modification of their milk.
I have already explained to you the conditions which are normally
found in early life from birth to puberty. All these conditions represent-
ing the various stages of a physiological development must be thoroughly
understood and remembered if you wish to appreciate the many diiBculties
which are to be dealt with in a practical investigation of infant feeding.
In my next lecture I shall b^in the consideration of feeding during the
first twelve months of life. This I have designated as " The First NvJbritive
Period:'
158 PEDIATBIOB.
LECTURE VII.
THE FIRST NUTRITIVE PERIOD.
I. Maternal Feediso— II. Direct Substitute Feedinq — III. Iitdirkct SuBsni-
TUTE Feeding.
Ah in my loctiiro on Development I endeavored to emphasuoe only those
facts which would lie of* ])nietical use to you from a clinical stand-point, so,
in dealing with tiie sul)jei*t of nutrition, I shall not attempt to dLscuss the
finer and nn)n» intricate (luestions of physiology and chemistry. While ex-
pw^ting to receive gn»at aid from the physiological chemistry of the fiiture,
we must not allow this fas(*inating branch of our art prematurely to set a^ide
evident clinical truths which for years have emanated from nursery practice
and have pn)v<'<l to Ik' of great value in it The nutrition of young human
Ix'iugs may 1h» dividcnl into three distinct nutritive periods, corresponding to
the degree of th(Mr dcv(»lopment. The first period consists of the first ten or
twelve niontlis of life. The st^cond j)eri(xl comprises the second and third
years, and the thinl iKTicHl the n»niaining years of childhood. The science
of feeding dei)en<ls ahnost exclusively, in addition to the general principles of
which r have already sjM)ken, on the knowledge of what elements of the food
an» rtHiuin^d by t\w gn>wing tissues in thc»se nutritive periods, and also on
the time when the various digestive functions are ready and able to dispoM
of them. I shall tiicn*fore lx.*gin with the disc*U8sion of the first nutritive
|XTi(Kl, which is (essentially the only one where human milk need be consid-
chmI. I have aln'ady refi^rixfl to the marked analogy which exists bet^vBen
the luitrition of human IxMiigs and other manunals, and the necessity of un-
derstanding the lactation of animals when we endeavor to explain that of
human beings. In order to ac(iuirt? this knowlwlge I have received eo
much aid ironi Mr. (j. E, (ionlon that I wish to acknowledge my indebted-
ness to him for placing at my (lis])osal the I'm its of his many years of studv
and j)ractical ol»scrvatioii on the lin^^ling, breinling, and lactation of cows.
The first nutritive jxTi^nl, whi<'h lor })uri)osi*s of simplicity I have arbi-
trarily made to i-cpnsciit the first twelve months of life, is obviously, frxjm
what I liav(» already told you, the most im|M>rtant one of the three. In this
jKTiod the infant may Im.* i'vd by a numlKT of methods. It may be nursed
by its mother, or a wet-nurse, or an animal, or it may be nourished by food
es}K»cially prej)artHl from the milk of one of tlu^se.
I. MATERNAL FEEDING.— The first of these methods, the maienial,
is so far su})erior to any other whi<*h has (»ver lx»en known that I shall
assume that it is the Ix'st, and the one from which in almost eveiy particular
all others should l)e ecjpied.
FEEDtiVQ.
159
N
The relative advantage of the milk-supply received from a primipara or
a multipai*u is not of so much importance in the case of mothers a^ in that of
wet-nurw^s. I whall thei*efiire defer what I have to s^ay on thi? e^ubjeet until
I 8]>eak of the latter, merely it^minding you of what I have told you con-
cerning them in a previous Iwtui-e (IxH-ture IV., page 100),
Normal Matkrxat. Conditions. — The assumption that the maternal
is when normal the ideal source of infant fcHxl-Kupijly pi*esnpi)oses niauv
impjrtaut enuditions amL-erning the mother and the function of her nuim-
mary glands. She should be strong and healthy, of an even, happy tern-
pc^rament, desin>us of nursiug her infant, and have time to devote herself to
this 8|»eeial duty during the whole peritxl of her laetation. She should have
a sufficient supply of milk, and should be willing to regulate her diet, her
exercise, and her sleep aciu>rding to the rules wliieh will l:ie,st fit her for her
task. Tlit^e may be Baid to be the ideal conditioii?^ wliieli we endeavor to
obtain for an infant which i^ Ui be nursed under the most favorable circum-
stances. It is true that women who are far from vigorous nurse their
infants with setmiingly good results, and that a frail, delieate-hxjkiug mother
may have an al)nn4lant supply of go^xl milk. These are exceptions, how-
ever, which make the principles just stated all the more true. We must
have some general jiriueiples to guide ns in our endeavor to pt^rtk-t the
nutriment of infants as a class, or we shidi surely in many iustauces do
serious harm to the individnaL
CoNTRA-IxDirATTONS TO Maternal Feeding. — "With few ext^ptinns,
the mothers wlio have uncontrollable tem|)erameuts, who are unhappy, wlio
are unwilling to nurse their infants, who are hnrricxl in the details of their
life, who ai*e irregular in their jienofls of n^t and in their diet and exercise,
aix? unfit to act s\s the soui-oe of tJKKl-su|>ply lor their infants. Even if their
milk hap{>cns to be sufficient in quant it}% it will probably be so changeable
in quality as to l>e a source of tlisoindbrt and even of danger ratluT than
the best nutriment for tlieir offspring. It is far Iietter for su<'li mothers not
to attempt to nurse, but to adopt some other method of feeding. It is of
still greater imiK>Hauw that mrjthers who are suffering inmi some chronic
dis€*asc», or one which their infants may directly inherit, should give up
all thoughts of nursing. Where therc^ is no question of disease in the
mtJther, it is our duty to investigate, and, if jM>ssible, U} counteract the
other tvintra-iudicatious to nursing, oJWn cmly ('ans^nl thnmgh ign<»rance
of what to lis seem verj^ simple truths, hut which t«> the young mother are
euveIo|X^l in mystery. There is, then, a double necessity for studying in
the closest detail the c«*uditi(ms which c<*ustitnte a normal lactation. First,
tliat, knowing what is normal, we should at onw rc<i>gnize \vhat is al>-
Dormal, and, by the intelligent use of our knowledge, render jK>ssible an
apparently unsuccessful attempt to nurst*. Sc^cond, that we may know
exactly on what the normal and vital crtnditions of a suc<^ssful nursing
dependj in order that we may understand what we should copy in substitute
feeding.
160
PEDIATRICS.
It is them narmal and vital etinditions which I shall endeavor to explain
to you, aod whieli, tor the reiwt^ns just stated, you must not look tipou a8
trivial, fur I have found tlieni of the greatest value both in the maim^
ment of huumu-br^a^t riiilk and in the i^ulaticiu of infant feeding, Tlit
matenial, then, being the ideal methtxl, 1 t^Iiall begin by showing you an
actual ilhihtratiim of this* methtxl.
XrusiNG Mother. — Here is a youu^ motlier (Case 60), pCTfcctlj
healthy aud gtrcmg, in the act of nursing an ioJant.
CAftX«t 80 ilXD 61.
Infiuit 5 numthfi old. Weight, 9600 1
4SWgnLmm
Nnit 21^4 pounds)*
Lilrth-WBtght,
I
The infant (Case 61) was healthy at birth, and hm grown continuously, with rvinilAr
weekly gains of about 250 grammeii (about A pound). Its birtb-weigbt was 4600 j^rammes
(about 10 pounds), and it now weighs 9800 grammes (about 2U pounds). It ia a fine ^ped*
men of normal development produci>d by human milk, und is bo large that it has had to b#
dn?s6(?d in r^hrirt clothe* nome months earlier than is uj»ual You will obeerve that thb nar^
mal nutrition dtipends in grvnt measure on iu birth- weight rather than on anj phenomenal
gain which it has made from month to month. You will iinderatand this by referring to
what I have said regarding weight in my leeture on Development (Lecture IV., page lOS)
where I have stated that the birtb-wetghl is normally doubled in the flnst five months of
life. 1 would ai»o call your attention Ut what 1 shall speak of more in detail later, that it
is not necessarily a milk of unuhUully gwd pereentage which has produced this prpgretaiTe
increase in weight. It is merely u gw>d nvilk adapted to the especial need of tljia particular
infant, and it might not at all suit a number of other equally healthy infante. Thia Ikct,
as you will soctn undoratand, merely deelare^ that praetically there is no one comhiitatiaii
of the elements in human milk which is the be^t for all infants, but that nature pw
.^L.
PEEOIlfO.
161
^
•li number of oombioations all equally good provided that thej ar« suited to the
individuul.
You see ibflt the natural method of feeding is by sucking. The infant i^hould be plac<;d
in a comfortable position in it* niother^s arm** with it* h*?ad and hm;k Bupported. It should
be made at once to understand that it ii to begin Ha meal aa soon as the breast h offered to
it, and continue, with, of course, breathing-spells, until the meat is finUhed* The mother
ehould herself preferably be sittiniu, as s*he can tbuf* ht'st tuatuige and cuntrul the infant if It
U inclined lo be re^^jtleijs.
Now nutiee mure clngely the method by whieh this infant is obtiiiaing iu food. The
fornmiion of m lij»n and buccal cavity are adapted to the nn?obanif^ni of auction, and you
aei' with what entie and perfiTt tranquillity it is rtn^ieiving its fo^Kl, The breast is «o organ-
ised Lhia it pn>vide*i a iVsh supply of food at the required ijiterviils. It prevents fermenta-
tii>n uf the food before it enters the infant 'a mouthy while at the same tinio the suction
incites to action both the necessar}' digestive fluids of the Infant and the function of the
gland itself. The gland avoids a vacuum by collapsing as it is gradually emptied, and
allows the fi>od to flow c*>nt*nuouaIy, thus obviating the tendency to exhaustion of the infant
and prolongation of the nursing-time which necetifearily accompanies a retnnled flow of the
milk* Finally* the brcfiftt is practically self-regulated aa U* the ami>unt which it h required
to provide iiccnriiing to the infant's age. A healthy infant tiliould empty the breast with
«ftij and uninterrupted sucking in about fifteen to twenty minutes.
I
Nipples. — In certain cases the mother's nipple is so small or depreseed
ihs\t it 18 a sonn*e of nim-h aunoyauce to the infant, and at times this inter-
feres so seriously with its o1>taiinij^ the pro{>er fbiMl-su{>ply that its nutri-
tion suffers, and s^ime other nieth^xl than nursing has to lie sribstitnte<l. It
is here that the ingenuity of the physieian is taxed to its utmost^ Every
kind of device may fail, and it Ls nwcssarv patiently to try one after the
other lx*fore dwidinj^ to give uj) tlie nursiiio^. Xipide-shieldH should \ye
experimented with, and will eometinies obviate the dittieulty. We shonhl,
however, always impress upcui tlie mother the fiK^t tlmt the value of liei*
milk as a iiKxl may Ix* entirely destroy wl ii* fiireign t'lements are allowetl
to enter with it into her inliint's month* This sim|>ly means extreme clean-
liness of tlie glass shield and riil)iK^r nipple. In a few cases where I itndd
al)solutely trust the mother on awount i>f her Imu^ able to ajtpn'ciate
intelligi^ntly the details of my iastructions and the danger nf nrit tarrying
them out, I Lave allowed, ii»r a short time, the ust^ of rublx^r tuhing con-
noted with the ni[>ple-shii'ld in place id* the diix^^t attacliment oi' the rubber
niiJple. When this is done, howi'Vt^r, fr€*f^h tnl>ing shmdd lie usi*il every day,
as it is extremely difficult to cleanse the interior of a rubber tube as one can
the rnblM^r nlpfde, which can bc^ tnnuxl inside out and scrublKfl. I would,
however, diK^^idedly state that I f\>iisid*^r, exf^|jt in thes<* rare instani^'S, the
nee of rubber tubing to l>e an alK>niination which sliould never be t*jler-
ati'cl mwlcr other circumstances, and t^jKK'ially in feeding from the brittle,
whciT its use is absiilutely nnne(?essary.
W^here the nipples are very tender and cause great discomfort to the
mother during the nursing, their ninditi*in fn^qiiently lMX'<»nies so st^rious an
obstacle as to prevent nursing altogether. This chang-e, however^ should
not l)e thought of for at least several days, or until it Ls al>solutely certain
that the exquisite pain is oiore than the moUier k willing or able to endure,
11
162 PEDIATRICS.
It is often the case that after a little time of the greatest sufieiing from
toiKlor or excoriated nipples the whole difficulty will pass away and the
mother be aljle to nurse her infant with comfort. I know of no especial
treatment which will pn»vent tliis condition of the nipples firom arising, nor
of any way by which it can be (juickly cured. Bathing with cold water
Ix'fbrc and after the nursing, and thus keeping the tissues in a healthy con-
dition, apix'ars to be a^ successful as the application of any medicamentge.
Mastitis. — Another tn)uble which may arise during the nursing peridd
is a disturhan<M> of the mammary gland it^lf, sometimes amounting merely
to a stasis in its milk pnKluction, but again going on to inflammation. The
latter is a serious matter, and should at once be placed in ilie hands of a
skilful surgeon. The former condition requires great care in its manage-
ment. Gentle mns«<i^> from the ixTiphery of the gland towards the nipple,
amounting in fact t<» merely a deli(*ate stroking with the ends of the fingen«,
is an im]K)rtaut part of the treatment. The breast should be withheld from
the inihut for alniut twenty-four hours, and the milk from time to time
drawn in small (juantities by means of a properly-adjusted breast-pump.
The bn-ast should also Ik* cart^fully sup|)ortcd by a swathe. If these meas-
uns an* Ik^^uu as soon as there are any indi(*ations of disturbance in the
breast, thes<* abnormal (conditions soon disapi)ear. The indications referred
to consist in the ap})earan(v of hard swellings in place of the usual soft
clastic con<lition of the milk glands. Th(»se swellings may occur without
any esiK^'ial ]»ain, but on {)alpation they are usually tender to a greater or
less degree.
IJuKAST-PuMP. — In n^gartl to the use of the breast-pump there is a great
difference* of opinion, but I have very dwidinl views on this subject, and
believe that those who have (tp|K)sed its use have been influenced to a great
degree by what they have seen in their hos[)ital practice, and also by the
views of otliers wlu» have, in like manner, met with unfortunate results in
lying-in hospitals. It is well known that all inflammatory conditions about
th(* hrvn^i are moix* likely to (Kfur in haspitals than under conditions where
the woman is h^s likely to \k* expose<l to i)athogenic organisms. This should
Ik* taken into account when we are de^'iding whether or not to use a breast-
pump. In my ex]K*riencc, ac(|uiix'd in a great degree from my pri\tite
practice, where ev(*ry precaution in ivgjiitl to cleanliness, fresh air, and
good ventilation could l)e obtaincxl, I have never met with any bad results
from the use of the pump.
In n^ai-d to the relation of micnK^occi to inflammation of the breast,
accf)rdiiig to Zweifel and Dmleili'in tlu*!^ are in mastitis two varieties of
organisms, the stiiphyloc()(*cus j)yo<renes aureus and the streptococcus pyo-
genes, but never the Hta])hyl<K*occus pyogenf*s albus. They admit that other
varietic*s may perha]>s Ix* found on closer inv(^ti<^ation, but at the same time
they consi<ler it striking that in all their cases then^ were never any local or
giMieral symptoms cans<'d by the staj)hyl<K»occ!is ])yog(»ncs albus, although
that they wen* virulent wa.s pmvwl by their inoculation of mice. Th^
FEEDING.
163
$
b
Fu*. 4i>.
is not much doubt that these pathogenio organisms gain access to the gland
through the nipple,
I have already said that the infant may iii>t l>e ahle t<» buhl the nipple
with sufficient lirmue?s oq account of some abminnal conditiiin of the nipple
itself.
Under certain circumstances, even whcR' tlie nipple is well formed, the
infant has iasuilicient suction-power to obtain its tWl, though tlic iood itself
may be perfti*tly adapted to its digestion* In these cases we often fiuil tliat
it cannot or will not be induced to obtain ite f<M>d through a shield and
rubl>er nipple or from rubber tubing. The breast-pump may then lK^x>me
of gi^at value, ils in the ctuse of an infant that wati nnder my care during
the hot weather of June, July^ and August.
Thia infant (Cufie 62) was seven montbH oH, and was dying of fttarvation, aB I had not
been able to prep«re lor it a food which it coyld digest and thrivt* on. (Thi* was before milk
laboratories were established.) It Wft» totally uiiahbi to iiin>e, iilthcjugh the brL'a>^t*mjlk was
ft gocxl cmi? and ag^n^ed with it perfwily when it was intivjduc'ed into its mouth with a apofm.
The milk was pniii|u'd fnim the breast"^ at rt'gular intervals and given Uj it from a bottk* for
over thrw? nj«jhths with tlie gmatej^t t^uccess, the iiilant thriving, and at the end of that time
being in a perfectly heullhy condition.
This vi\<e shows the exceptional hut at thiies very great value of the
breast-pumj).
As I shall later bive occasion to speak
of the ii!!^ of the pimip in varittus int^taiK-es,
not only for i-elieviug the hjva^t but Jor uIh
taining milk lor purposes of analysis, I will
sliuw you the Ibrm of pump whieh I ani in
the habit r*f using (Fig. 40)*
The a[>pamtns should be one which can
be carefully eleansed, and slionid, therefore,
preferably Ix^ made of glass. No one sjXM'ial
pump will, in all prc»babilityj suit every case^
and it b of importance that yon should use
the grt^alest care in adapting the piuup to the
individual. Ah I have stated, however, this
ift the one which in mo8t cases I have fi>und
to be suitable. When ap|ilie<l to tlie woman
it should causi» little or no pain or disttim-
fort Yon see that the jmrt whit h is aflafitiKl
to the nipple is like an onlinary nipple-
shield. This is attached to a ghiss bull), into
whieh the milk falls m it is drawn from the
breast. The mechani.sin is very simple, A
vacuum can be produc^tl iti the* ^dass bulb
by means of suction throuti:h a rubl>er tube attached to a rubber bulb with
ita valve working backwaixl. This is a far better method for pnxlncing
\
BieAst-pump.
164 PEDIATRICS.
miction than the direct application of the mouth to the end of the rubber
tube, wliich uuder all circumstances should, if |X)S8ibIey be disoounteDanced.
MILK. — The product of the mammary gland of all mammals b
es.sentially the ssime. It is comi)osed of elements which in an individual
milk n*si'mble the corres|)onding elements in all the others. Although the
attempt has long Ix^en nuuh*, and may in the future prove to be sueoeasfiil,
to distinguish l>et\vei*n the comi)onent ])art8 of each element, yet at present
we must, with lew ex(*i*pti<»us, accvpt each element as a whole and as alike
lH)th in human Ix^ngs and in animals. This must practically be done until
tlie analyti<al and physiological chemists provide us with much more exact
dat;i on whi<*h wo can deix^nd in elalMinuing our methods of infant feeding.
It is the combination of the various elements of the mammary gland which
makes the rtsulting pnHluct characteristic of the s])ecial mammal^ and it is
thereiorc? Ix'st first to di^scrilx* this uniform product as a whole and then
t«» study it as it (x^cui's in its various combinations, whether in human beings
or in animals.
In addition tt» the general i>rincipl(»s which I explained to you in my
hist h><'tuiv, a numlxT of ]>hysiol<>gic*al tacts regarding milk as a whole
IxH-onu* of gr(»jit int4*rest and of the utmost im|N>rtance when we attempt to
mo<lifv or change the pnKlu(*t <»f th<^ mammary gland.
Formation. — Bunge's inv^'stigatiuns on the comiKirison of tissues show
that the maniniary gland abstra<*ts fnun the blood very nearly the amount
of salts found in thr* tissues. Act-ording to Foster, whose remarks on this
subjcK-t 1 (piotc fnH.'ly, milk is the n^ult of the activity of certain of the
protoplasmic cells (K'cnrriiig in the epithelium of the mammary gland. So
I'ar a< w(; know, the fat is fornuil in the cell through a metabolic action of the
2>roto]»lasin. Mi(Tosi'i»pi<-ally, tlie fat (-an l)e seen to be gathered in the epi-
thelial cell in the same way as in a tiit-<'<41 of the adiix>i% tissue, and to be di$-
chargnl into tlic clianncls of the gland either by a breaking up of the cells
or by a eootnietile extru-iion very similar to that which takes place when an
anneba ejects it> dlge>te<l 1o<k1. This ol)servati(m is thoroughly supported
by other faets. Thus, the quantity of fat jin^sent in the milk is directly
increased by proteid f(MKl, but is not incrcase<l by fatty food ; on the con-
trary, it is diniinislied. In fact, protei<l f(MKls increase and fatty foods
diminish the metal)oli>m of the IhkIv. A bitch fill on meat for a given period
gave oif more fat in her milk than she could i)ossi]»ly have taken in her food,
and tliat, too, while she was g;iining in weight, so that she could not have
supplie<l the mammary gland with iat at t\w cxikmisc of fat previously exi^
ing in her iKnly. Wr alsr) have evid«»ne<» tliat the cascinogen is, like the fat,
fornie<l in the gland itself. When milk is k?pt at 35° C. (96° F.) outside of
the IxKly tlu^ (-aseinop'n is increased at tlie exp^ns<^ of the albumin. When
the aetion of the <'<^ll is iniiM'rii*ct, as at the JK'ginning and end of lactation,
the albnmhi is in cxa»ss of the easeinogen ; but so long as the cell possesses
its pro|MT activity, the iormation of easeinogen lMH*oni<»8 prominent^ That
the milk-sngar also is formed in and by the protoplasm of the oeU is indi-
FEEDUiG.
165
^
^
cated by tlie fact that the sugar k not cle]j€Ddetit on a carbohydrate? fwwl,
and is maintaiDeil iu abuudaot'e m the milk of carnivora when thes€ are
fed exokisively on mc^t as frte as pjsi!?ible from any kind of sugar or
glynig:en. We thus have evideut*e iu the mammary gland of the Jbrnia-
tioU| by the diiXL'ct mt'talwilie at'tivity of the st^ereting cell, of tlie rejnx^H^'U-
taiives of the three great classes of food-stuHs, pmteids, latti, and carlxi-
hydrates, ont ejf tlie comprehensive substance^ protoplasm.
Nkrvods Disturbances affecting the Milk. — The secretion and
ejection of milk are very evidently under the control of the nervous system,
vk'hirh pnKlnrxs markt^l changes iu Iwtli tbc rjuantity and the quality of the
mammary protluct in proptntiou to the relative nervous excitability oi' the
fipecial manmiab Women are especially sensitive in tlik reBj>ect, and when
living in the midst of our mfxlern civilization, so harmful for the pro-
duction of good nursing, pi-esent an exaggerated example of disturbance
of the efjuipoise of the mammary glaiuL The chemistry of the etjuijwtise
and lat'k of etpiipoisc^ of the mamnmry product af»|»cars to be closely <"on*
nectcd with its proteid element. Tliis clement is known to be a ctuupound
one and tlecidHlly cxjmplex, but for purposes of illustratiun we can safely
say that the wonl albuminoid or proteid is a general term, which includes
casein* ►gtMi ai»d albutnin ; alH1^ that tliest:' factni's of the complete' whole vary
in their proportions to eacli other according as the mammary function is or
k not in a state of equipoise. In the eolostnim |>eriml, and probably in the
analogous pcrifKls represented l>y the abnormal conditions already S|X*ken
of, the albumin is in excess in pro[>ortifin to the caseinogen, while as tlie
ec[ui[ioLse of the fum-tion hccfjmes more c<:»mplete the caseinogen is inereasetl
pri:i}H)rt innately to the albumin. PrtjJmbly at the end of lactation, its in
the Ijeginning, we shall finil this same tMinditirm of richn<?ss of allium in and
deficiency of casi'iuogen* This increase of the albumin at the cxiteuse of the
caseinogen explains what I have previrmsly told you concerning the excrt»tory
functiun of the gland at times tjeeoniing more piiominent than the srvretory.
Tbi>^ nervous disturl>ances, however, may also cause, as I shall dcs(jril>e
to you later, an over-production of the total proteids, as shown by their (ler-
eentnges. In some eases also the iat has b<M*n fluind to Ije much re<liKXHl in
its total j>ercentage. Instances of this have arisen where, as observed liy
Zukowski and quoted by Jacobi, seasons of fasting with their accompanying
excitement of the emoti<»ns have induetKl sneb a distnrhauee of the CH]ui-
librinm of the milk that the fat has Iw^en foimd to l>e deiTeased to the low^
pert^'utage of 0.88, with the result that the infant ha^ be<x>me sick and
given evidence of inipaii*ed nntriti^ai. These same nervous influences in
all probability have Ui a greater or less degree their analogy in the milk-
product of all mamnuds,
CoK8TiTtrEKTS AXB PROPERTIES. — Milk eousists of a large amount of
water and a c<imparatively small amount of solids. The .s^ilid eoustitnents
cfjmprLse, in varying pro[M>rti(ms, certain proteid elements, fai^ sugar, and
mineral nmUer^
166 PEDIATRICS.
** Milk is an emulsion, the fats existing in the fi>nn of globules of
vanning but usually minute size. It is this condition of the fiit which
gives milk its lx^culia^ white color." (Foster.)
The njH'cific gravity y rawtiou, and other propeiHea can best be spoken of
when describing the milk of an especial mammal.
The closely aiialog«)Us (H)nditi(>ns, however, of the earliest days of lacta-
tion in the woman and in the cow lead me to describe in my general xemarks
on milk the rolostrum period of these two mammals,
CouwTRUM. — During the early days of lactation the manunaiy gland
secretes a somewhat ditlcrent fluid from tliat which is producsed hy it later.
The milk at this ix?ri<xl is called colostrumy and the period is called the
colostrum period, on account of certain elements called coltmbrum eorpusda
which are present in the milk. I have already spoken of the oonnectioD
lx»tween loss in weight of the infant (Lecture IV., page 100) and the
presemx? of colostrum in the milk ; also of the excess of albumin over the
caw'inojrcn in colostrum milk.
Colostrum is sup|)osiHl to have a somewhat laxative efieot, and in this
way to ai<l in displacing the meconium. Whether it is of any especial
advantage to the infant is a question of much doubt, for it appears to me,
and it will, I think, Ik» undcrst4K)d by you, from what I have already told
you rc^aniing the manininrv' gland, that the appearance of these colostrum
cori)us<'l(»s is simply an indication that the equilibrium of the mammarr
gland has not l)ccn established, or has been disturbed, and that it is an e\'i-
dcncc of dis<>as<' rather than of health. It may be that the not infrequent
disturbance of the iiifantV digt^tion, amounting at times to acute conditions
of Icrincntatinn, is pHnhu'^Hl by an cxaggcratinl abnormal condition oocur-
riiig in th<» (•ol<>strum jhtI^kI as well as by the return of the colostmm at
irn'guhu' |>cri<Kls. This may l)c the rcu*<on why numbers of infimts aie wiaHp
si<^k by tlicir mothers' milk at an early iK-riiKl of lactation.
The analysis of (Hilostruni milk is something which as yet hag not been
thnronglily studiwl. Wlictlicr it will 1k» of much importance or not is a
question to Im' det4TmiiH"d in the future. It may, however, prove to be
of (^>n?iid( rabh* use to us wiicn we attempt to pre|)are a substitute food for
the early <lays of life. It is |H)ssible that a combination of elements coire-
siKHiding in tlieir iK'n-^'nta^ivs to tiios** wliieh an? shown by the analvsis
of tin* colostrum, but ire<' from the t-olostrum (*or]>uscleSy may be found
to suit lH*st the infant's digestive funetion at this wirly period of its life.
I have under one of tiies*' inieros(M>|M's a drop of colostrum mil^ (Fie.
41) taken from a <^nv, and under the otiier a drop (Fig. 42) taken from
a woman.
In ad<litir)n to the i'at-^dolniles of various sizis which you see floating in
tJiis film of milk you will n«>tie<> the lar<rc nils whi<'h occasionally appear in
the fiehl. These* aiv the eolo-truni eorpus<'l«»s. The one to the rieht above
the centre in the cow's milk ap|K*ar** t<» Ik* alxmt one-third larger ths^r\ the
one to the left and below the centre in the woman's milk.
Fi.i, 41.
Ck)l(j»lruui [fuik fro lu cow. (J*Jiou>-iiiit'ri>|,'rd|iti-)
Fjfi. 42.
ColoBtnini milk from wom&tL (Thotomicrogruph.)
II
FEEDING.
167
milk
An analysis (Analysis 6) made by Dr. Harrington of this eow^s
colostrum gave the following results ;
ANALYSIS 6.
Tut , . . L71
Milk-«ugftr .,.,,,. 4.90
Proteids , 1.72
Afih 0.79
TuUlftoUds 9.12
Wnt^r , 90,88
100.00
This table (Table 33) represents the analyses of some specimens of
human colostrum milk, which I have also had made by Dr* Harrington :
TABLE 33. (Harrington.)
I
n.
in.
IV.
V.
Fftt
. . 1.40
o.ns
2.40
5J3
4.40
Milk-eugar and
proleida , .
9.44
11.53
11,16
10.69
11.27
Ash .....
, . 0,17
0.31
0/26
0.16
021
Tiptwl solids . .
, . 11.01
12.52
13.80
16.58
16.88
Wftttr . . . ,
, . 88.99
87.48
66.20
83.42
84.12
100.00
100.00
100.00
100.00
100.00
I
I
I
Theae analyseSj while not determining minutely the [percentages of the
elements of oolostnim milk; tend ^ to show the great variations which occur
in this yK^riod and how little knowledge wo have a^ncerning it.
In 8[>eakiijg ki you atxmt the coloHtnuii in my k^eture on normal devel-
opment (Leetui*e IV., page 100) I stated that the eolostmm corpuscles .should
di^iaf»pear from the milk in a week or ten day?^ ai'ter hirtli. They diminish
rapidiy in nunil>ers during the sei'ond week, and if they eimtinue into the
third week, or return at any time during the lactation ^ tliey almost inva-
riahly ranse disturbance of tlu' infant's digestion ; they also lieeome an
iudic^ation tliat laetntion shotild be susfx^ndcil temporarily, and, if" they
eimtinne, that it should Ih' entirely given up.
On the tlisapfH>a ranee of the colostrum corposeles the milk should rap-
idly acquire its normal equilibrium, and, with t!ie exii^ptirm of its well-nxTig-
nized daily variation, sliould show a auuparative uniformity in its analysis
during the whole of the nursing jxTiod, and until the ecpiilibrium of the
mannnary gland is again disturl)Hl, a< at the end of lactation.
HUMAN MILK. — 1 havt^ .stated the gi:'rieral (M*nditious which affect
the mammary pnxluct. of all animnls. I will now descrite especially what
is known connTuiug human milk.
(iCANTiTY. — I have already told you how tJie mammary gland adapts
its quantity to the amomit needed. The question so often arises as to
whether the total amount to l3e s«:'crctiKl for each fetxiing can in any way lie
increased, that it is well to mention tliis now and to dispose of it. Beyond
the general conditions atJetiting the mammary prod net of the mother, which
I have spoken of, I know of no means of increa^sing the flow of milk, I
168 PEDIATRICS.
have little confidence in galactagogiies in the form of dnif^ or special foodfl,
for their numbers betniy tlieir inetficieucv. The milk becx>mes lessened in
amount from many causes. Some of these are identical ^ith those which
commonly pnKluce any disturlwrnce of it" equilibrium such as I have men-
tioned. Certain dru^s, such as belladonna, will in some individuals cause
a nobihle decn*:ise in tlie flow of the milk, and must^ therefore, be given
with care during the nursing ix?ri<Kl. An active cathartic will also lessjiea
the milk, as will also a diet comix>seil of solid flnxl and very little water.
(iUAMTV. — Tlic (juality of the mother's milk is of the utmost impor-
tance t<» the welfare of the infant. It is very necessary, therefore, that we
should thon)Ujxhly investigate* and clearly understand what the normal com-
])osition an<l cliaractori>tics of her milk sliould be. This can be done only
])y having analysis nuulc l)y ex|KTt chemistij. Even with the aid of these
analysis the information which is obtaiucnl concerning the percentages of
the various elements is liable to be inexart in some of them.
This is unfortunately true n^gartUng the two elements fat and protexds,
which an^ luidcr any circumstani'cs the ones most likely to var^-, and we
must (siRvially allow for some slight error in the proteid ]x?rcentage.
The givatcst |)ra<*tical Jissistauct*, h(»wever, can be obtained from these
analysi's, as they rcj)rcscnt the true foundation for most of our work on
infant ik'ding. I shall not attcm])t to dcscrilx; the method of analysis which
is us(*d, as it is t<M) purely a chemical (luestion to be of practical use in clin-
ical work.
My analyst's have in almost ever}- case been made by Dr. Charles Har-
rington. To obtain a s|)c(imcu for analysis your hands should be sterile,
and the breast and nipple should Ix' cart^fully washed with sterilized water,
and from '20 to 30 c.c. (5 to 8 drachms) <)f milk drawn by the breast-pump,
which, Uing made of glass, can also Ix.' thoroughly washed. The milk
should tiicn Ix* i)ourc<l into a sterilized l)«)ttle and tightly corked. It should
inuncnliatcly l)c taken to the chemist, and kei>t on ice until ihe examination
Ls made.
In (?very cas(.» it is very imiM)i-tant to know the exact percentage of the
fat, ]x>tii from its Ixing the most variable element and from its use in the
d(rtcrminatioii of the i)en*^*ntagcs of the other elements. Any means, there-
fbrc, which will pHxrure the exact jK'rccntage of the fat should be made u«
of whert^ for any reason a <M)inplct4' analysis cannot be procured. The most
exact means f<>r this pur|M»sc r»utsi<le of the chemical laboratory is an appa-
ratus callc<l the Tkfhcock Fat Trsfn\ which I shall show and explain to von
at the Milk Lalnn-atory in a later lecture (Lecture IX., page 250). As this
is not an ex|K»nsive machine, it lias seenunl to me that in conmiunities at
a distance from an ex|x^rt chemist, or whciv the j)eople are unwilling to
pay for a cc»mj)lete analysis, a Bal)cock machine muld he owned jointly bv
a iniml)er of physicians and kept at some <iMitnil jilaw.
The smallest amount of milk re<juire<l for determining the peroentage
of fat with the Babcock machine is 17.50 c.c.
FEEDING.
169
I
1 103
^M OCCI
NORMAL LACTATION, — Id order to understand the many varia-
tions which are oontinually arising in human milk during the j^ieriml of
what may he consideretl a noraial lactation, we should clearly apprei'iate
tlie various eonditiuns existing in humau iiiilk and ite composition m de-
termined by a study of a very large number of individual sptvimens of
milk. In this way we obtain a knowledge of the composition of the
average humau milk,
Mi(:"Roscx:>pic Examination, — The mere microscopic examination of
k beyond the dctcrmiuatitm of the presence or absence of colo8trum
corpnscle.s and foreign matters, such as pns, bloody and epithelial cell>i, is
tx) nnceitain and mirfleadiug to Ix' in any way dep^ndt^l u]wn, the chemifsil
analysis being the only practical meth(xl which can be recommended. The
truth of this statement was lately impi^esseil upon me when a physician
skilltMl iu the ust! of the microscope sent me a sjiecinien of woman *s milk
which he stated was rich iu fat, but which the analysis showed to have only
a little over one and a half per (%mt, of this element.
The presence of an nntlue amount of yellow c<»loring matter is at times
very misleading, I have also seen human milk which had a greenish color,
evid<*ntly prodocetl by some of the mk*ro-organisms which are known to
occur in cow's uiilk, but the nature of which is not yet fully determined
and which mider the miciT>sc<:ij>e are not represented by anything abn(»rmaL
CUMCAL Examination of Human Milk,— The rules by which ttie
percentages of the other elements of the milk can be deduced when once the
pcT<_vutage of the fat biis Ujen obtained by the Kaln'oek uiacliine ai*e the
same as those wliich I slmll presently s|>eak of iu c<*unectJon with anotlier
method of clitiical examination, wlicrc^ however, the dctcrnii nation of the
&t is not so accurate as that by means uf the Balwxick. We cannot be
too particular in regard Uy the act*itracy of the method which we employ for
obtaining an analysis of the milk ; yet, as the most af^jurate analysis can be
obtained only tlinjiigh an cxi^rt chemist, a simple approxiunite clinical test is
otlen very dt*sirable, even though it is less aetairate, Under these cirenra-
stances the mcthml employed by Dr* L. E* Holt, of New York, ^\ill be
Ibund to be of practical use. Holt diX"s not assert that he reaches by his
methml anything but a fairly accurate knowledge of the [lereentages of tlie
dirtertmt elements of the milk, and he recommends it for the analysis of
human milk only where a U^ttcr one cannrit l»e had. His results an^ based
U|xm the comparative examination l*y his nieth<Kl of a large nnml>er of
specimens of milk and on the following well-known chemical facts ;
(1) That the specific granty of hnnian milk varies Itetwt^n 1029 and
1032, the average being 1031, at 21.11'" C. (70° F.). Abnormal variations
occur between the limits of 1017 and 1036. An increase in tlie fat lowers
specific gravity ; an incrt^isc* in the other solids raises it.
(2) That the mifA do not vary much iu their amount in ordinary human
milk. They arc too insigniBcant iu f>erceutagc to affk^t the sfx^^ific gravity^
and iu tlie cliniml examination of milk tbey need not be considered.
170 PEDIATRICS.
(3) That the proportion of the migar is nearly oonstant in human milk
under all circumstanced. Thid point has been emphasized by all the chemists
who have made milk analyses.
(4) That in striking a)ntrast to this uniformity in the sugar are the wide
variations met with in the fai and proteids, as is shown by the following
tables :
TABLE 84.
VariatUmM in FaL
From 48 analyses hy LocmI* 2.11 to 6.89 per cent
*^ *' Konig 1.71 to 7.60 *• •*
** 29 '' ** Chcm. Lab. Coll. Phys. and Sur. X. T. . 1.12 to 6.02 " "
TABLE 86.
Variathtis in Proteids,
Prom 43 analyses hy Lotnis 0.86 to 4.86 per cent
*» «' *^ Konig 0.67 to 4.26 *• *'
" 29 *' *' Chem. Lab. Coll. Phys. and Sur. N. Y. . 1.10 to 8.62 «« "
(o) Tliat to dotormino the comixwition of milk we must have a knowl-
cdgt^ of tlie projjoiiiontt in which the two elements which vary most widely,
namely, tliQ protvuh and the/«/, are pres<»nt.
(()) That fn)ni the fact that the proportion of sugar is so nearly oonstant
and that the sjilts an} in such small amounts, we may for clinical purpo&es
oonrsidcr the Hprrijic (/raviti/ as modified solely by the/a< and the prtjiteids.
(7) That then* is no known method of determining directly the per-
centage of the ))rotci(ls in the milk by a clinical examinatipny and that a
(M)iii])lct(> chemical analysis by an ex|K*rt Ls the only one that can be accepted
its accunitc. It is possible, however, from a knowledge of the specific
gravity and the )H>rccnta^^ of the fat, to make an approximate calculation
in n^pml to tht» iK'n-i'ntajre of the pn)teids, at any rate sufficiently close to
determine whetlier in a ^iven ca«» they are near the normal, or are in very
larji^o or very small pro] M^rt ions.
Mktiioi) of Ex.\ mi nation. — It is newssary first to determine the
siKM'ific trravity of the milk and the iwrciMitatri* <)f the fat.
To determine th«' comiM)sition of the milk by Holt's method the only
instruments nee<h*<l an' a small liydrometer, a pi|K»tte, and a glass-stoppered
cyliiuler «:nuliiat<Hl in mic hundred parts and liolding alxmt 10 cc,
Th(? sjK'i'iineii of milk fnr analysis should l)c taken from the '^ middle
milk/' and it is important that the milk should \)Q freshly pumped and
handled as little as |>ossible. also that the ^niduati^^l ^lass cylinder should
Ih' seru}>ulously clean, otherwise the milk will often wmr Iwfore the cream
has had time to ris(^ This is particularly true in summer. 1.5 c.c. (J
oimce) is the amount of milk rcijuired for the test.
Specific Gravity. — The sjM'cific gravity is obtained by means of the
hydrometer, for the use of which only lo c.c. (i ounce) of milk are
nc»c<l<*<l.
Percentagre of the Fat. — The i)crc<'ntage of the fat is determined
FEEDING.
171
»
I
by estimating the percentagt* af the ci-eam, wbkh is ascertained by the
fbllowing mt^hml ;
The glasa-stoppei-ed cyliDder is filled with milk exactly to the npyier liue,
which is miirkid 0. The pipette shoultl l>e used for putting the la^it few
dtT»]>8 into the cyhnder, care being takeu ofit to allow the milk to rnn down
the inner side of the tube, since this somewhat obscures an exact reading.
The cylinder is then corked and allowed to stand for twenty-four hours at a
temperature of its nearly 21J1° C. (7U^ F;) as is prac^tieable. A variation
of a few degrees on either side of this point is unimportant. Ji\ however,
the variatif>us are wide, the rapidity with which the cream rises is some-
what modiiie<i*
In the gi-eat majority of OLses the lower line of the cream has be-
come sharply defined at the end of twenty^-lbur hours, and can then be
recorded. If this is nut tlie case, the milk should l>e allowed to stand for
six hours longer before reading the percentage.
By comparing the percentage of the cream Avith that of the fat, as de-
termined by a chemical analysis of the same specimen, it has been discovered
that the ratio of the cream to the fat is very nearly 5 to 3, and for clini<'al
purposes it can be so estimated.
Estimation of the Proteids. — In e^^timating the proteids certain sup-
positions must and can be iiiirly accepted ;
(1) Supposing the proteids to remain unaltered : if the percentage of fat
be low, the specific gravity will be high, but if high, the specific gravity will
be low,
(2) Supposing the fat to remain unaltered ; if the pei'centage of the pro-
teids be high, the specific gravity will l>e high, but if the percentage of the
prr^teids Ix^ low, the s|)ecific gravity will be low.
If, therefore, the iat and the sjMX'ifie gravity l>e known, the pn>teids may
be estimated by the foUomng rules :
(1) If the jiereentage of the fat be foimd to be high and the si>ecitic
gravity higii, that is, from 103*i to 1034, we may a^.sume tJiat the proteids
arc also of high perceutage, otherwise the excessive fat would bring the
8pet*ific gravity Ix'low tlie normal average*
(2) If the fat be found to be tif low |>ercentj:^^e and the specific gravity
high, we may assume the proteids to be nearly normal, since the high
8pec*ific gravity is ex}>lained by the small pro[^ortiou of fat.
(3) If the percentage of fat be high and the specific gravity low, the
proteids may be assumed to be normal, since the variation in the sjxH?ific
ivity is explain(xl by the high [lercientage of fat.
(4) If the jKTwntage of lat b* low and the specific gravity low, the
percentage of the proteids is also low, since otherwise the small proportion
of fat would make the spet*ific gravity above the average.
Of etiui'se it is only the wide variations in the jirriteids which i-an
m recognised by these ruk^ ; but these variations are often very impor-
tant.
172 PEDIATRICS.
We can tlien siiy that, knowing the specific gravity and calculatiiig the
lilt as tliree-fittlis ol' the known peixvntage of the creamy we can judge
whether the proteids are nearly normal, very high, or in very small amount
Holt a^^feserts that the estimation of the composition of milk by this method
is as exact as tliut obtained by ordinary examinations of urine.
Chemical Analysi-^}. — There is no doubt of the great value of an
ex|K'rt chemical examination of the milk in cases where aa infant is not
thriving, although appan'ntly receiving a sufficient quantity of milk from
its mother. On the other hand, you must remember that a chemical analysis
will never give any information regarding the quantity of the milk, and it
often liupiHMis that where such an analysis has proved the quali^ to be
g(MKl, the infant is not thriving because the quantity of the milk is very
small. The sym])toms which indicate that it is tlie quantity of milk which
is at fault rather than the quality arc that the breasts at the nursing time
are soi\, and that only a small quantity of milk can be extracted from them
by the breast-pump. A i)eriod of nursing longer tlian the usual fifteen to
twenty minutes l>ef<)re the child is satisfied should make us suspicious that
the milk is lucking in quantity. We can also determine the actual quantity
of the milk which the child has imbibed at an especial nursing by means
of weighing, as described in a previous lecture (liccture IV., page 79).
A numlKT of olwcrvations at diffen?nt nursings in the day must, how*evcr,
be made l)eii)re a corn»ct a)nclusion can he reached by this latter procedure.
Average Analysis of Human Milk. — I will now call your atten-
tion to this analysis (Analysis 7) of average human milk, which represents
the work of such chemists a*< Konig, Forster, Meigs, Harrington^ and others,
and the mammary |)roduct of a large number of women of all nationalities.
Tlic figures opjM»sitt» each clement arc the j)ercentage8 which that element repre-
sents ii< a part of the total solids, without reference to ita own composition.
analysis 7.
Average Human Milk,
RcnctifHi Slightly alkaline.
Sptcilic gnivity 1028-1U84
WnttT . . / 87-88
Total solids 18-12
Fat 8-4
Sutjar e-7
PrnH'Ids 1-2
Total ash 0.1-0.2
You can obtain from tliis analysis a fair knowledge of the normal
composition of human milk, and you will at once notice its simplicity and
its few constituents.
Reaction. — The normal reaction of human milk when freshly drawn
with snitaMc j)rccautions is, as a rule, alkaline; it is, however, sometimes
neutral, rarely acid, and in the latter c*asi» it may be considered abnormal.
Specific Gravity. — The sjxK'ific gravity varies normally to a considerable
FEEBING.
17a
Fwjgligeon account of tlie variations in temperature to whicli tlie milk ha})-
pens to be exposed at tbe time when the sjiecific gravity is taken. When,
however, the milk has its average normal w>ni|K>sitif)n, and tlie teni|K^rature
to which it is exposed is 15.50^ C. (60° F.), it* avei-age s^iecific gravit}' is
1031.
Water. — One of the most imjKjrtant chemical fatts to \ye rememlKM'cd
for clinical purposes is the very targe projKjrtion of water which Ls found in
normal human milk, for it tcaclics ns that it is a highly dilutcil iinxl hy
which the best results can be obtained in infant feeding. It also explains
to us how careful we should be not to overtax the c^imparativcly j^light
pf>wer ibr absorbing a concentrated fbtKl which exists in the early mtmtlis
of life.
Fat, — The fat of human milk is made up of palmitin, stearin, and olcin.
Ab(jut tAvo |jM?r cent, of the total fat consists of the gly(.t?rides of Ijutyric,
capr*Jic, caprylic, and myristic acids. The pnjductiiui of animal heat is
80 very important a part of the infant's vvcll-b<niig that it is not surprising
we shoulcl find s<> large a percentage of iat as well as of sugar in the IIkkI
which Ls providtn:! for it* The [)resence of fat in the milk is not only for
the purj)Ose of nutrition, but alst> as a means lor the maintenance nf ImmIiIv
heat. This latter functinn of the iat cannot with impunity Ix^ trifh^l with,
and is c»ssential for that active metal>i>lism of whicfj I have sjiokcn in an
earlier loctum (Lectni^ I^^, |>age W}), A proper amount of fat is pn>bably
of great aid in the regulation of the ffei*al discharges. An ami unit of fat
prcjpoi'tionate to the proteids is presumably necti'ssary, or at Ica^t of givat
aid, in their proper digestion. We should naturally expei*t that nnlcss the
gtandaixl jriventagc of fat, or at Iciist a near a|>i»roach to it, existt^l in the
motlier's milk, tj*<jul>le would Ix^ Hkcly to arise witli her infant, and this tH>r-
ix^sprnds with my experience in cases where the sfx'cial ingn*tlient wliich has
intcrtci*e<l with the success of the niii'sing has Ikk^u the fat. I have found
clinically that where the fat was much lessc^ncMrl the nutrition suffered, titat
tlie digestion was not gCMxl, and that tliere was a tendency to consti^jatiim,
while where its i>ereentage wa^ detMdedly alxive the standanl the digestion
was weakened, there was a tendency to diarrhoea, and in conse^jucnce a
resulting ]xior nutrition.
These clinical observations at once suggest to us that in the management
of infant fec»tling we must r€>cognizc the cxistenc<> of two imjiortnut con-
ditions. < hie of these Ls the digi^sti^m af t\w infant, the other is its nutri-
tiou, These two rcfpiirements for a sueix'sstiil lactation an? based on the
fiftcts tliat the milk may iMM-it-iily *ligt*stc<l liut not nutritious, and tfiat it may
be higlily nutritious but ditticnlt t*> digest, s<» that it is the ctpulibrium of
these two ajuditions which prtxlnei^ a |x^rfcx-t infantile develoirmcnt. It is
€S]>ecially im|>ortaut that the jx^rccntagc of fat in an iufhut^ tiwwl should lx»
w^ithin the limits of the normal variations which arc found in the milk of
healthy nursing women with healtliy infants. For, although it is admittctl
that a large peroeutage of surplus fat is frequently found in the fseoes of
174 PEDIATBICB.
infautH whose digestion and nutrition are normal, and whose food is human
milk, yet we liave no more right to conclude from this that a small peroent-
age of fat i:s sufficient tor nutrition, or that a large surplus will be eliminated
by the tseces, than we have to assume that there is too much oxygen in the
1)1<kk1 beitiiL^ we find a certain surplus of oxygen in the arterial bloitd
which is returned to the lungs in the pulmonary veins. In fact, it L< far
more pro1>al>le that nature introduces a c*ertain percentage of fat into human
milk with a pur])ose which can be accomplished only by that percentage, m
that it is an error to change this |)ercentage beyond the variation which com-
monly (Hvurs in average human milk.
Sufirar. — The form of sugar which is found in human milk is called
milk-sugar, and, as you see by referring to this average analysis (Analysis
7), has the highest {K'n^entage of all the elements constituting the total solids
of the milk. The sugar is more digestible than tlie fat, but does not have
so much |K>teutial eni'rgy — that is, so much heat-producing power in a
given weight — as d<K»s the fat, which is to the sugar as 2.4 to 1. The
convcrsiim (»f milk-sugar into lactic acid gives rise to many of the changes
occurring in milk.
Proteids. — Although there have been a great many different opinions
exi>ressed as to the avcnigt* iK'n-cutage of the total proteids in human milk,
we are led at present to lx4icve that it is normally one or two per cent
The proteids or albuminoids, for the terms are synonymous, are general
names including (*ascinogen and an albumin (lactalbumin), which in iu
g(Micral features n»senibles onlinary s(»rum-albumin, but the chemistn- of
thcs(» elements is too ol)scure to make it worth while to consider them
practiciilly and clinically more minutely. We recc^nize that this albumin
is pn>st>nt in small an<I variable (juantitics when the mammary gland and
its s<'cn*tion an> in a normal condition, while at the time when the glandular
function is l>eing established, and during ]KTiods of glandular disturbance,
it IxH'onies |)ro]>ortionately hirger in amoiuit. I have already explained to
you sufticiently the relative j>roi)oii:ion under varying circumstances which
tiio cas(>inog('n and albumin U'ar to each other, and I will merely add to
what r have alrcjuly said, that the proteids, as a whole, are a valuable
soun-e of infonnation to us when we are dc^tcrmining whether the milk is
normal or abnormal.
Ash. — The ash, which is sometimes calkxl the mineral matter and some-
times the siilts, has an avenig<' jM'R'entagt* of irom 0.1 to 0.2. Up to the
pres<'nt time, althou»rli a c<*rtain numlxT of analyst»s of the ash of human
milk have Uvn made*, yet tiu» nsnlts, for various nuis<ms, have been deemed
unsjitisfactory. S) large a (quantity of milk is needed for a reliable
determination of tlu^ |KTcentage of each element which makes up the total
amount, that this in itself has Imimi an ini]H>rtant reason for failure in
ac<Minicy. The determination of the mineral matter of cow's milk has not
Ikhmi attended with the same rlitficulty, and its jK'nx^ntages have been esti-
matcnl with comparatively reliable results. It has always been supposed that
FEEDING.
175
there is a nuliL-al difference between the iiercentages of the mineral matter
of cow's milk and that of human milk* The exact knowledge of the per-
foentages which exist in the latter ha^ hetNime nf still greater imjKjrtauee
I ginee such deeidtHl advances have hoQu made in the modifitation of the
elements of the former* With a view of maldng »ome advance in this
difficult question, and af providing fiir the milk-nioJihers of the future a
more exact basis i'or perfecting a substitute ftHxl ivsembling an ehjsely as
possible the product of the himiau breast, I midertt^ok, in tlie spring of
1893j Uy prfK*ui^ an unusual and sufficient quantity of human milk tor
analytical jiurpases* In the course? of a few weeks, by means of the cr»nc<:^rted
action of numeroa^ assistants^ I collected five and a half liters (alx>ut six
quarts) of human milk, which is an unusually large quantity for experi-
mental purposes. This milk was immtxliately reducc<l to its minenil con-
stituents in the laboratory of Dr. Charles Harringt^m. The analysis of
this large amount of mineral matter was then made by Dn Harrington and
Dr« L. P. Kinnicutt, with the following results :
ANALYSIS a
The A$h of Human Milk,
XJDCongumed carbon 0.71
Chlorino 20.11
Sulphur • 2,19
Phospboric acid ... 10.73
Silica - . 0.70
Carbonic acid ..,..*... .,.,»♦,,. 7.07
Iron uxid© tind alumina 0,40
Lime . , 15.69
Mag^netiiA , 1,92
PoUu^sium 24,77
Sodium , . 9.1»
Oxygen (calculated) $.16
100.64
Cbmpomtion of the Ash talciUaiedfrom the ahove Atml^sis.
ITnenmbin(*d curbDH . , - . 0.71
Cttlcium phuaphate 25.35
Ciilcium siliciite . , . * 1^35
Calcium Mulpbite ...,...., 2.11
Oolcium nxide ...*,...< L72
Magneaium oxide ,.*...«... 1.91
Potaseiuin cnrbunatc 24.98
Pfpttt8.*!ura ftulpliito .,..,,,,.. ^ fH
PotaHHium chloride 12-HO
8odium chloride , 28.18
Iron oxide and alumina 0.40
1^.46
A elo&er appmxiraation t«> the relative pr<jjM>rtions of the salts iu the
form in which they oec^ur io milk, mleulatt^ from the above analysis, may
be stated as follows :
176 PEDIATBIOB.
Calcium phtufphate 23.87
Calcium liilicatv 1.27
Calcium sulphate 2.25
Calcium carbonate 2.86
Magnesium carlM>iiatti 8.77
Pota^isium carlxmatc 28.47
Pntassium sulphate 8.38
Pntas>iaiii chliiridc 12.05
Sodium chloride 21.77
Inm oxide and alumina 0.87
100.00
In (N)ni])ariiig the ])ivvi()us analyses which have been made, and which
can Ix* found in Koni^V Xahningsmittel, II., 2* Auflage, with this new
analysis, wi* must nMuenil)er tliat the previous analyses were made some
ytmr.'i a^». In the la^t few years the processes which have been employed
liave Uvn s<> much mon^ exact that these results must be considered &r
mow trustworthy than those made at an earlier date. It is not remarkable,
thert*fore, that distinct dii!cn»n(\»s should be found between this new analysis
and the analyses which have hitherto lK>en made, and presumably this last
analysis is the correct one. It has Ix'cn made with the greatest care, and
by nutans of the most impn)vcd tc<»hnique, by two eminently oompeteot
and w(>IUkno\vn chemists, who in their work have acted aa controls od
each other. In this way ^n^at preiision has been attained.
The n'sidue obtaimnl from the eva|M)ration of about six quarts of woman's
milk was extnictc<l with naphtha to remove the fat, and then ignited at a
v(Ty low t<'inpenitui-e so as to prevent the volatilization of the chlorides.
The ij^nitioM was accomplishe<l by ])la(*in^ the residue from the naphtha ex-
tnu'tion in a platinum dish whi(*h was supi)ortird on a platinum coil inside
of a larjrcr platinum dish, the latter Ix'in^ heated with a free flame. Evai
at this low t<>niperature a partial chan^' in the c-omposition of the ash took
places the siilphat<*s In-inj^ n'duced to snl])hit<'s, but not to sulphides, as the
a**h on U'injr rarefully t<»sti'd showe<l that sulphides were not present All
the carl)onat<'s of calcinni an<l all the carlxmates of magnesium were reduced
to oxides. The ash also coutaineil seven-tenths of one per cent, of unoon-
snmed carbon.
In woniMuV milk of course there would Ixj no free carbon. All the
<'al«*ium that <lid not exist as phosphate would Ix^ in the form of sulphate
and <"arlH)uate, not of sulphite and oxide as found in the ignited ash. The
nKiirnesium would exist as carlNtnatc, not a« oxide, and the potassium as sul-
phate, carlN>nate, or <-hloride. Xo sidphitc of |K)ta8sium would be present
Thechii'f <litlenm«'s In'twci^n this new analysis and all previous ones are
as follows :
(1) The i>hosphoric acid is less than half as much as previously reported.
(2) The mapu»sium is also less than half as mu(^h.
(3) Silica and aliunina are present. They have not been returned in any
previous analysis.
FEEDING.
177
f AsBuming the truth of the statenieat that the oonstitueDte of the miDeral
elemeiite of huiiiao milk are subject to great fluctuation ac<3ordiug to age
mid other causes, it is right to assume that the minei*al matter exaiuiuetl by
Kiiuiicutt and Harriugton, Ijeing tiie product of a large number of women,
is a fair average specimen.
¥nmi what I have already said you will uridei^ytaud that althougli
cliemical analyses cuable us to work more intelligently, yet the conclusions
which we can draw from them are far iniiu being (nxxisc, mving to the
variations which may occur and to the insufficient uumlH^r of n'litible
analyses which have so far Ix^eu made. We should thercfijrc Im? extremely
guarded in drawing couclusions, for the pix'sseut merely looking upon tht*ae
analytical results as important. It is very desirable that when reliable
analyses are made tlicy should Ix^ published, and thus lis r>nr infr>rniation
increases we shall be enabled to arrive at I'csult^ which h ill gn^atly aid us
in regnlatiug the perir>rl of lactation.
Variations in Milk, — We are \vd to expet-t that we shall find that
where the milk is jKK>r and dcK^ not agrt*e with the iniknt there is an
€XoesB of proteids and a dimiuution of fat beyond what we have so tar
been able to dettTraine ns the normal average jierceutagt^ of thes<' two ele-
ments. Again, when* a variation takes place in the milk it is more likely
to be found in the fat and pmteids, as ah-eady state*!, than in the sugar
or the a^h, I should also atlvise you to have a number of analyses made,
on dittert^nt days and atdiHcrcnt times^ in unler that tlie error of an es|)e(:*ial
or temporary variation may Ix* cx>rrecttd. The inn>ortancc of the assistance
which can he gaintd from these analyses is^ in my opinion, ver^^ great, and
many more analyses should Ik* miide than we are now in the habit of
deeming necessary. The questiou of expense should nut for a moment be
considered by those who can afl'orti ta Lave analyses raade^ for not only
will real lienefit ct>me to their own children thrfiugh nnjuey spent in this
way, but tliese analyses, when pnblishtd and collated, will pruve of great
value for tlie pmper regulation of the ft^tnling of infants in all cIjibscs of
society. An error for wdiich we must always allow may interfere wiili the
true analysis of the milk whicli the infant has actually rt^-eivctl in its
stiimiach at the end of the nursing, and is <inc whicli must ntN^^cssarily invali-
date the information which we receive from our analysis, I have already
referred to thii^ subject in speaking of tJie changes which arise from slight
caiLses and influence the sjiecial sjiccimen wliicli is Ijciug analyzt^L Thus,
we should recognize diat the milk varies Cfmsidcrably in its percentage of
fat and total S4>Iids in the diflPerent |ieri<Kis **f a nursing* and that the com-
position of the milk which the infant hiis in its stomach may differ very
widely from the oompoeition of a s|iecimen taken directly before or after the
nursing. Harrington's analys<}'s td' the throe jxTitds of a milking will
illustrate the meaning of what lias just l>ecn said, and althtmgh they were
made from tlie milk of a cow, yet, knowing the closely analogfjus a^nditions
existing in human and in animal milk, we shall find them et^ually valvxaJaV^
12
178 PEDIATRICS.
ill explaining the o<)rre8|)<)iuling changes met with in woman's milk. Ther
are n»pre:*eiited in tliLs table (Table 3G) :
TABLE 86.
Fat. TbUlSolldB. Water. Ash.
"Fore-milk" 8.88 18.84 86.66 0.B6
** Middle milk" 6.74 16.40 84.60 0.81
" StrippiiiKs" 8.12 17.18 82.87 0.82
The analyses of J. Rc»isi»t and Peligot are also of considerable interfst as
showing not only the inenuse of solids at the end of a milking, but al^o
that tiiis inen^ase is iii<»stly of the fat, and to a lesser d^ree of the proteids^
and, as I have aln^idy stati'd, that a short interval of nursing increases the
.<olid constituents in proiK>rtion to tlic A\'ater, the reverse of this being true
when' the intervals ait» long.
II(>idenhain explains tiiis physiological phenomenon by saying that his
invi'stigations ]M)int towards tiie fact that during the pauses between the
mil kings the cells of the glands are growing. During this time a propor-
tionately small amount ni' solids and a pro[X)rtionately large amount of
water an* stx'retc<l, while the irritatitm of milking causes increased activity
of the niilk-i'ells, witii a corres|K)ndiiig increase in the solid secretion and a
h^^'iiing of tile water. IVligot's table, giving the analysis of an ass's milk
in tlinv diilenMit |M»i-tions, shows the relations of the solids both to the
water and to one another :
TABLE 37. (Peligot)
Ass^s Milk.
l8t Portion. 2d Pdrtkn. 8d FdrtSon.
BiUtiT O.tfG 1.02 1.52
Milk-Mipir 6.&0 6.48 6.fi0
(Vtin 1.76 1.96 2.96
His second tabl(» sliows the changes of projwrtion according to the
intervals of milking:
TABLE 38. (Peliirot.)
Ass's Milk.
MiUdxie Inteirala.
1% houn. 6 hoim. 24 hoaa.
BiittfT 1.55 1.40 1.28
Suirar 6.C5 6.40 6.88
(■u.si'in 8.46 1.66 1.01
The next table is also inteix»sting, and should Ix; recorded :
TABLE 3<». {WvUvi.)
O.'tr'.t Milk.
Ijist Time Perrentage of BoUds aft
Fiiut' Milkinff. Boginning. ihw^
l*2h'»urs 9.33 16-04
6 " 12.80 16.06
2i " 12.84 18.08
FEEDING.
179
Harrington's analyses of woman's milk tjliowing the ** strippings*' of
a two-hours interval and the " fore-milk" of a twelve-hours interval are
also of oonaiderable interest ;
ToIbI solids
Wuler . .
TABLE 40.
(Harrington.)
••strippliiifB,"
2'hoiiTs lutcrvaL
. 16.32
10.14
, 84.68
89,8«>
100.00
100.00
Witli these chemical and physiologit^ facts before us, we are forced to
acknuwleilge tliat we must be very cirt'uiris|xvt in the cc^iicliL^ions which
we deduce from such analyses of human milk as have l>ct*n made up to
the present time. I have referred sufficiently to the errors which may
arit*c» ill determining the jiereenta^e of the varicnin elements which con-
stitute the k^tal aulid.s, and I will once more merely state that an error
in these concluijions where a correct chemical analysis has Jxmiii made is
less likely tij occur from the sugar and the aah than from the pmtcid^ and
the fat.
Reasoning from the strong analogy which must exwt between human
milk and cow's milk, and being aware of the great variations which fM'cur
in the latter, we may assume that huumti milk is liable to vary in its com-
position considerably n ith different milkings on the same day, and ako with
the milkings of the same hours on different days, so that at present we are
not in a j>osition to state that our knowlwlgt* of liuman milk is ^iiffiejr'ntly
exact to justifv an attempt to fbrmidatc a table to show the ix)miKJsitiou of
woman 8 milk at different |>erirKls of her lactation, however valuable sm-h
information may in the fntui-e prove t*_> be. We must also understand that
human milk of normal ipiality, and proving to Ix* <x|ually nutritions to the
specrial infants tiiat lire fed on it, may vary ainsitlei'ably in tlie |>tTccntage9
of all its elements, and in the combinations of these percentages. This fact
is well illustrat*M^l in this table (Table 41), j^howing the analyses of fourteen
8|X'<nmens of human milk all ditlering in the aimbinations of their different
elements :
TABLE 41. (HaiTini?tnfi.)
Human Srea«t'Milk Amdy^s.
{Mothers healthy^ an4 in/an in at I digtatin^ v^ell and ffaininff in weight)
L
n.
ra.
^v^
V-
VI.
VU.
PefCent.
Per Ceiu.
l»er Ci:nt.
Per CeuL
Pter Cent.
Per c*tit.
Per Cent
Flit
, 6.10
4.88
4.84
4.37
4.11
8.82
380
Hitk-su^jir , .
. fjM
6.20
6.10
6 30
6.90
6.70
6J5
PmU'id.s
. 4J4
3.71
4.17
3.27
8.71
1.08
8.53
Aflb . . - .
. 0.17
0,19
0 19
0.16
021
0.20
0.20
Totnlsnlids. .
. 15.16
14.^8
15.80
14.10
ia.98
10.80
13.68
Water . . , .
. UM
86.02
84.70
86.90
86.07
89.20
86.82
100.00
100.00
UKl.OO
100.00
100,00
100.00
100,00
180 PEDIATBIGB.
TABLE 41.— Omfifitied.
VIII. IX. X. XL xn. ■gTTT XIV.
Percent. iVrtVnt. Percent. Percent Per Cent. Percent. Percent
Fat ».7*J :i.m 8.1« 2.W5 2.86 2.09 2.02
Milk-suirur . . . iiM T.aO 7.20 6.78 7.10 6.70 6.55
Pn.tdds .... 2.iVl 3.07 l.«6 1.91 2.20 1.88 2.12
Asli 0.14 0.12 0.21 012 0.16 0.16 0.16
T..tal solids . . . 12.89 18.7l> 12.22 10.77 11.82 10.82 10.84
Wut»*r 87.11 WJ.21 87.78 89.28 88.18 89.68 89.16
100.00 100.00 100.00 100.00 100.00 100.00 100.00
All these sixx-imens of milk were obtained from healthy znotherSy and in
even- casi» the infant was thriving. In a number of these cases, however,
when one of the infants which was doing well on its own mother's milk was
fnl with one of the other c«)nibi nations, it soon became sick, and had to be
ehanged \n\vk to the one ada]>te<l to its diges^tion. Human milk mav, then,
Ik' eonsideiiJ to repn^s^'iit imt an es]K»eial f!)od but a oombination of ibodi^,
and its fat, sugar, proteids, and a.<h to represent these diflferent foods. In
other wonls, we iind by ex|x»rienw that the digestive capabilities of infants
differ, just as do those of adults, and that nature provides a number of
varieti(*s of g^xxl himian milk adapted to the vanning idiosyncrasies of infants.
Ba<tkkh)L<k;i(\vl Ex.vmination. — Although human milk is usually
considered to U* sterile, ex(vpt in some castas in which the woman is diseased,
yet (j)Iin and Neumann have examineil the milk of forty-eight healthy
wonuii and have i'ound l>aeteria in forty-three cases. These otganisms
wei-e mostly repn'SiMitcnl hy the staphyhxxx'eus pyogenes albus, with a few of
the staphylmiK'eMs pyogenes ainvns and the streptococcus pyogenes. They
fi)un(l fewer l)a<*teria when the bi-east had lx?en emptied a short time pre-
viously, and more when there had bc^n a stagnation of the milk in the breast
Mon» bacteria weiv also fi)und in the first few drojis than in the last ones, and
from their ex])erim(?uts they eon<'ludtxl that the bacteria enter the nipple
from without. The (M)nelusions dwluctn:] from their experiments, as well as
from the exjK^riments of others who have met with similar results, seem to
sh(>w prartirally that bacteria <an enter the duets of the nipple and penetrate
to a greater or h^s distance ; also that the milk in its course from tiie gland
to the ni]>])le wasln's out the l>act<'ria, and that we can in this way aooount
for the pn'sen(v of th(*s<» organisms in the milk which is first drawn from
the bivast, and their al)sence from that which comes later.
Young animals at lurth lx»gin to receive their nourishment immediately,
and a eorres]K)nding incnaist* in their weight takes place from the first dav
of life. The himian infant in like manner should l>egin with its nursing
early, getting what it can from the breast until the full supply of milk has
c«)me. In this way it will not Ik? so likely to have a large initial loss of
weight to regain, a condition by wlii<h it is often handicapped at the very
beginning of its caixvr, when then^ is most danger to be apprehended fibm a
depression of its vitality. Every day, every hour, is of the utmost importance
I
I
^^^" T^^^^^ FEEDING. ^^^^ 181
in tlie early days of life, and, provided it c^n Ik* done witLoiit detriment to tlie
oanditioii of the m€>ther, the s<3ouer the infant is put to the breast the Ix'tter
St will be. Under exeeptionally favorable eircumstances, as 1 have aliTady
told yon, we see the breast-fed ioliint steadily gaininf^ m weight during the
first year of its 11 ie (Lei*ture IV., i>age lO^ti), (Jrthnarily, however, we iind
this uniform inereai^e in weigh t» wbich I have just indicated to you in
s{>eaking of the infant at the breast (Case <il, page ItiO), to l>e Interrupted
from time to time by vai'ious eausei^j. These may arLse during the dental
period, in vatx'ination, from some temporary trouble arising in the breast of
the mother, or fr<*m a e<:imbinatinn ttf eireumstances whieh may ]>reveut the
infant i'rom reeeiving the proj^ier qualitative elements in its ftxjd, or from
c»l>taiuing a sullieieut quantity. This eootinual inerease in weight is of the
greatest iniportnnee in the fii*st year, as it is the ehief index l>v whieb we
note the pn^gress of nutrition in the infant and the normal ecmdition of the
milk. During the fii-st twelve hours of life, and in most eases during the
first tw^enty-four to thirty-six hours, owing to the inability of the mother
to supply milk for her infant, seart-ely any fixKl is, ns a nile, obtained. If
during this peritnl the infant is restless and evidently hungry, o to 10 e,c.
(1 to 2 drachms) (»f a sugar solution may be given at intervals of two or
three hours. This solution shuukl Ix^ made by dissolving milk-sugar in
sterilize<l wuter^ aiul its strength sluuild Ix^ ironj five to six {>er tx^nt. If the
mother's milk is delayed still longer, stvraethiug additional must l^e given to
the infant, and if the trwKl ran Ik? obtaintxl fmm a milk-lalx>nitory, I should
order die tbllowing piieseription :
pRKSCKrPTlOK 3.
Fat , , 1.00
Sugflr , . 6.00
PiY.teuJfi . 0.76
Heiiotion Hlightly alkaline.
10 feedings, each SO c.c. (1 ounce). To be heuted for thirty minute at 75" C. (167** F.)-
Where the infantas fwxl has to be prepared at home, these proportions
of fat, sugar, and proteids c^n lye obtain*Hl, as I shall exjdain to you later
(Leeture X., pag<^ -79)^ in ray lecture on the home motlifieiition of milk.
The younger the infant the grt»ater the metabolic activity, and hence the
greater need of frerjnent ftH?ding, fiu- fo(xl is re^juircd not only for repair of
waste, but also tor the infant's rapid prr>p<irti(mate growth. This, with the
increased demand for additional imimal heat, makes eascjntial the regulation
of the intervals of fi^ediiig aeix>rding to the age.
Inter VAi-s of Feeding. — The int*rvalB constitute a very important
part of the management of breast fwHliug, where, as I have told you, the
piantity is regulated by the breast itself. These intervals should l)e defi-
nitely s^tated to the mother at different times tlimughout the nursing |>eriml,
and should be atlhereil to. I have reprt^senteil iu this table (Table 42, jmg©
182) the intervals which should be reeommendeiL Y^m m.v\fti, Vio\4^N3«^
182 PEDIATRIGB.
understand that these are only average nilcfl, and that the intervals of feeding
should be made t«) correspond to the stage of development of the individual.
TABLE 42.
The day feedings are aupponed to begin with the 6 A.M. feeding a$id to end with the 10 P.SL
feeding.
Number of Number of
A«e. Intcnala. Ttedingi In Night FawllMi
Mboun. "
Fruin birth to 4 vfoeks . . 2 houn 10 1
** 4 1<> « ** . . 2 ** 9 1
" 6to 8 ** . . 2i *« 8 1
" 2 to 4 nn.ntha . . 2J " 7 0
" 4to 10 ** . . 8 «* 6 0
" lOU) 12 ** . . 8 ** 6 0
When the milk has Ix^m to be produced in the breast, the infiuit should
be fed once in two hours during the day and onoe during the night until it
Is six weeks old. The day feedings are usually reckoned from 6 a.m. to
10 P.M. This interval of two iiours should be adhered to, allowing that
exceptional eireumstances may arise w^hcrc the physician must judge accord-
ing to the individual (usc, until the sixth or eighth week is reached, when
the inter\'a1s may Ire made two and one-half hours, and the number of
f(>edings in the twenty-four hours eight At about the fourth month the
intervals can be made three hours, and the number of feedings six. When
the infant is two or three mcmths old, the night feeding can be omitted.
The numlxjr of feo<lings at ten months may Ix; reduced to five. Allowing
the motlier to liave its many hours of continuous sleep at night as possible
is t^siK-'cially imiM)rtant, in onler that she may not be exhausted by the lack
of tliat regular an<l suilicicnt I'est which is of the utmost necessity for the
pnKluction of a normal milk.
Irregularity in nursing, t(M) frequent nursing, and too prolonged intervals
often so disturb the (piality of human milk as to transform a perfectly good
milk into one entirely uniitted for the infant's jKjwers of digestion. Thus,
as I have pn^viously ex])laincxl to you, too frtHjuent nursing lessens the
water and increases the total solids in human milk, making it resemble in
a certain way eondense<l milk ; while too prolonged interx'als result in such a
d(HT«is(» of the total solids as to n»nder an otherwise good milk too ^^atery
and unfit for pur]H)ses of nutrition, however well it may be digested. I
n'])eiit, then, that the lesson that may l)e drawn from these facts is that
some g(.'nenil rule for the fee<ling intervals should not only be recommended
but enforced. The mother should neither injure her infant's digestion by
nursing it too frecj[uently, and thus giving it a t<K) concentrated fluid, nor, bv
neglecting to feetl it often enough, interlci-e with its nutrition by giving it a
f*>od that Ls too dilut^rd.
Regimen of IjAcrrATiON. Diet. — The di(»t of the nursing mother
should not essentially differ from what would 1x5 considered to be a healthy
one for her at any time. There is no s|)ecial diet which, under all cixcum-
FEEDING. 183
Btanees, is best for all nursing women during the period of their lactation.
In the early days of the puerperiuin tliere is, as a rule, more danger of over-
feeding than of underfeeding the mother. The tendency, in my ni>inirHi,
is to give too raueb meat and Hjlid WkkI^ with the result that when the :?et're-
tion of the milk is \mng f^iMUhed the total .<olid.s are inere^ased to a dt^^^ree
beyond the capaeity of the still umleveloix^d digestive fhuetion of the infant.
I have usually found that infants in the early day?^ and weeks of lift* tlu*ive
better on a milk tliat shows a high percentage of water in pnipijrtion to
that of the total solids. A rule whieli has in my ejcperienoe become alm^jst
an axitira is that the age of the individual ijifant is in inverse pn>p*>rtion
to its lowers of abs«irhing solid fotxl, and in dirwt profMirtion to the need
of a large amount of water in its food. A light and plentiful diet should
tlierefore l>e given to the mother while she is (xinfinfHi t^i her Iml, This
diet should e<3nsist of milk, gniels, soups, vegetiibies, bread and butter, and
after the first week a small amount of meat onet* during the twenty-four
hours. When the mnther is able to go out of the house again, and has
resumed her usual fiabitri, the quality of the diet ean l>e very much
inci-eascti, and she ean have the usual variety of fiKxl rc»presented by meats,
vegetables, milk, fruits, and cereals. Thert^ are no sjieeial kinds of fm>d
which arc cfJutra-indiaittMj, pmvidtnl we keep tlie fmxl within the limits of
the ordinary artielen whieli wmmouly represent a plain bnt nutritic^us diet.
It is ver}' imjMirtant for the nursing mother to have her meals at regular
intei'\'als, and during the early part, of the laetati<m to take I'imhI somewhat
more fmjneutly than wlit^n she is not nui-siug. Tht: additional meals, as a
rule, should be made up of milk or ooeoa. I have not s<^rn the advantage
of adding any sptn-iid beverages, such as beer, malt, or stimulants, Uf her
diet. She should reeeive as much milk as is <:^>mpatible with her digestion^
and should drink aplentifiil supply before retiring at night, I have reeom-
mendetl this wide range of food for the nursing mother with a pur|>osc% —
namely, that it scn^ms necessary to eitunteraet many erroniKUis ideas and
false views whieh are held on this subjetrt. In my ex|3erience I have fre-
quently met with mothers who were being deprived of the very articles
which would in their specnal c*ase have tended to aid in the production of
gotxl milk tor their infants. The ib<Kl of the nursing woman Ls witliuut
doubt closely connected with that which she provides for her infant. I have
already s|xiken of the possibility r>f the elinunati^m of various substaiiees
by the mammary gland, and we shtuild tlicn?f<>ri* impress U|M_in mothers the
impt»rtance of a f*arefully arranged diet wlien they are nursing. Certain
vegetables, and sometimes fish, will in individual ca^^es affect the milk and
cause discomfort to the infant. We must, tlicu, in rvery tu-^e, seek to deter-
mine which article of diet may cause disturhmee in the sjieeial woman's
Lmilk secrt^tion, and eliminate that article. We should, however, be very
careful not to prohibit this spei*ial article of diet from the rc»gimen of a large
numlmr of women t^i whom it might be of Ix-nefit ratlier tlian of harm,
simply Ixicaiise it has affected the milk of a few women. For the aven^
I
I
184 PEDIATRICS.
woman a plain mixed diet, with a mcKlerate excess of fluids and proteids over
what she is normally aeeii-stomed to, will, as a rule, give the best results.
Exercise. — Exereiric has so constant an influence on the changes which
take plac^e in the daily sei*retiou of the milk, that the mother should be
encDourafi^Kl to be out of Ixxl and to walk about her room as soon after
her a)nfinement as is i)ossible without injuring her physical oonditiun.
Exerciser is so im]K)rtant for promoting the proper elaboration and equi-
librium of the milk secretion during the entire period of lactation, that it
should always lx> insistinl uiK>n, and regular hours for walking should be ss
definitely arranged during the day as the hours for eating. The exercise
must, however, Ix' in accordance with the strength of the special woman, for
fatigue has tlu* same delet^'rious influence (m the production of the milk ba
has lack of exercise.
DisTURBKi) Lactation. — The dLsturlxuices which are liable to occur in
the course of lactation are frequent and varied. They should be studied
carefully and reeogni%(Kl at once when they occur, or the continuation of the
laiintion may not only Ik» interfered with but be prevented entirely. When
discussing the signific^nee of the ap[)earance of colostrum corpuscles in
human milk (licetun* VIT., ])age 1 06), T dwelt so fully on the variations which
are coineident with this upix^arauce, that I shall now merely refer to them a»
among the ix)ssil)ilities of a disturlxd lactation. When they are found aflwr
the first two wei'ks of lile the milk should l)e looked upon with distrust, and
s|K?cial efforts should be made to discover their cause, and to prevent the
dangers which an* liable under tliese circumstances to arise. These dangers
may l>e not only from c(»ml)inations of the milk elements which are incom-
patible with the iniantV dig(*stion, but also from the disturbances which may
arise from the fret* mammary (>limination of foreign material, which I have
already refernnl to.
Druers. — AVe know that during [X'riods of mammary disturbance there
Ls a much greater possibility, than when the gland is in a normal condition,
of the dire<'t transudation from the blood of such inorganic substances as
arsenic, antimony, lead, i(Mlide of [K>tash, mercury, and others, taken by the
mother. AVell-authenticaUil c-as^'s come to our notice from time to time
where injury has been done to the nursing infant in this way, and where
even death has (K-eurnKl from tlie elimination by the breast-milk of certain
organic substantias, such as colcliicuni and morphine.
The great<'st variety of substances have l)een found in the milk, but no
definite nilc as to the amount of this elimination has yet been established, so
tluit our knowledge of the existenci' of this ])rocess is valuable as a prophv-
lactic against harm, rather than as a means of direct, benefit to the infant in
discjise, which latter ])oiiit I shall not disctiss except to call attention to
the fact that the medicinal treatment of infantile disease tlirough the breast-
milk is exceetlingly inexa<'t.
AVe nnist also recognize the clini<'al fact that this elimiiuition may occur
at any time during tlu? nui-sing jieriod in the brc^asts of women who, so &r
FEEDmO,
185
as we can asoertain^ are io a jjeriectly healthy condition. Thus, ever)" prac-
titioner has at times doubtless observed the laxative effect on the infant of
Buch ilnigs as er)m[K»und liquorice jx)wder given to the mother ; and a ease
baa lately a>me to my notiec whem an infant vomited for weeks while taking
the milk from the breast of its mother, who was unusually well and strcrng,
but who was in tlio habit of drinking a cM:>nsiderablo quantity of porter daily,
iUler tlie pi>rt*?T was omitted the vomiting ceased at onee^ and did not return.
These fac-ts warn Uii that the use of drugs during the period of lactation
should be far more limited than at other times* Valine cathartics may not
only act unfavorably on the infant Uirougli the mammary exeretion, but
may lessen very dei'idedly the flow o{ the milk, and even sti>p it alUjgetlier.
Menstruation. — We must next consider the question of the variaticjn
in the milk which takes phict* from natural causes, such a^ the i-eturu of
menstruatitm. Does such a ix'turn nec<'ssarily contra- indicate the c^jutiu na-
tion of nursing? As in all questions of this kind, we cannot adupt and
follow an inflexible rule, but must l>e guidt^l by wliat 8*'ems liest tor the
individual case. Infants uit» at times atfecte*! so seriously by the ahemtion
in the a>nstituents of the milk which occurs once in four weeks that their
nutrition is marktxlly iiitcrfcrtMl with, afid a change to a more stable fcM>d is
indicatecL Again, the only disturbance which may arise is a tempirarv and
slight digt^ative attack for a <lay or two, w^hich apparently dues not mate-
rially aflec^ the inlimt, and makes us hesitate to run the risk of de]iriviug
it of a food on which it thrives during twenty -six days out of tweniy-tnglit.
We must alw> not be too hasty in concJnding from the bad symptoms in
the infant that we should at once withdraw it permanently from the breast,
for the catamenia may apj>t»ar once, and then not agaui for a number of
montljs, the intant's jx>wers of digestion in the mean time beei)ming so
much more fully develoi)ed that tliey are unatfeeted by the milk of the
catamenial ixTiml, Even whei"e the catamenia rec^ur regularly, tJie disturb-
ance which may have been great at one j^eriod may for many reai>ons fail
to recur at the next ; so that the question is reduced to whether the compo-
sition of the milk shows a i-ecovery of the equilibrium of its constituents
within a fe^v days, or nimains affected to such a degree as to endanger ttie
integrity of the infant's nutrition.
My own experience is in favor of allowing the infant to continue with
the breast, unk*s9 it is decidedly contra- indicate<l by circumstances such as
have just been mentioncth
I have seldom met cases which could not without permanent injury be
tided over the small anukuut of temjiijrary digestive disturbance \vhich may
arise, Withiu a few days I have set^Ji a case w^hei'e tlic return of the cata-
menia pr(»duced no efftn't whatever on tlje infant ; and this is only an instance
of what in all pr<jbai)ility often t>c<'U!*i^ where njHtlier and infant are at the
time in an otherwise normal a>nditi(>u. There have, as yet, betni Uyo few
analyses made during the catimieuial [^eriixl t4> justify us in drawing any
definite conclusions as to the chemical status of the question ; but the proba-
186 PEDIATRICS.
bilitv is that the milk will be fouud to be deficient in fat and to have it?
proteiils increased, following the general rule of disturbed mammary secre-
tion, and tiiat cou9e(|uently it is in a condition to interfere temporarily witli
lx)th digestion and nutrition.
Pregnancy. — A much more serious question arises ^when the nui«ng
mother Ixt'omes ])ri*gnant ; for here the almost universal clinical experience
is that tlu* infant, for various reasons, cannot continue to be fed by its
mother, it lK»ing unusual for a woman to have sufficient vitality to nourish
|)ro[)erly her living child and growing foetus. The danger of reflex miscar-
riage from the continual irritation of the mammary gland by nuisii^ I
]x*rsonally have had no ex])erience with, but this is mentioned as one of the
danglers contra-indicating the continuation of nursing by a pr^nant woman.
We must, however, here also not judge hastily, but take all the eiiaun-
stances of the (U^ into c*onsideration before deciding on a measure of sndi
vital im|)ortance to both child and f(etu8. If the mother remains strong
and vigorous, and tlie analysis of her milk shows no deterioration, while
the infant is a delicate one just Ix^ginning to thrive on its rightful supply of
natural fo<Kl, or if it is during a hot ]x?riod of the year, and especially
where a wet-nurse or fettling from a milk-laboratory cannot be employed, it
will oilen Ix' wisest to take some risk and continue the nursing for a certain
time, ixTJuips six or eight wwks, and then, according to drcumstanoes,
gradually to sulystitiite another flMxl. Almost every case will difler in the
(|nestions to l)e deeidcKl, and must Ix* judged on its own indications and
(•ontra-indications, always, however, recognizing the accepted rule that lac-
tation and pivgnancy are usually incomjwtible.
The nursing mother is inclincnl to believe that if she feels well and
strong her milk must Ik* gt^nl fi)r her infant under all circumstances. She
tlu^i-elon' friMiuently transgr(?ss<>> the rules which are necessary for keeping
her milk in (><[uili1)rium, and she should Ix^ made to understand that some-
times al)normal variations are liable to arise, however good her general
healtii may U\ She is simply fulfilling a task demaiided by nature from
thos<' who U'ar I'liildren, and her <lutv, when once she has Vindertaken to
nui-se, is to prevent as much as jjossible these variations by r^ulating her
life to a normal standaixl and avoiding excitement. Both of these requisitfss
of a normal la<*tation c<)me within the ])rovince of the physician to explain
as he would any other branch of rational meditjine. He should impress
upon her that em(»tional mothers do not make good nurses, and that the
physiological influ(»nc(^ of tiu* emotions on the nerv^ous system, with its re-
sulting changes in tiie mammary se<»r(?tion, has necessarily a much wider
range in women wiio are subjccti'd to tiic (Mistoms and vicissitudes of modem
life than it has in those who live in a more natunil way.
Having shown you in Table 41 tii(^ great variations which occur in the
percentages of the elem(»nts of human milk, I will now endeavor to explain
to you by means of another table (Tabic 43) the ])ercentages and combina-
tions which you will lx» likely to meet with in abnormal milk.
FEKDIKG.
187
TABLE 43.
'flKilirtPi^ typiecd ancUff9es of a noi^nal^ a poor^ an over-rkh, uwi o had huTmm
breast^milk.
Nonnnl Milk.
iBealthy life
AS to exercise
imd fuod.)
Fat 4
Sugar ....... 7
Proteids 1.60
Ash . , * , , 0J5
Total solids . , 12.66
Wwter . . . , 87.36
Poor Milk.
<8UinftUtm.)
1.10
4.00
2,50
0,09
7.(59
92.31
Over-rich Milk.
(Richfoerliiig;
lack of exer-
cise.)
6.10
7.60
8.50
0.20
10.80
83.70
B4idMillL
(PPCglJWJCf,
Di£«Atiti, etc. ^
0,80
5.00
4.50
0.09
10,89
89.61
lOO.OO
100.00
100.00
lOtiJJO
The terms poor and bad milk are merely relative, and in common use
do not have a definite ©leaning. I shall, therefore, explain the distino
tion which I make between them. I have adopted the terms for tlie pur-
pose of simplicity and to distinguish a milk which can be restored easily to
a normal condition from one where the difficulty of such restoration k veiy
great. By a ptwr milk I mean one which represents a condition of lack of
nourishment or star\^ation in tlie mother, but one which can easily be changid
by the projjer feeding of the mother. In this case the normal mechanism of
tiie mammary gland has not been interfered with. By a bad milk I mean
one wLich i*cpresents a profound disturbana* of the me<'hani.sni of the mam-
mary gland produced by many causes, disease, pregnancy, and especially
extreme nervous conditions in the mother, and one Avhich cannot be easily
changed to a good milk.
I shall now show you a table (Table 44) in which I have condensed the
many means w^hich you wnll have t4} make u.se of in managing the most dif-
ficult question which we meet witli in tlic treatment of infants.
TABLE 44
Oenerat Principles for Ouidanct
To increfli&e the total quuntitj
in managing a Disturbed Lactation.
Inerease proportionately the liquids in the
mother's diet, and eiic<mmge her to bt*Ut*ve
tht^tshe will be etiabl*?<i U* nurse herinfmit.
To deoreasc the total quantity D(.»crf»ii8L" proportioniitely the liquids in the
(Rarely necessary.) uiother^s diet.
} T^ increase the total solids ..,..,. Shorten the nursing intervals ] decrease the
exercise; decn?ase the proportion of liquids
in the mother's diet
To decrease the total solids ...,,*.. Prolong the nursinji^ intervaU j increase the
exercise: increase the proportion of liquid!
in the mother'** dift.
To increase the fat I nerense the proportion of meat in the diet.
To decrettse the fat Decrease the proportion of meat in the diet.
To increase the proteids ...... Decrease the exercise.
(Very mrely indicated.)
To decrease the proteids , . . Increafie the exercise up to the limit of fatigue
for the individual.
188
PEDIATRICS.
In attempting to formulate these niles I must warn you that I am dealing
with a subjeet of which very little is known definitely. I can, therefore,
at present only state ray exi)erienee in a large number of cases, and giv*
you 8ome general idea of how you are to recognize whether you are dealing
witli a \mi or i)oor milk rather than with a normal variation of a good
milk. This knowledge, however, of the variations which take place in
human milk is of the utmost eliniral importance during the period of huta-
tion, for it is the only means by which we can decide definitely and intdli-
gcntly many vital questions in this |x;riod.
The Mana(4Ement of Disturbed Lactation. — Instances have con-
tinually been brought to my notice where infants have been allowed either
to c*ontinuc wuth their mothers' milk when they were not thriving on it>
simj)ly Ixx'ause it was mother's milk, or, on the other hand, have been
weaned from their m4)thers for what would evidently have been insufficient
reasons had the (u^ Ix'en thoroughly understood. In both instances a
])n3i)er knowledge of what c*an Ix^ done with human milk — ^that is, with the
management of its different ccmstituents by increasing or decreasing their
relative pro]>ortions — would have lx?en of benefit to both mother and child,
and in some erases would have saved the life of the latter. This lack of
knowltKlg<», or, I should say, lack of adaptation of the knowledge which we
jK)ssess of this branc^h of medicine, is, to say the leasts reprehensible, and in
other bnuich(»s of our art, whi(4i are more intelligently and carefully studied,
would Ik* (Ui^med inexcusable. Physicians are continually stating to their
patients that human breast-milk is the Ix^st f<x)d for infants, and at the
same time art> content to ignore the ver^" principles which would make
their stat^'menti? true. We sliould underst^md that when we speak of the
su|)eri<>rity of brcast-niilk as a food, we mean good average breast-milk and
for th(^ avenigc infant.
In all these cas<s of disturlx^d lactation we must first determine whether
the symptoms in the infant an* rtuiUy caused by a disturbance of the milk-
supply. AVc asct^rtain first wlu^ther the supply of milk is sufficient in quan-
tity by the mclh(Kls which I have aln-ady di^scribed to you. We tlien in-
vestigate the quality of tlu? milk. A chemical analysis shows us whether
the i)erc(Mitag(»s of the diifercnt <'lements are (1) normal or (2) abnormal
If we find thcni to Ix* normal, we know that it is not the milk which is
disturbing the infant, and we must seek for the cause of the disturbance
in other sources iK'vond the breast. If we find the percentages to differ de-
cidKlly from those of average? human milk, we must determine whether it
is the variation from the nr)rmal averagi* {X'ree'ntage which is producing the
trouble, or wheth(T tlic»sc i)erccnta<rcs an? I'cally well adapted to the infant
and the cause of the trouble? is to lye. lookcil for elsewhere. This can be
done only by changing the diifcrent jxTcvntages and watching the result
If we find them abnormal, we can usually determine whether it is one or
several of the elements which are ])n)du<'ing unfavorable symptoms, and we
should endeavor by our treatment to change the percentages of
FEEDING.
189
^
^
N
meniB so as to correspond first to the normal average peiventages, and then,
if this is not sufficient, to rediUK^ them to lower percentages than the avei-age
until the infantas digestive iimetioiis have recovered their ei|uilibrium. We
must nut forget in applying these j>rinei]>les that the eause of the disturb-
ance of the milk exists in some abnormal eondition of tiie mother, whether
jihysiolo^ieal or pathologi<"fll, and tirnt we must first remove this ejiuse or
we shall fail to regulate the milk.
A sedentary life, ^ath abundance of rich, mixed food, provided the
woman has a strong, healthy digestion, ap{x^ars to increase the total solids
and to da'r*ease the water. This increase is almost always in the iiits
and proteids ratlier than in the sugar and ash ; in fact, the marki^ vari-
ations in human milk are almost always shown in the fat and proteids,
and hence our attention must almost invariably Ix^ dii*ected to «>rre(*ting
these elements. This is fortunate, as we know id' no siieeial treatment,
except on very general principles, by which we can alter the projioiiion
of sugar or salts to the i»ther constituents. A meat, r^r rather a nitro-
genous, diet in the woman increases the fat in her milk. Our physiologit-al
knowledge also indicates that much fat eaten by the woman tends rather
to lessen the fat in her milk. Hence to increase the proiMirtiou of fat in
a woman's milk we should give much meat and *>nly a moderate amount
of fat. The proteids are more difficult to deal with. They have a ten-
denev to ioeroase in verv bad and in very rich milk. The Tirol>h*m whiiJi
we have to solve is almost always liow to dei^iva*^e them, no matter what
the milk is. Our knowledge, untbrtunately, conw^rning a sure means of
reducing the i)roteids Is very limited, Praetically, however, I have found
that where the woman is in gf>oil health it is physical exercist^ w!ii*'h we
must insist upon, preierubly walking in the ojkmi air and within tht^ Umits
of ihtigue. A walk of from one to Uva mik^ twice daily I have found
to Ix* alx>ut what the averagt* liealthy woni:»n in New England needs to
retluee the jx^recnitagf* of tlie proteids in her milk ; but the amount of cxer*
cise must be carefully regulated ai-cfinling to the physical ciijiabiHties of
the individual.
Bearing in mind these sim|>le rules, and having determincfl, by means
of an analysis or analyses, the canst* of the sjxK*ial disturlianccs you will \m
able to regulate the nursing |xn'iod in (tis<«^ where a lack of this knriwkxlge
woidd often necessitate weaning. Yon may in this way als<» avoid seri*jns
harm to the infant.
I shall next call your attention to tlu^se illustrative tabk^, which still
further explain the rules I have just given you, 1 shall prt^^ntly dt^^rilx*
in *letail some of" these cases and disciiss tlicir analyses, but this re|)etiti(>n
I deem advisable, as the subject is both imp:»rtant and difficult. For the
pur|M>se of still greater clearness I have in each of these tabk^ first nx*ordt^
the analysis of a normal milk, aiwl have then, in parallel <x*lnmns, shown
the abnormal jK^rtx?ntagcs and the changes produced in them by the manage-
ment of the mammsB*
190 PEDIATBIGB.
TABLE 4&.
(Human Milk.)
Showing the influence of a luxurioi4a life on a pooriy^ed btU heaUhy wet^urtie.
I. II. m. rv'.
^?^ and but Foodand
NomuO. r™^ little ex- exeivfa*
amaotb.
Fat 4.00 0.72 6.44 6.50
8upir 7.00 6.75 6.26 6.G0
Pn>ti^ids 1.60 2.68 4.61 2.1K)
Ash _ai6 0^ 0,20 0.14
Total 8f>Iia8 12.06 10.22 16.60 15.14
Water _87.Sf> 89.78 88.60 84.86
100.00 100.00 100.00 100.00
TABLE 46.
(Hmnnn Milk.)
Showintf a bad milk anH tmc irhirh if was iw/ws^ihlf to manage on aeeofint of the rontinual
recurrence of ihe same cauMff uncontrolled etnotione.
JEmoCioiH caosiiw ■U»'
Normal. turtMun-e in liiik&t'i
digest ioD.
Fat 4.00 O.r/2
Siipir 7.00 6.80
Pn.toidrt 1.60 4.21
Ash 0.16 0.20
Total solids 12.66 10.83
Water 87.86 89.17
100.00 loaoo
TABLE 47.
(IIumOH M.tk.)
Shtni'intj n milk jutssihlr fu tnnnof/r, hrratfsr fhr mnt/icr, though exeitoblej ufos (ible and
irUlimf to cttfitro/ hfr rmntUmft.
Infiiiit iloln^ Imdiy. Infiint doing welL Wet-nuxse pro
Nonual. Colli'. .M(ith«>rU'- Mother after Tided but nut
foi\' treatment. tn>atmenL ond.
Fat 4.<M) 1.02 3.20 8.01
SuL'ar 7.<M) O.IO 6.40 6.60
Pr..t<-i(l.s .... l."><) 3.54 2.52 2.82
A>li 0.15 0.17 0.18 0.12
Total snlids. . . 12.05 11.43 12.80 12.08
WaKT x7.:^.5 88.57 _87.70 87.92
1(N).<M) 100.0() 100.00 100.00
In th<* alM)V(> cju^o tlic motlKT was vctv ncn'oiis and wished to nurse her
iniant, but tlion^ht that she could not, as she had bocn disoooraged by her
\\\\T<i\ and pliysirian.
She was then told that sh(» could nurs(» in a week, if in the mean time
she t<M)k pro|x*r finKl and exercise and withdn'w the infant from the breast
This she did, and had her brea.sts it^gularly puniixHl, with good resoltB.
FEEDING.
191
TABLE 48.
{Human MUk.)
Showing the effect of the catamenia on human milk.
NormaL C»tamenia, Seven Days after Forty Days after
Second Day. Catamenia. Catamenia.
Fat 4.00 1.87 2.02 2.74
Sugar 7.00 6.10 6.66 6.85
Ppoteidfl .... 1.60 2.78 2.12 0.98
Aflh 0.16 0.16 0.16 0.14
Total solids. . . 12.66 10.40 10.84 10.21
Water 87.86 89.60 89.16 89.79
100.00 100.00 100.00 100.00
TABLE 49.
(Human Milk,)
Showing a milk in which the proieids, which were disturbing the infant, could not he re-
duced until the mother was made to walk comfortably, and thus without fatigue.
Infant as before.
Mother walking
two milee daily,
NonnaL '
Fat 4.00
Sugar 7.00
Proteids .... 1.60
Ash 0.16
Total solids. . . 12.66
Water 87.86
100.00
Infimt with colic
and vomiting.
Mother taking
no exercise and
very rich food.
8.05
6.10
8.89
0.16
18.20
_86.80
100.00
but havhig blis-
ters from French
shoes.
0.66
6.26
8.82
0.18
9.90
90.10
Infant doing well.
Mother walking
two miles. Easy
shoes, no tilis-
ters.
100.00
8.84
6.80
2.61
^16
12.41
87.69
100.00
TABLE 60.
(Human Milk.)
Showing how a milk can be managed while the nursing is continue.
Infant two weeks
old, with serious
Infant
four
NormaL
general nervous
pain. Mother
Mother walking
and eating less
meat. Infant
months old, with
pain and diar-
rhoea. Mother
Infant doing well.
Mother walking
two miles daily.
Milk dUuted
one-flfth.
eating much
entirely well.
not walking so
meat and taking
much.
no exercise.
Fat. . . .
. 4.00
8.44
2.09
8.98
8.19
Sugar. . .
. 7.00
6.60
6.70
7.00
6.60
Proteids .
. 1.50
8.96
1.88
2.22
1.78
Ash . . .
. 0.16
0.20
0.15
0.19
0.16
Total solids
. 12.66
18.20
10.32
18.39
10.78
Water .
. 87.86
86.80
89.68
86.61
89.27
100.00
100.00
100 00
100.00
100.00
As is seen from the analyses in Table 50, the infant did not do well
nntil the mother began to exercise, and at four months it was again aifeeted
by apparently the high percentage of the proteids. The infant was con-
siderably mider the weight corresponding to that of tlie average infant of
192
PEDIATRIOB.
lour months. It was found to nurse twenty-five minuteB at a tune, and br
oaleulution from its weight Motq and after nursing, it was found to take
from 80 to 120 c.c. (20 to 30 drachms). This amount being larger than
the prolmble size of its stonmi'h demanded, the time of the nursing was
n>du(*ed to twenty minutes, and 20 e.c. (5 drachms) of sterilized water were
given in the middle of tlie nursing, thus changing the percentages in the
milk to the figures wliieh are represented in the last oolumn. This calcula-
tion is on the l)asLs of 100 e.c. (25 drachms) to each nursing.
So long as this method of feeding was adhered to, the infisuit did well
It was evidently a case where the infant could not digest over two per
cent, of proteids.
TABLE 51.
(Human Milk.)
Showing that even for a long interval the breastn may he pumped and the reault be a
suecetisful nursing.
NomiaL
Fat 4.00
Sugar 7.00
Prf)t<'id.s 1.60
Ash _0._16
Total si.lids 12.05
Water . . . . " 87.85
100.00
Infknt Bhowing qervoos Inlknt showing no urie
symptonifl and nmoh add and thrlTioir.
uric arid. Bfottier
Uking no ezerdae
and much rich fixxL
Mcyther waUdi« two
mUea and not citii«
much meat.
5.71
2.67
4.00
6.60
4.29
8.18
0.19
14.19
0.17
12.62
85.81
87.88
100.00
100.00
In this case the infant was withdrawn from the breast temporarily^ and
the hn'asts i>um|K*d for twenty-.s(»ven days.
When the analysis pn^s^mted the figures seen in the last column, the
milk was treated hy diluting it, as in the previous case, and the infant was
put back to the breast.
TABLE 52.
{Human Milk.)
ShoivLug the value of retainiug fhr hreajft-milk hy managing even an unprominno i
Inftmt^%ith colic
Fat . . . .
Su^ar . . .
Proteids . .
Ash ... .
Total solids .
Water. . .
NormaL
4.00
7.00
i.r)0
0.15
1205
87.35
100.00
and failing.
Mr>thcr no cx-
ercute, nursing
irrcKuliirly,
Im-Knlur and
1 ni p r o J) f r
sweet foo«l.
Nenoiis. wor-
rie<l con'lilion.
0.34
5.40
3.01
0.18
0.53
90.47
100.00
Infant put on
lx)ttle. Bnflat«
IuimiH.*<l every
four hours.
MiMlerate ex-
erciKC—one
mile. Full
n'Kulnr diet
Tranfiuil.
3.24
5.45
3.95
0-26
12.80
87.20
100.00
Exercise In-
creased to two
miles. Btaudl
amount of
meat
2.79
6.06
8.66
0.20
mneh
it Eza<-
theMia&
11.70
88.80
100.00
FEEDING.
193
^
The above represents a bad milk from the failure of the healthy mother
to conform to the rules of lactation. This bad milk, iiepreiseiited in the sec-
ond eolomn, had t<» Ik! madt* into a rich milk by i"egular feetliag l>efbre any
attempt cx)uld be made to alter the ratio of the constituents. The jiroteids
were then rediicsed somewhat by exercise, and, after the breasts had been
])omi>ed for two weeks, the analyt^Ls showe«l the ixrcentagcs as repr^ented
in the hi^st txjhimn. The milk was then diluted with sterilized water by
the same method as was explained in Table 50, and the infant was put to
the breast and did well ; in faet, was carried through an attat^k of retro-
pharyngeal abscess with this breast-milk.
If you have caivfolly studied these tables (Tallies 43, 45, 46, 47, 48, 49,
50, 51, 52) and the principles (Table 44) on which they are based, you can
appreciate the importance of the interesting illustrative eases which I am
ab<uit ttJ describe to you* I have selectetl them from a large number of my
patients heeanse they represented so well the value of a knowledge which aids
us in tlie management of human milk during j>eri(Kis of disturbed lactation*
The decitiase in the total quantity of the milk is of ordinary occuirrence
at any time during lactation, but it is most common among civnlized rai.'es iit
about the eighth tt* the tenth mfinth. When it occui's early in the lactation
it Ls very dishearteniug to the muther if she is desirous of continuing her
nnrsing. She becomes fearful that the flow of milk may stop alfa>gether^ and
the nerv^ous influence thus brf»uglit t-o Lear on the mammary gland tt^ids
to inere^ase the disturbance. We should therefore encourage her h* Ix^lieve
that the milk will return. I have just suceee<:led lu restoring the fidl quan-
tity of milk in the mammary glands of a multipara (Case 63) who was very
anxious to nnrse her infant, which was three weeks old and had l>een digest-
ing her milk, but had never nursal vigoroiLsly, and was not gaining. The
mother was much discouraged because her milk lessened in quantity so early
in tlie lactation, and she was convinatl that it would not it^tnrn. She had
been taking, without my knowledge, a disprop^irtiouately small amount of
fluid in her diet. There was an element in this case which the intelligent
nurse brought fci my nr^titn?, — namely, that the infant (Case 64) was not vig-
orous, and when put to the breast suekeil ieebly and callixl upon the gland
for very little milk. Reac^ting to this lack of stimulus, the gland, although
in a normal condition, secreted ouly the small amount demandi^l by the
infant, and the milk lessened day bv dav. Tnvatmeut was instituteil on the
supposition that the mammary gland is practir-ally self-i\^gnlating as to the
amount of food w^hich it wnll elal>orate at a given nursing. If it happens
to Ix^ called n|xm to nourish twins, it will increase the amount of its supply.
If tlie iniant which is put to it has a small gastinc capacity, it \%^ill produce
the amount needed for that capacity. I assured the mother that the milk
would return, and I trcate<l dirertly the mammary gland itself. An in-
crease was made in the amomit of li{|uid in the m<»ther*s diet, and the
breasts were, after each nursing, [)um]x<l gently, skilfidly, and thoroughly.
The breast-pump supplemeuted the feeble action of the infant, and when
la
194 PEDIATRICS.
more work was required of the gland it began to prodnoe more milk. The
increase in the liquid diet supplied the gland widi materials to work with,
and its mechanism ceased to be disturbed by the nervous influence emanating
from the mother. She became cheerful when she found the milk returning,
while the infant, now that tlie milk could be procured more easilj, demanded
more, sucked more vigorously, and thus satisfied the sensitive menhanism of
the mammse.
The next case (Case 65) points to liie possibility of our being at timtt
too ha^^ty in the decision to deprive an infant of its mother's milk.
The muther (see Table 47, page 190), a rather delicate primipum, twenty-live
of age, was delivered of a boy seven pounds in weight Within four houn puerpetml con*
vuUions FCt in, fVoin which she recovered, but was left with albuminuria 0.S6 per cent and
casts. The latter disappeared in a few days, but the albumin, although somewhrnt dimiii-
ished, continued ; and the patient, naturally of a calm disposition, was in a highly nervooi
condition, fearing that she could not nurse her infant, but decidedly opposed to having ■
wet-nunte. The milk appeared in considerable quantity on the fifth day, hut the infknt did
not thrive, and, although it gained somewhat in weight, was yeiy ftetftil, slept very little,
and kK)ked ill, so that the attending physician became alanned, and after treating it for
its dyspept»ia without much success until it was five weeks old, and finding that there wis
still ul>out 0.26 per cent, of albumin in the mother's urine, decided with me that the breast-
milk should be withheld until we could determine the cause of the trouble, and an analysii
(Analysis 9) was accordingly made, with the following result :
ANALYSIS 9.
Fat 1.62
Sugar 6.10
Ppf)teids •. . 8.54
Ash 0.17
Tntal solids 11.48
Water 88.67
100.00
This Analysis suggesting the probability that the large amount of proteida was causing
the disturbance of digestion, and that the small amount of &t was not sufficient for nutri-
tion, the attending physician was very anxious to procure a wet-nurse ; but while we wen
endeavoring Uy get a proper one, we d^Kjided to empty the mother's breasts with the braait-
pump every day, thus relieving her fn.)m the worry of attempting to nurse her infitnt and
seeing it fail to gain. She also obtained in this way undisturbed nights and a great deal of
out-<loor life. The infant was in the mean time placed on a substitute food, which wai
digested ver\' well, and, as it ceased to cry, the mother's mind became tranquil, and the
albumin in lier urine in a few days was reduced to a trace. The treatment waa canied ont
for a week, the milk continuing to flow freely, and an analysis (Analysia 10) waa then
made of the mother's milk and also of that of a healthy wet-nurse (Analyaia 11) whoie
infant was thriving on its mother's milk.
ANALYSIS 10. ANALYSIS 11.
Mother. Wet-Noiae.
Fat 3.20 8.04
Sugar 6.40 6.60
Pr<»teids 2.52 2.82
Ash _0J8 0.12
Total solids 12.30 12.08
Water 87.70 87.92
100.00 loaoo
FEEDING.
195
I
I
I
I
I
I
' The two milka being equally g:ood, it woa decided to allow the infant to begin to take
one nursing daily fD>m its mother, although the proteide were still about one per cent
higher than the infant seemed likely to digest ; it was given to its mother, nursed well,
aeemed satisfied, digested ils meal without trouble^ and at six montlw is still being nirned
and is thriving.
The next case (Case 66) which I shall describe to yoii illustrates the
priocipie that tcKi frequent niir^iDg lessens the water and iuci-eascs the total
solids in hujiiaD milk, making it re^mble in a certain way condensed milk.
It also illustrates what I have stated concerning the two imiwrtant question.'^
to be considerGtl in the management of' a normal lactation, — namely, that
the digestion as well as the nutrition must be regarded. This case is one of
the numennis instancies of the same kind Avhich have come to my noticx^, and
also emphasizes the fact that infants are often weaned from the breast where
tliere is not the slightest necessity for it.
The mother, a healthy primipara about twenty-two years old, had nursed her infant for
six weeks, during which time the infant was fretfbl, suffered much from colic, and never
seemed satisfied. There wae, however, a continual gain in weight, although the fiecal dis-
chargos showed evidences of the fo«-Ki not being properly digested and were numerous and
watery. By advice of the attending physician the infant was weaned. The mother came
to me for advice in regard to placing her infant on a substitute food. On inquiry I found
that this infant had been nursed almost continuously night and day, with iolem'ub usually
of only one honr^ and it wa* evident that the frequent nurising» had resulted in producing a
conoentrate<l milk which the infant's gastrtv-enteric tract wa« rebelling agaiuet and was not
digesting, although sufficient ff>nd was being absorbed U> prevent up to thifi time any inter-
ference with the general nutrition. This infant, then nx weeks of age^ waa deprived of it*
supply of good human milk in tht? middle of the sumtoer simply because the important
matter of changing the intervale had not been thought of as a means of improving the
miik and relieving the pain and apparent hunger. There seems to be no doubt that if
the milk in this case had been properly managed it wrmld have agreed perfectly with the
infant. X would also add in connection with thb eadc that where the digeiition h not carried
on properly the nutrition must !>oon suffer, and it is only in the early weeks of a disturbed
digestion that, as a rule, we find the nutrition to be unimpaired.
The next case (Case 67) is one of a multipam who was under my care at the City
Hospital, and who up to the time of her entnmee had been nursing her infant, which was
thriving* This patient stated that her milk had always been abundant and of gorKl c^lor
up to the time when li^he was aepurated from her infant, which was twelve hour? previously,
aa she had to be away from home for that time. At the end uf twelve hours the breast was
found to be so distended that the breast-pump hod to be applied. The milk was dniwn with
great ease, almost fiowing of itselfi and in considerable quantity^ but it no longer r«ecfmbled
the milk of the previous nunlngi which had been at the pr<iper intervale. On the contrary,
it was clear, with very little color, the total solids were reduced to a minimum, and it no
longer would have nourished the infant
Tht» treatment of this case was of couw© to pump the breasts every three hours until
the infant cuuld again be nursed.
As an illiLstration of the harm which may come to an infant from the
percentage of fat in its mother's milk being too high, and also of the means
to employ either to infrease or to def-rease the fat in breast-rail k, this c^ase
(Case (\S) will be of interest. The mother was a healthy priraipara. She
had plenty of milk, but the infant suffei^ed from colic and had very fm^uent
watery dejections. Finding that abe was eating a great deal of meat three
196 • PEDIATRICS.
times daily and not taking much exercise, I naturallj supposed from the
symptoms of the infant and the diet of the mother that an over-peroentaiic
of fat was one of the elements which were disturbing the lactation, aod
that a high percentage of proteids would also be found. The analyst
(Analysis 12) proved my 8upjx)sition to be correct:
ANALYSIS 12.
Primijmrn. — Healthy; eating much nieai; not taking much exercise.
Fat 4.96
Sui^nr 6.60
Pn)U-ids 8.29
Ash 0.17
I thercibre doi'ideil to reduce the meat to a minimum^ which was done,
and three days later an analysis gave the following figures :
ANALYSIS 18.
Eatitig Utile meat.
Fat 1.78
Su>?nr 6.70
Prr^teids 8.74
Ash 0.18
Th<» milk was found to l)o lesscMiing in quantity. The infant's dejectimis
wore less numon)iLs and had more consistency ; but it was not gaining, and
eontiniiwl to have pain. In fact, tlie analysis showed a poor milk or even
a l)ad one, as rc^prc^cntcd by the usual combination of a low percentage of
fat and a lii^h jxTcvntagt* of pn)teids. The woman was consequently made
to cat a niodtnitc ani(»unt of meat, and to exercise more, and three or four
days later the analysis showed an improvement in the &t :
ANALYSIS 14.
Enfitiff iiHulrrnie amount of meat; taking lYuyre exercise.
l-'ftt 2.42
•^"^'•''' 6.60
^r"ti'id8 3 55
^^^^^ 0.16
The infant now Ix^gan to gain in wcijjht, but oontinued to have colic,
as was cx|K^ct4Hl from the high jwn'cutagc^ of proteids. The exercise \i-as
still further incrn^ased, and a later analysis sliowed a decided leasenine of the
proteids, jus Ls seen in this analysis (Analysis 15) :
A>' A LYSIS 15.
Exercise still further increased.
^ftt 2.85
^uj.'"r 3^26
Pr^'toids 2^39
^«^ 0.16
The infant be|^n to have regular movements, of p^iud ainsLstency,
and no longer had pain ; it also gained regularly in weight, and, as you see,
looks well and strong. The mother has regulated her diet, ejcereise, aud
deep in aeconlanee with tlie requirements of her infant, and her milk has
^igain l>eeome abundant.
We shall, of coursej often fail in our attempts to manage the pereeutage
of fat in this way, but tills case illustrates exactly the changes which it is
usually necessary to produce in order to alter a liigh fat percentage. The
proteids also being high, I had an over-rich milk to deal with ; taking away
the fat-prixlueing element reducefl the fat to a low jjercentage ; exercise
reduetil tJie high i)ei'centage of proteids, and a combination of sufficient
meat and exercise finally produced a milk which conld be digested*
This next case (Case 69) is an interesting one, as it illustrates a number
of points in the management of lactation. A high percentage of tlie proteida
was creatiDg the disturbance in the infant, and it was their final reduction
through treatment that |>ermitted the lactation to go on.
The mother^ a remflrkably henlthy and vigorous multipura, living in the country, hfld
a plentiful supply of milk. Her diet consisted mostly of vegetiibleSp and she did not tiike
much exercise. The infant waa not thriving, having had fontitiued attacks of t^olic, with
fVequent vomitin^T '*ii'i it did not gain In weight. The analysis (Analysis 16) showed n bud
milk* which wm cuntrary to what we ahuuhi usuaUy expect to ^nd m the milk of a mother
who was io such perfect health as this one was.
ANALYSIS Ifi.
Fat . . 0-52
Sugar 6.80
Proteids .,.,..,. 2.48
Ash 015
Total *^r>lids . . , 9,96
Water mm
WkOO
The mother was instructed to eat meat and to walk two miles every day* One month
later, as thp Infant had not improved, another analysis was made (Analyab 17)* which
showed that the milk was in a wonie rather than a better condition.
ANALYSIS 17.
Fftt , . 0.46
Sugar 6.15
Pn>teid9 2.47
Ash 0.16
Tatal solids . 9.20
Water 90.77
100.00
I found that the mother had eaten meat but once a day, and in small quantity ;
> that *he hiid not walked much. I then insi^ited on her eating meat three times a day,
and walking three miles. Thif ?he did for two weeks, when the infant was found to have
gained slijpfhtly in weight, hut to still have colic and vomiting. Another analysis (Analysia
18) showed an increase in the fat.
198 PEDIATBIOB.
ANALYSIS 18.
Fat 1-W
Sugar 6.68
Proteidfl 2.48
Ash 0.16
Total solids. 10.86
Water 89.16
100.00
During the next two months the walking was oontinned and the meat increased in
quantity. The infant continui*d to vomit and have colic until the mother was made to rids
on horseback every day, when the pain ceased, and from that time the infknt gained ste«Ur
in weight, and was well and strong during the rest of the lactation. An analysia (Analyai
10) made two and one-half months after this procedure showed that at laat the proteidt fatd
been n*duccd to come within the limits of the infant's digestion, and that the &t, although
still having a low percentage, had been increased sufflcientlj for the infSuit'fl nutrition.
Thus a bad milk was finally changed to a g(x)d one. This infimt evidently oould not digest
a percentage of proteids approaching 2, but fortunately could be nourished on a low p»
ceiitage of fat.
ANALYSIS 19.
Fat 2.01
Sugar 6.90
Proteids l.M
Ash 0.17
Total solids ia62
Water 89.88
100.00
In the next case (Case 70) I liad a poor milk to deal with. The infiuit
was four months old. It was {lerfectly well and was digesting well, but had
not gainiMl for three weeks. The mother was producing from her breasts a
sufficient (luantity of milk, but the analysis (Analysis 20), as you see, shov^
that this milk had to be miKlified within tlie breast by a r^^ulation of the
diet of the mother :
ANALYSIS 20.
FHt 1.29
Su^mr 6.06
Proteids 2.08
Ash 0.12
Total Holids 10.89
Wator S9 Ql
100.00
She was consequently made to eat an increased amount of meat, and in
the a)urse of a few weeks the infant was thriving and gaining in iveight.
The next case (Case 71) is that of a wet-nurse whose infiuit was digest-
ing well, gaining in weight, and ha])pcnc<l to ]ye of about the tutm^ age as
that of tlie infant whom she was hired to nurse. In order to see if this
nurse's milk would agree with the foster-infant, the nurse and hep infiuit
were brought to the house of the foster-child, and were comfortably lodged
and plentifully fed. Twenty-four hours later Iwth infants began to have
H^P FEEDING. 199
colic and green feecal dischai^es. An analysis (Analysis 21) of the milk
ehowed a high percentage of proteids :
AKALYSIS 21.
Fat 8.19
Sugar e.40
Frotdda 8.11
Ash ....,». 0.16
Total Bolide 12,85
Water 87a 5
100 00
The nurse wns then given a lighter diet with a greater proportion of
liquids, and was made to walk one mile twice daily. By weighing the
infants jnst before and ju5;t atter a nursings it was found that they took
from 90 to 120 C.C. (3 to 4 ounces) in fifteen minutes. The iniante were
then allowed to nnrse for ten minotes, SO e.c. (1 onntxV) of sterilized water
was next given to them, and they were then allowtxl to nui-se for ten
minntes longer. In tliis ^vay I estimated that they wei^ receiving in
their 8t*>maehs 120 c.c. (4 ounoci?) of fcxxl in which the jjcK^ntage of the
prrtteids was imder 2.5. The inlknts ceased to have colic, and the fsecal
disf^hargeii betume normal. The nurse's infant was then sent away. Two
weeks later the foester-iofant was thriving, and, as another analysis (Analysis
22) of the milk showed a sufficient reduction of the proteids, the sterilized
water was omitted.
ANALYSIS 22.
Fftt 2.87
Sugar. . 6.26
Pn>u?id8 . , . 2.90
Ai»h , , . . . 0J5
Total solids , , , , . . 12.17
Wiiter 87,83
100.00
Dnring the rest of the lactation the infant digested well and gained
fairly in weight
This yonng wTiman (Case 72), who has brought her infant to show you,
is perfectly healthy, and is nursing her infant, which has been digesting well
and steadily gaining in weight for some months. I wish you to see this
infant in order that you should undt'i-starid how at times an infant can thrive
on what apjK^ar to Ix* tmi high percentag**^ of some of the solids in the milk.
This Is the analysis* (Amilysis 2i\) (>f her milk :
ANALYSIS 28.
_ Fat 4A1
Sugiir , 5.90
Froteida 8,71
Ash 0.21
Totu! aolidfi 18.98
Water . , 86.07
100,00
200 PEDIATRIOB.
In wntrast to this woman (Case 72) is another woman (Case 73) vho
lias brought her infant for you to see. The infant is evidently thrix-ing.
The mother is delic^ate and frail, and the infant is being fed by this healthv-
looking wet-nurse. In the early part of the lactation the infant did not
thrive, and, as the mother wa>\ so delicate, it was not deemed advisable to
attempt to improve the quality of her milk. The interesting point in mu-
nection with this c*ase is the inability of the infant to digest a poor milk
and its ability to digest perfectly well this wetr-nurse's milk, which in its
analysis (Analysis 24) shows a very high percentage of fat and of proteids
and a low |x.'rcentage of sugar :
ANALYSIS 24.
Fat 4.72
Su^ar 4.65
Pmtoids 4.74
Ash 0,19
Total solids 14.20
Water 85.80
100.00
This mother who has bnnight her iniant to see me to-day lepresentB a
case (Case 74) where I entirely failed to change the percentages of the ele-
ments in the milk. She had a moderate quantity of milk, and nursed her
iniant for two or tlu*ee months. The infant did not gain, it had colic, and
at times vomited. The analysis (Analysis 25) showed that it was in the
class which I have designated as " bad :"
ANALYSIS 26.
Fat 1.61
Sugar 4.67
Protoids 4.07
Ash 0.17
Total Molids 10.62
Water 89.48
100.00
An increase of meat in thi? mother's diet and more exercise had no effect
on the iK^i'eentaj!:es of the elements ol' her milk^ and the in&nt was therefore
weaned. Soon after Ix^jrimiing to take a substitute food from the Milk-
Lalx)ratorv tlie inliuit <'eas<.Kl to have eolic, gained in weighty and it is now,
as you set*, in a liealthy condition. The {x^rt^entages of the elements in the
substitute tb(Kl which ])r(Kluced such an immwliate ehange in the infimt's
conditicni were as represented in this j)n*s(Ti|)tion :
PKKSrKIPTloV 4.
Fat 8.60
Suj^'ar 7.00
Pn.teids 1.00
FEEDING.
201
It was merely necessary to raise the percentages of the fat and sugar, and
reduce that of the pTOteids, in oixler to prtduce this rapid and .satiislaetory
reeidt
The next analysis (Analysis 26) which I .^Imll show you is that of a
woman's milk (Case 75), which is instructive for a number of reasons :
ANAI.YSIS 26,
Fat 2M
Sugar 6.66
Prtiteida , 2.&7
A»h , . ,...,. 0,12
Total ftolida 11 C4
Wftter * . . 88.36
moo
^
You see that the fjereentage of fat is low, and that of the proteids is
rather high. The iiiiimt (Case 76), with the exception af l>eing somewhat
t^>nstipated, was always well, gained in weight, and showed no digestive
distnrban*?e during the kictatirm. This wa*i n^markahle, as the mother's
catimicnia n^turned regularly during the lactation iVom the time that the
infant was four months old. There was c^>n!^iderahle flowing at the
time of the catamenia, and the mother wa^ liabitually eousti|>atnl and
did not have a very gowl api>etite. Tlie iufkut did not seem U) l»e allected
by any of these conditions. The analysis of this milk was made from a
6|^meu of the " middle milk," which was taken between tlie eatamenial
perifMls.
It may be of interest, in connection with what I have said concerning the
variations in the milk which may arise from emotional causes and menstrua-
tion, to report the analysis of a milk of a mother and a wet*nurse where
th<»se influences api)eared to priKhice ci'rtaiu chemical i-hanges, Tlie mother
(Case 77) (Table 46, page 190), a healthy but rather delicate primipara, the
period of w4iose jiregnancy had Wn suj>ervLsed by me with the greatest care,
but whose tcm|>tM'ament was subject to extiTmes of desp(*ndcncy and excite-
ment, was deliverHl, at\er a short and easy lalxir, of a healthy lx)y (Case 78).
She was exceedingly anxious to nurse her inthnt, Ijut within a few hours alter
its birth she was seized with an uncontrollaljle fear that she would l>c uualile
to do so. In spite of all the assurantx^s to the contrary whii-h could lie
given to her, and the plentiful suj»ply of milk which in due time came In
the breasts, she remaineil in a very nervous, despondent condition. As the
infant liegan to show dc4^idtHl signs of iniligestion, I thought it Ix'st, liefore
proceeding further, to investigate the c*)m{)osition of the milk. The analy-
sis (AnalysLs !27) rcsidted as foll<*ws, and plainly showed the necessity of
not persisting further, as it was cvi<lcntly niucli altcnxl from unavoidable
nervous conditions, which seemed likely to recur through the whole of
lactation :
202 PEDIATRIOB.
ANALYSIS 27.
{Mother's Milk.)
Fat 0.62
Sugar 6.90
Proteids 4.21
Ash 0.20
Total solids 10.88
Water 89.17
100.00
Under those circumfltanoes, a healthy wet-nune (Case 79) (Table 48.
l>age 191), wliose own infant (Case 80) was strong and thriving, was em-
ployed, and the foster-infant immediately began to gain in weight and ceased
to show any digestive disturbance. After a month, however, it was found
not to have made its weekly gain, to be unusually restless, and to be having
frefjuont frocal diseharges. It was then discovered that the wet-nurse was
menstruating, and on tlie second day this analysis (Analysis 28) of her milk
was made :
ANALYSIS 28.
( Wet-Nurae.)
Fat 1.87
Su|?ar 6.10
PrDtoids 2.78
A«h 0.16
Total 8<)Hd« 10.40
Water 89.80
100.00
The catamenia lasted alx>ut four days, and did not return for some
months. The infant after tlie first t\venty-four hours showed no disturbance
wliatever, stm^u Ix'gan to gain, and was not affected by the subsequent
n'currence of the catamenia. This analysis (Analysis 29), made one week
aiivr the catamenia had wsised, showed a decided change for the better ; that
is, increased fat and dw^rea^^d ]>n)tcid8. Forty days after the catamenia a
still greater imi)rovcment was found in the milk, as was anticipated from the
thriving condition of the infant. The change in the percentages is shown
in this analysis (Analysis 30).
ANALYSIS 29. AKALTSI8 Sa
Sewn Dayn Rvtj Daji
after Ca- aAer C^
tamenia.
Fat 2.02 2.74
Suijar 6.65 6.86
rn)teid8 2.12 a98
Ash _ai5 0.14
Total 8(»lids 10.84 10.21
Water 81».1G 89.79
lOO.Oo" 100.00
The following case (Case 81) is of considerable interest with inference
to what I have told you in regard to the incom{)atibilii7 of pr^nancv
P FEEDING. 203
and lactation. Unfortunately, a full ct>n9ideration of the condition of the
milk cunnot be presented to you, b& it rapidly dLsappmrwl from the breast
after the first analysis was made, and, before another specimen eould l)e
procured, had disappeared entirely.
The milk was taken from one of my putienU who had been pregnant for three niontba
and at the scune time was nuniag an infant (Ctise 82) nine montlis uld, '
ANALYSIS 81.
Fat . , 7.64
Solid* not fat 6.04
Total solids 18.68
The infant at the breast was not thriving. It had been digesting its mother's milk
perfectly and hrtd been gaining in weight until the pregnuncj had existed for some weeka.
At the tiine the analysis waa made the infant 't* digestion had evidently been weakened, and
as a result it had ceased to thrive and was rupidly^ losing in weighi.
This analyain will be found to illustrate several facts. In the first place, it represents a
very rich fix>d. The total ?f>lids arc even greater than appear in moat cows' uiilk^ and the fkt
b almofit double tbe percentage which is considered n<>rmal in both human and cows' milk.
It also shows that a foijd may be unusually high in tbe ]H'rcentage of its total solids and
yet not of a character suited for the nutrition of an infant. The explanation of this fact is
that although for a time an infant may digest fairly well a rich food, yet that nature has
provided that the peroentages of the element* in its food should renmm within certain
limits. If these limits are transgressed,, either by giving too It^w or too high a percentage
of any of the solids in the food^ the nutrition will be interfered with. In the latter case the
digestive function of the infant actuaUy becomes weakened, and the strong food soon begitis
to act as a foreign btidy. The absorption of the food is next interfered with^ and the infant
starves as readil^^ on the strong food which cannot be absorbed as on tbe weak food in which
the needed elements are lacking.
This analysiB also repr^ente a condition which , in the majority of cases of pregnancy,
occurs after the first six: or eight weeks, — namely, a much di??turb<:*d mammarj* e*^uilibrium.
The percentage of fat in pro^xjitiLin U) that of the solitis not fat is so entirt^ly diflx?r«mt from
the percentages of the diflerent elements in a nonnal milk that we may say that this milk
of pregnancy represents a condition of profound disturbance.
This especial analysis must not be taken as a standard one for the milk of pregnant
women, for, in ail probability, analyses of milk under these conditions differ very widely,
yet invariably show an absence of the normal percentages.
This next case (Case 88) (Table 49, page 191) represent* a milk which could ha%*e been
changed with comparative ease, provided that the mother had followed the directions given
to her. She was a multipara, strong and vigorouii, with a g>>od ap(>etite and a perfect
digestion, and her life was entirely free frt»m care. She had a plentiful supply of milk,
but insisted on eating much more solid fo«d during the puerp<^rium th»n wiis compatible
with keeping the elements of her milk in pn>per proportion*. The infant soon began to
be restless, and, although it gained in weight, it voniiti'd at times and had colic quite fre-
quently* An analysis (Analysis 32) of the milk showed what I had expected to find, —
namely, a petroentage of proteidi too high for the proteid digestion of the infant.
ANALYSIS 82.
Fat 3.08
Sugar 6.26
Proteids 8.51
Ash , 012
Total solids . . . , HMU
Water _fj ^^
100 00
204 PEDIATRICS.
The mother, who was able to go out of the home, was told to walk two miles twin
daily. I also ordervd her diet to be regculated bo that there should be a smaller proponioD
of Bulids than she was now having. Sterilized water was given to the infiint in the middle
uf its nursing. Fur a few days the infant seemed to improve and was less restless, but in
another week the symjitoms of indigestion returned, and, suspecting that the proper propcv^
tions of the milk were again disturbed, I had another analysis (Analysis 88) made, with the
following result :
ANALYSIS 88.
Fat 8.05
Sugar 6.10
Pr«»teid8 8.89
Ash 0.16
Total solids 18.20
Water 86.80
100.00
The percentage of the proteids, as you see, was now even higher than at the time of the
last analysis. The mother declared that she had been walking up to the prescribed limits
but complained that the exercii«e tired her very much. It was very evident that the walk-
ing did not fatigue her sufficiently to influence her milk badly. I found, however, that £he
was not carrying out the rules which I had laid down for her diet, and had eaten frevfly of
many rich f<.»od.s. 1 then insii^ted on her leading a more rational life if she was to continue
her lactation, and i*he prrnnisiHl that she would. The in&nt for the next few days ceased to
have colic and was uppan>ntly perfectly comfortable. At the end of another week, howerer,
the symptoms of a disturbed digestion returned in the inftint, and I had to investigate sUQ
further the cause of tho mammary dititurbanco. The mother had been carrying out all mr
rules as to diet, sltvp, and cxcrciKO, but I now found that for walking she had used sbuee
with high Fn>nch hetU, and that she had blistere on her feet. Another analysis (Analy.<i»
84) of what wtus practically a '^ foremilk'- showcHi the low percentage of fkt and sugar which
might Iwi cxpuct«.*«l in ii " foremilk." The percentage of proteids was very high, considering
that it wass u *' fore-milk."
ANALYSIS 84.
Fat 0.66
Sugar 6.26
Prot«id.s 8.g2
A^h 0.18
Ti»tul solids 9.90
Water 90.10
100.00
Tho mother was now made to exorcise in shoes fitted to her feet and having low broad
heels, iiud to carry out riironmsly all the rules which I had given her in the early part of
her liict^ition. Fn.jni this time the uiituvoniblc symptoms in the infant disappeared, and it
gained in weight and dii^esrted it> fixid well. One wiKik ai\er this change was made in her
f^hoes the analysis (Analysis :^r>) of her milk showed that it was now in normal equilibrium,
and that the {HTcentai^es of its fl»Miients were such as to lead me to conclude that the con-
dition of the infant's dii^estion had becinne normal.
ANALYSIS 85.
Fat 3.84
Su£^ar 6.80
Proteids 2.61
Ash 0.16
Total .solids 12.41
Water '87.69
100.00
N
V FEEDING. 206
A few weekjB later the infant again began lo show aymptoma of colic and general dia-
turbaDce^ and although the mother said that she had not been eating any fi>od but what
1 had prescribed and that she waa taking a long walk every day in properly fitted shoes,
I knew l»y the hi^rh percentage of proleids which was shown by the analysis and by
the condition of the iutant that *he was not telling the truth. I therefore decided that in
the interests of the infant it would be better to wenn it, which I did at once, and gave it a
Bub&titute food with a low percentage of proteids^ on which it thereafter throve.
Prolonged Lactation. — To what I am about to say regarding tlie
extension of laotatirm beyond tlie normal pericKl of twelve mouths I shall
not include the more pronounced pathological conditions^ espc*'ially of a
nervous type, which occur iii certain women under these circumstances. In
healthy women the milk towards the end of a normal lactation has a
tendency to return to the condition wliich wx* notice at the very Ix^ginning
of lactation; that L?, the prmluct of the mammary ghmd Ijccomes unstable
and the peix?entages show a |KK>r or a In id milk. In rare case^ I have met
with women whose milk remained i>f tair <juality an<l who «>idd wuitinue
tlieir nursing into the second year without aj>parent detriment to thcmsi^lves
or to their iniants. There is, however, no rea^in for thus continuing the
lactation, even if the mother is licalthy and the milk gtxid, for at the end
of the first year, humau milk, whetlier goixl or \m\, is not a footl which is
adapted to the cor rt\sjK>n ding stage of development of the iatant's digestive
organs. Unnniditied ccjw^s milk and etarch in mniQ form are much Ix-tter
adaptcil to iiie stage of development of the digestive organs of the siH.tind
year, anil should thLTcfiire at that time Ixe substituted for humau milk.
Mixed Feeding. — It not iufi-equently happens to nursing women, when
their general health is not in a normal condition, that the supply of milk,
while g*><Hl in quality, is not sufficient in (juantity to satisfy the iniant, and
the question arises whether tin* mother^ milk should be entirely given up,
or whether it should l>e supplcmcntt'd by other fooib My ex]X»riemx* is in
favor of assisting the mother to nurj*e htr infant during the earlier months
of it8 life. I have found that where tlie sidistitute fbtKl is cjirefidly regn-
lattxl, this method Ls sujwrior to that of withdrawing the mother's milk and
feeding the infant exclusively u|x»n a substitute frH»d.
We have, on the one hand, a In'tter oi>jxjrtuuity for reguhiting the
mother's milk, by inerea^siug or dimininhing the numl>er of the suljstitute
feedings, and, on the other hand, if the mother's milk agrees witii her
infant, an exn-llent opportuuity trir making our sul>stitutc ft^d correspi>nd
to what nature ha* provided. We can regulate more* intelligently the
infant's lltnling by this methfKl than by any ntlier which is known.
In arranging a mixed fetxling we should in every case first have an
analysis made of the mother's milk, and» if her milk has been agreeing
with tlie infant, make the subetitote food corresfKmd to the maternab I
would also rtK^immend the practice of having an analysis of the mother's
milk made at an early perirxl of her lactation, as s(.xtn as the mammary gland
has acquired its ef|uilibrium and when the infant is thriving. This is a very
206 PEDIATRICS.
im|X)rtant preoaution, which may be of great use to ns at a later period
Avhen the mother's milk may from many circumstances be distarbed or en-
tirely lost. When such an ac(*ident happens, we know exactly what the
c4)ni[XKsition of the milk was on which the infant was thriving, and can &t
once arrange a pn)[)er substitute food. As an illustration of the truth of
this statement, the following cases (Cases 84 and 85) are instructive :
An infant (Case 84) was thriving on the milk of a healthy wet-nane. One day, with-
out givini; any warning, the nurse left the house and never returned. The infant had to be
put on a substitute fiKx), as another nurse could not be procured. It was left in the middle
of the hot weather without the fcMKl which had been so well adapted to ita digestion. Un-
fortunately, the precaution of having an analysis made of the wet-nune'a miUc had not been
taken, and it was some time before I was able to substitute a food which would agree with
the infant.
The second case (Case 85) was the one which I have already mentioned in l^ble 50,
whore the mother's milk, afler careAil management, had become fitted for her infant, tad
wher^t the infant was thriving. One day the mother received ja nenroua ahook ftom seeing
the unn of another of her children dislocated. Within a few houn the milk entiielj
disappeared from her breasts and did not return. The analysis of her milk, which bad
been previously made, prr)vidcd me with a guide by which I could at onoe have a substitute
food prepared which would correspond to the food which the in&nt had been reoeiving fkom
its mother. This was done, and the infant continued to thrive, ihowin^ no bad aymptona
from the change of fiKxl.
Tliere are oi»rtain iwints to be considered in mixed feeding. Firet, if
the m(»tlier'H milk is agreeing with the infant, the substitute ibod ahoiild
be of the same comp^)sition. Second, if the mother's milk is fiillj digested
by the infant but Ls lacking in certain nutritive qualities, the abeenoe of which
prevents the infant's nutrition from being normal, we should, after the firet
week, alter the c<>m|x>siti<)n of the substitute food so as to make it fulfil
the re(juirenients of nutrition by increa«^ing the percentage of that special
element in the sul)stitute which is deficient in the composition of the maternal
milk.
The tinu.»s at which the sul>stitute food should be given will depend upoo
the numlKT of fwKlliigs which are found to be necessary in addition to the
maternal fwlings, and we should carry out the same principles in this mixed
Iccding that I have laid down for the general management of human breast^
milk. If the mother's milk is lacking in quantity we should make the
intervals In'twecn her nursings longer, and introduce one or two substitute
fwHlings acconling as the age of the child reciuires shorter or longer intervals.
U\ on the contrary, the mother's milk is abundant, but either too strong or
t<M) w(»ak, we shouhl make the intervals of her nursings correspondingly long
or short. In this way, with an accurate knowh^dge of the percentages whi(£
exist in the mother's milk, and with our [wwer to change these pextsentages
in sulwtitute feeding, we can usually in a week or ten days regulate the sub-
stitute feeding of the infant to such a degree that the mother's milk will also
agree with the infant, and the infant will thrive again.
Weaning. — There is no doubt that in a considerable number of caaes
occurring in the practice of physicians among civilized nations the molher^s
FEEDING.
207
^
milk appeare to be entirely imfit for her offspring, and it becomes a question
whether the infant shall be withdrawn from its mother's breast temfMjrarily
or entirt^ly. In sneh an eraergeney tlie careful and re{>eated analysis of the
milk will enable us to determine this qumtion wisely.
I am wnvinced that a large numlx^r of infants are deprived of their
natural ft*cwl and weanetl on insufficient grounds. We thus assist to keep up
the resulting high mortality figures, and I Mieve that tliese tigui'es will \te
sensibly reducetl when, in consequence of our taking a nioi'e enlightcuHl
view of the subject, we incrt^ase the number of infants who are fe<l during
the first three or four months of lite ajKin a snitirl>le breast-niilk.
A particular reason among many for waiting at least three or tbor months
before weaning is presented by the fact that the stomach, after growing
rapidly, has by the fourth or fitlh month become a more perfect receptacle
both as to size and to function.
A number of nursing women find that at variable periwls in the course
of their lactation their milk Ix^gins to fail, and they are forccnl first to lessen
the numlx^r of their nursings and then to wean entiRdy. The time, then,
when the iniant shonkl be Moaned almost always settles itselt'i witliout our
intervention, at varying periods. The peritxl of lactation, and the one which
might be t'alltHLl physiologically normal, can, when the breast-milk remains
of gixA quality' and quantity, be carried through the first year with iK^nefit.
We have eertain guides which aid us in determmiug the proper time for be-
ginning to wean. Physiologically, we know that certain functions, such as
that wliich converts starch into glucose, are but slightly develnpctl in the
early months of life, and that they are only gradually establishetl dming the
first year, and not, as a rule, jierfected and in a tNjndition in which we can
call up(m them with impvmity until the la^^t two or three months of that year.
A sign which aids us in judgmg the progress of this development of the
functions is the appearance of the teeth, calling our attention to the fact that
natuix^ is pre|)aring the infant to digest and assimilate a tbrm of focxl different
frrjm that which it has thus farrt^eeived by sucking. The pi'est^nce of si.x or
eight incisors c*)rresponds usually in the normally developed infant to tlie
full tlevclopment of the panciTatic secretion.
A ttn>st valuable index which assni-e^ us that we need not be anxious to
change the infant's food during the first year is the continuous increase in
its weight, which, with a general healthy ctindition, results from a normal
lactation. Wt' must alluw, however, tor ceitaiu variations which in siK^-ial
Qtmm are as important as is the rule to terminate the lactation at a definite
|>eriod. The [ktiikI of lactation may l>e curtaihxl or lengthened by a mr^nth
or two according to the season of the year, the development of the teeth, or
tlie condition of the child fn>m illness or convalescence. Under such cir-
cimistanees it may IjK? wiser to feed the infant from the brc^ast during the
heated portions of the year, and to wean it in cool weather, liefore or after
the hot season, atxi'ording U) the individual ca^^e. An intertlcntal {>eri<Kl is
also preferable to a dental period, on account of the possible disturbances
208 PEDIATBICaS.
wliu'h nmy avitse in the latter and interfere with the proper actions of the
new functions to which I have referred. In these exceptional eircumstances,
where tlK'i*e in any uncertainty as to the character of the milk which the
infant Ls taking, a (chemical analysis should be made. at onoe, and repeated
several tini(*s at intervals of a few days. These latter months, though not
S4) difficult to manage intelligently as the early period of the infant's life,
arc much more likely to need careful supervision than the middle period,
which, irom its usually uninterrupted tranquillity, has been called the period
of normal nutrition.
Where on account of an insufficient supply of milk in the mother the
infant has for some time become accustomed to several meals of a substitote
i(Kxl daily, the matter of weaning becomes a very simple one, for we know
that we have a i!>od which will agree with it ; but where -we have to begin
to wean directly and to adapt a food to the infant's digestive capabilities, »
in cases of sudden failure of the milk or of sickness in the mother, this pn)-
ceduR^ l)cciomcs much more intricate, and is at times fraught with consider-
ahlc danger. It is in these ceases that an analysis of the milk made when
the mother was in g(MxI condition often proves to be of great assistance.
The method of weaning which I have adopted, and have found to be the
safest and l)est, is the one which I have been enabled to use since having a
milk-lal)oratory at my command. My rule is, provided that the infant is
tliriving or digesting its mother's milk well, to order from the laboratoiya
sul>stitute f(KHl tlie iK»rccntagt»s of the elements of which are very similar to
what the iniunt lias l)cen taking from its motlier. After a few days, if thia
i(MHl is agnnnng with the infant, I l)egin to change the percentages of the
dirtcrcnt elements, with the ol>je<4 of gradually combining these percentages
in su<li a way as to c<)rrcsiK)nd to the |x?rcentages of the elements of un-
modiliKi (^)wV milk. This is easily and precisely accomplished. For in-
stance, snpjKisiiig that the infant is nxxMving from its mother a milk in whidi
the j)creentage ol' the lat is 4, of the sugar 6.50, and of the proteids 2, 1
iK'gin by giving tJic siinie iK'H'cntage of fat (4), a lessened percentage of sugar
(r).o()),aii(l an in<Tease<l jMTccntago of pn)teids (2.25). After a few days^if
tliis milk is <lig(:^te<l well by the infant, I make the fat 4, the sugar 4.50,
and the prot<'ids *i. In a lew more days, if this food is digested well, I
give ])lain cow's milk i)rei)are<l by heating to 75° C. (167° F.), with lime
water siiffi(;ient to make it slightly alkaline. If this still agrees with the
inlant, I soon eliange to <x)w's milk unheated and uimKxliiied.
Unlf»ss under wry exceptional circnmstanc^es, sndden weaning is to be
depnrated, though of course? we must admit that it is sometimes done with
impunity. The safest methcKl, S(» lonjj; as we cannot judge beforehand which
infants will Ikj likely to l)e unfavorably affect^Kl by sudden weanine is
to take i)lenty of time and gradually ascertain by frequent changes, sudi
as I have ch^crilxKl, the fixA l)est adaptiMl to the cjise. The infant dionld
Ik? jrradually ac<.*ustomcd to this fixxl, omitting the breast-feedings one hy
one, until finally we are sure that we have a substitute food on which it
FEEDING.
209
will thrive. At the tenth or eleventh mouth, provided that the weaning of
the infant is deemed desirable at so early a perird, and after having aceus-
tomed it to taking plain c<:>\v's milk, stareh in some form can ako be given.
It will be necessary to determine how mueh of this new element may be
introduced into the infant's diet, carefully adapting the amount to its am}'Io-
lji:ic fnnctionj which varies in different infants^ and which has but lately
arrived at its full development. When the.se changes have lieen accoin-
plirihcil, the breast can with safety l>e entii'cly withdrawn.
The danger of injudicious weaning was strongly impressed n|x>n me in
a case which I watched for stn^eral days through the courtesy of Dr. Sinclair,
of Boston J and w^hich it seems w^ell to put on reeonl,
A delicate infant {Case 86), backward in its development, digesting well, and « little
over on© yeiir oltL wus, without Dr. Sinclair's advice, suddenly deprived of the pleDtitul
supply of bniyi*t-milk of its healthy moth^^r and fed on oatmeiil gnie!. Totjuting and pros-
tration immetliately begiojt and continued until the oatmeal was omitted and the breast-
feeding resumed, when the infant began to thrive again. Three weeks later the mother,
through ignomnce, suddenly and without any preparation fed it ugain on oatmeal gruel.
On the following two days the intunt vomited ince,*aantly and was much proetxated.
Seveml clmnges wen.^ then made in it^^ food, but the symptoms grew worse, and the now
thoroughly territled mother iigain put the infant to her breast, with, however, thia time a
ditiufltrous result, as her milk from nervous influences was &n changed in its i^uality that it
acted like a poison on the infant, who fell into a condition of oollApae. Dr. Sinclair waa
ftent for, and a few honrs later I mw the caae. A wet-nurse with a healthy infant four
months old was immediately pn>cured, and after several days of complete pro&tnition the
foster^infant began to revive, and later wtw gradually weaned without trouble. It may be
well U} add, fur the encouragement of physician* who have cases of this kind to deal with,
that after the mother'^ milk had poisoned the Infant, and when I first saw it, the ^kin waa
gray and cold, the fontanelle sunken, and the eye« fitted, yet rectjvery took place. Under
the game cireumatances equal suoceafi in the treatment would probably lie obtained by
writing for a milk prescription to contain fat 2.60, sugar 5, proteide 1. This, of course,
would be an exceedingly weak fot)d for an infant twelve months old, but it would Iwj the
safest combination to begin with, and could be increased in strength as the infant recovered,
II. DIRECT SUBSTITUTE FEEDING.— Women.— Where for any
reastm it is im[M)88ible or inadvisable for the mother to nnrse her infant,
some other food must be siibstitntecl for the maternal. The milk of another
woman approaches the mother's in it8 characteristics most closely, aiid
shonUl be obtaintHl unless contra-iudieated.
It is ^oemlly supposed that the mother's milk, as a rule, is more likely
to be suited to her infant- s <ligt^ti<m than the milk of another woman ; but
we have as yet too few cases where direct inve^^tigation by means ol* chem-
ical analysis of the two kinds of milk has been made to lay down actually
as a fact what we can nierely grant as a snpjwisitioo, that an idios}Ticrasy
in the mothers milk will find an analogue in her in fan t^^ digestive p4iwers.
The reverse of this prop<isition has als<i been held to \n} tnie, that at times
some idiosyncrasy in tlie mt^ther's milk will make it nidieally unfit far her
iniaDt. The prolwibility, however, is that analyses will show either that
these varieties of milk are poor ones, or that the intants have unusually
weak digestive powers*
210 PEDIATRICS.
Tlie fact that every mother cannot provide as good a milk for her infiint
as can be supplied by another woman finds its analogy in the inability of
Jersey cows to rear their own calves.
In connection with what I have said about an infimt sometimes havii^
an idiosyncrasy of digestion corresponding to some unusual percentage in
its mother's milk, this case (Case 87) will be of oonsiderable interest :
The inothc^r, a priini(>aru, whs healthy, but of a highly nervous temperament TIh
infant was thriving, hut, ad a moadurc of precaution In oaae of Duunmazy disturbance at i
laUT period of the lactation, I had an analysis (Analysis 86) nuide of the milk, with the
following result :
ANALYSIS 86.
Fat 5.16
Sugar 6.68
Pn)U*id8 4.14
Ash 0,17
Total solids lfi.15
Water 84.85
100.00
The rep<trt made by Dr. Harrington in connection with this analysis was, " The precipi-
tated curd is quite similar in its app«>arancc to that obtained in the analysis of cow's milk.'*
I advised the mother on general principles to take more exercise^ and ten days later
another analysiti (Analysis 87) of the milk was made.
ANALYSIS 87.
Fat 4.88
Sujfiir 6.20
Prf.t^-ids . 8.71
Ash 019
TiHmI M.lids 14.08
Water 85.02
100.00
Thi* second analysis was S4» similar to the previous one that, in onnjunction with the
porfoct diii:i*>tion uiid hr-alth nf tlio infant, I concluded that this in&nt had an idiosyncrasy
of digestion wliirlj frnu))li^d it to thrive on what would in most cases cause extreme disturb-
ance. Thiri view of the case provt-d to he. correct, as the infant, which was under my care
for a number of months, cr>ntinu<Ml to thrive. If you will compare this analysis with thst
of th»' milk of the w<t-nur-.e (Table 40, Analysis Til., page 190) which I have fnevicnuly
de.-<Tih«*d to you, wher^; the hi^h percentage of jiroteids caused vomiting of thick curds in
the infant, you will l)e impressed with the strikinij similarity of the two milka. There is no
douht that in the majority of rus«s a milk such as is represented by these two analviei
would he totally untit, and would not only cause marked indigestion but often moi« seriiHU
n.*irult>, su<'h a.- convulsions.
The lollowing wi.s<» (Caw* 88) pn'scnts an illustration of the reverse of
the supposition tliat the mother's milk will suit her infant's digestion better
than the milk of a wet-nurse :
This infant (Cttw^ 80) woj* beinp nursed by its mother and showed continual disturtMDOe
of its di^f^^tion. At tirnr^* it would U- (f •njitiputc-d, und ft-^uin it would have attacks of ccdic
with wat'-ry di'iehunxi's. The colir wu.« tin* most prominent symptom, and the child, tfaougfa
looking fairly well, was not gaining in weight. An analysis of the mother's milk showed
I
V FEEDING. 211
that the pereentap^ of fieit was from 2 to 3^ the sugar was of about the normal p^reentagCy
and the protdd^J varied fVom 8 to 8.60 per cent. The mother was of an extremely nervtJUfl
temperament and waa unwilling to carry out the rule* for the management of her milk,
which were absolutely necessary in order to reduce the high percentage of proteids, whieh
evidently caused the disturbance. I therefore procured a wet-nurse^ the aualyiiis of whose
milk waa as follows :
ANALYSIS 88.
Fat , 2.96
Sugiir . 5.78
Proteids . . . , 1.91
Ash 0.12
Total solids 10.77
Water 89.28
1(30,00
The infant on taking this new milk ceased to have colic, hut was more coDStipatod and
did not gain in weight. I therefore decided that it would be wise to increase the percentage
of the fat in the nurfie^a milk. Thia was done by giving her considerably more meat Vj eat
and making her take moderate exercise. The infant within a week begun to gain in weight
and to sleep well^ the bowels ceased to be eonstiputed and were moved naturally every day.
There was also a plentiful supply of milk. Another auAljsis of the milk was then madOi
with the following result:
ANALYSIS 89.
Pat 8 31
Sugar 6.45
Proteids 2.88
A^h . . . . 0.16
Total solids . 12.28
Water 87.72
100(10
This last analysis is of great significance. The increase in the percentage of the fat
evidently regulated the fiecal movements. The total solids increased from 10.77 to 12.28,
and the plentiful supply of milk made the infant gain, especially as it now was digesting
perfectly. You will observe that it cfmld digest a milk with a percentage of proteids ImiIow
2.60, while it was a percentage of 3 in the mother^^ milk which prevented her from carrying
on her lactation.
In this case it will be seen that the milk of another woman was far preferublc to that
of the mother, and that the idiosyncrasy of a high percentage of proteids in the mother's
milk did not find its counterpart in an idiosyncrasy in the proteid digestion of her infant.
WET-NtmsES. — The general question aa to whctlicr a wct-nurst* shall he
employecl Is one which m of seriong inip^vrt, and must id t^ch inRtance be
decided by giving full weight to all of the many circumstances wliieh are
involved in tlie case. Foster-lceding, whei^e all the c<^>nditioiis iii\» ^tMid,
is superior tn sauhstitute feeding. The reverse of this statement, Imwever,
must always lie kept in view, that a poor nurse, whether from temperament,
or age, or general healthy or the fjuality of her milk, had Ix^tter lye set aside
where tlae amditioiis are favorable for a siicecRsful substitute feeding* It is
perhaps better that the ourst>'s milk should eorrespcmd In age somewhat
nearly to that of the infant she is to suckle^ but a difference of some montlis
in age may not be a oontra^indication, aa we are not yet in a poeltion to say
A
212 PEDIATBIGB.
definitely that the milk diiTerB sufficiently in diflbent months to make this
a reason of im|)ortun(*i' in clioosiug a nurse. A feeble child will nnrw
more easily and probably have better care from a multipara than from t
primi|)ara. The preferable age of the nurse is between twenty and thinr
years. Her other recjuLsitos are a condition of good health and a quiet tem-
jKirament. It will save much trouble and often obviate the frequent necer
sity for changing if Ix'fore her engagement we have made a chemical analysis
of her milk ; in fact, all the ]K)int8 which have been already referred to for a
sucit^sfnl maternal nursing are of equal significance in the case of a wet-
nurs(».
The general health of the wet-nurse should be carefully investigated, as
women suffering irom (iionstitutional syphilis or any chronic disease are
manifestly unfit for nursing. At the same time we should be careful, unlei«
de(;ided symptoms of disea.se are present^ not to set aside the milk of a
delicate-looking woman until it has been analyzed. The wet-nurse (Ca&e
89) whose milk proved to suit the infant better than did its mother's was
a frail, delicate-looking woman, but healthy. The mother, on the other
hand, was a large, strong-looking woman, but of a very nervous tempera-
ment. The ni]n(\ progress which is being made in the detection of the
bacillus tulxTculosis, not only in the sputum but also in the milk and in
other scH'rctirms, may in the future 1x3 of much practical importance in the
determination as to whether a woman should nurse an iniant or not> but the
pn^sent state of our knowledge is only sufficiently advanced for us to stale
that this bacillus has Ix'cn found in the secretion of the mammary gland.
Diet. — Th<i same general principles that I have given in speaking of
the diet of the mother should be applied to that of the wet-nurse. We
should Ix* extremely careful not to change suddenly the customary diet of
a healthy nursing woman on purely theoretical grounds. For many years
the mistake was made of k(»e])ing women on t^x) low a diet in the early period
of lactation, with the conse<iiient delay of the establishment of a suffidendy
nutritious milk-supply, and a corresponding initial loss of weight in their
iniaiitrt. Where, however, we an* t^i)ecially likely to err is in permitting
a healthy, hanl-working Met-nu!*se, accustomed to a somewhat coarse but
nutritious diet, to adopt totally different habits of exercise and a diet to
which she is unaccustonuxl, rather than to have her continue her usual mode
of life. This sudden change^ of habits frecpiently results in loss of health
to the nurse, with its accompanying deterioration in the quality of her milk,
or at least a change in its quality so as to make it an unfit food for her
ioster-child. A notable instance (Case 90) of t<x> radical a change of habits
was brought to my notice by Dr. Swift, of Boston.
A wot-imrse had l>efii pnK^urcnl fr)r an iTifiiiit (Ca!*e 90) ten days old. An azialyiu
(Analysis I.) of hor milk, two days before* sho iK'jxan to nurec, is seen in the followine
table (Table 53). Her milk wus dij^ested well for two or three weeks, during which
time she wiu fed on an abundance of good fcKxl and rich milk. The infant then benn to
FEEDING. 213
▼omit thick curds identical in appearance and tougbnees with the curds of cow's milk.
Another analysis was made (Table 58, Analysis II.), which showed the amount of total solids
to be increased in a most marked degree, the percentage of proteids corresponding far more
nearly to that of cow's milk than to that of woman's milk. The nurse was then given
plainer food and skimmed milk, and the infant ceased to vomit. The infant and nurse con-
tinued well and strong during the whole year, the infant making a weekly gain in weight.
I have here an analysis (Table 53, Analysis III.) of this same nurse's
milk, made in the twelfth month of her lactation :
Pat
TABLE 58.
(Wet-Nurse.)
Analysis L
Two days before
change of food.
0.72
Analysis n.
Rich food for a
month.
5.44
6.25
4.61
0.20
16.50
88.50
100.00
Analysis m.
Food regulated and
milk agreeing with
Infieait.
5.50
Sugar
Proteids
Ash
6.75
2.58
0.22
6.60
2.90
0.14
Total solids ....
10.22
15.14
Water
89.78
100.00
84.86
100.00
Animaus. — I shall merely allude to the other method of direct substi-
tute feeding by means of animals. In parts of France, notably in Brittany,
infants are put directly to the ooVs teats, and sometimes with good results.
I know of one &mily of eight children all of whom were nursed by the
family cow, and all of whom grew up healthy and strong. Yet the unde-
sirability of feeding human beings directly from the udders of animals is
BO manifest that this method need not be discussed.
I shall at my next lecture deal with the third division of the First
Nutritive Period, which I have designated " Indirect Substitute Feeding."
214 PEDIATBIOB.
LECTURE VIII.
THE FIRST NUTRITIVE PERIOD^Gontinued.)
III. Indirect Substetutx Fxbdiko.
To-day, gontlemen, I have asked you to meet me here at the fknn
councctod with the Milk-Laboratorj', in order that you should study practi-
cally what will Ix of great use to you in your future careens. I would im-
pn»s8 ujwn your raiuds that in this subject of indirect subatiiuie feeding we
have many links of a l(»ng chain, all of which should be as nearly perfect
as we can make them if we expect to obtain a satisfactoiy result.
CHOICE OF FOOD. — I have laid great stress upon the importance
of feeding infants during the early montlis of life by means of human milL
We know, however, that in civilized C4)mmunities the necessity will often
arise for supplying the infant with SkmI not from the human breast. In all
probability the employment of sul)stitute feeding will increase rather than
decrease as our civilization advances. With this prospect before us, and
appreciating the difficulties which in a large number of cases are liable to
arise when we attempt to adapt a substitute food to the wants of an infimt,
it manilestly iKH^omes a duty to endeavor to reduce the high mortality figures
resulting fnmi artificial feeding. With this purjKMW in view, we should caw-
fully investigate ditlercnt mctluKls of feeding and adopt some more uniform
plan lor starting human Innings in liie ; for diversity and not uniformity is
now th(? rule. While inherited diseases contribute a certain proportion of the
deaths which (kvut in inlants, yet diversity of method in feeding is the most
])rolitic scjurcc <»1* (]is<'as(» in early infancy. The group of symptoms which
for want of a l)etter name is designated as difficult digestion occurs most
frcfjuently in the tJinv |K'ri(Kls when tlu* infant's digestion is likely to be
tanii)ered with, — namely, in the early wet»ks of life, when experiments are
being made to det<Tmine what finxl will l)e Ixst to start with ; next, when,
in addition to the irritation arising ln)m the beginning of dentition, new
articles of diet are addtnl to the original f(MKl ; and, thirdly, at the time of
weaning, when then* is olbn a sudden and entire change in the character of
tlie fiKxl. The j)rr>|x*r management of the first of these periods is of the
greatest iniiK»rtance, iKM'anse it is the time when, as Iwfore stated, the stomach
is in its most active* j)eriod of growth, and when the function of digestion is
being established, and, i'ol lowing the rule of functional establishment, is in
a state of unstable (N|nilil)rium.
We should recognize the fact tliat th(» j>robh»m of substitute feeding is
not a simple one. We cannot reiterate too often that the question which
commonly Ls sup|)osed to be a simple one, and the one which in the great
FEEDING.
215
I
majority of cases is alone considered^ — namely, " Which focd shall we give
to the infant?** — h a misleading and in^nffieient one. The problem is a
combination of fai'tom of which the kind of food is only one^ and I j:»er-
sonally have long been eonviueed that the ni'glect to investigate thoroughly
and carry out in detail the eombinati^m of these by oo means insignitieant
general factors has had much to do with our failm\*rt with gubstitnte feeding
in the past. It would seem, also, that the present Ls a mo^t npjxirtuoe time
for raising a note of warning against allowing our enthusiasm uver any one
esi)e<?ial theory to warp our l)etter judgment. There will surely be a reac-
tion which will relegate to it8 pp^pcT placx* every the-ory built ujxjn single
fact<jr8 of tlie problem iTetbi'e us*, and which is actual ly doing harm by keep-
ing in the background other theories which, each iu its own sphere, as a
BigDilicaQt part of a wmiplete whole, may lie of very great im|Tortance in
ihe suooessful solution of the geneml problem. An error of oven^ight of
one-eighth in a mathematical problem is not so great as one of one-fourth,
but neveitheless the w^rrectiug of tlie greater error will not prevent an over-
sight of the smaller from completely destraying a corret^t result. Until
lately it has been the qtiality of the food which has Ijeen monopolizing to
too gi'eat a degree the attention of the medical profession. To-day it is
sterilization which in feaiing has Ixttmie (jromiuent. Already one of the
latest German writei^ on substitute feeding has stated that the physiology
and pathology of infantile digestion dei>end not on the chemical but on tlie
biological character of the frM)d, If we are not on our guard, tliJB exagger-
ation of each single factor will piTvail, and by its influence will blind ns to
much gofxl work wliich in otl^er directions has already been done» and which
we cannot affoitl to ignoi-e. Not that I would for a moment Iw miderst^xwl
to underrate the value of feeding an iniant on a sterile fboil, for it has for
years proved of very great benefit in my practice and that of others, but I
pRnlict that l)y just so much as we enhance the value of this one important
part of the whole at tlie exjiense of others, just so much farther shall we
be from an intelligent conipi-ehension of the w^hole subjtY't.
To feed an infant one month nld with six ounces of acid cowl's milk every
four hours, no matter how thoroughly such a mixtiu^ has Ix^^n steriliiied,
would be a radical offence against well-known anatomical and physiological
laws. It therefore seems to rae that time will be well spent in the discussion
of the subject of substitute feeiliug, if we investigate and cndcvivor to copy,
eacli in its turn, the various devices which nature makes use of, for we must
admit that we are not in a position to improve on nature's method.
It is certaiidy wiser and im^rc etxMiomical not to spare exjiense and
trouble in arranging the infant's diet, tor, as I have exidaimJ, the jiericxl of
active growtJi of an organ is the time when its function is readily weakened,
and, when onci? weakened, the digestive function Is a prolific source of
annoyanw and expense in childhood and adolescents. Cheap folds and
cheap methtxls of fecfling, imlcss tliey are the Ix*st that can be procured,
should not be tolerated in the early feeding of infants. We often, however,
216 PEDIATRICS.
see a food re<x)mmendod for a yoiiug infant because it is cheap and easily
preiMin-d, iu spite of tlie fact that its well-known lack of nutritive ingre-
dients would with achiltH Htanip it as unfit for use.
In discussing the treatment of disease we advocate what is best, without
reference to what it costs, and then, in the special case where expense is an
element which has to be taken into consideration^ we endeavor to adapt our
treatment to these considerations, and approach as nearly as possible to our
first standard. In like manner I believe that we are doing wrong to the
public if we allow ourselves to be handicapi)ed in so difficult a question as
infant fmling by the cry of exiiense. Infant feeding is an expense which
Ls vital to t)ie welfare of the human race, and we can, without being aocosed
of extravagance, safely relegate to the province of the manufactorers of
patent iiMxls the recommending to the public of foods which if judged b^
the amount that ls oifeR*d in bulk are cheap, but which ivhen judged hj
their nutritive properties are extremely expensive.
Our scientific knowledge and clinical investigations have not yet enabled
us to follow nature exactly, and we therefore have not yet obtained an ideal
method of substitute fcixling. We must, nevertheless, go as far as the present
state of our knowknlge will allow, thus gaining a little ground every year;
and we must be espe<*ially caR'ful not to be led astray by the fictitiouslj
brilliant n^sults which arc rc{)ortcd from time to time in favor of certain
foods. Instances an) continually occurring where one food will fail and
another, when sul)stitutc<I for it, will succeed, and yet these successes are
mcr(»ly teni|xirarv, and the mortality n»sulting from the use of variom
ini'ant itNxls always remains iar al)ove that from the employment of human
bn'it^t-niilk.
SOURCE OP POOD.— Having decided to substitute some food in
places of woman's milk lor the infant, we must decide from what source the
elements of this fcMKl shall come. The linxl which approaches most nearly
in every resjKH't the prcKlurt of the human mamma is that produced by the
mamnue of otlier animals. The reason for this is that the food which all
mammals pnivide ihv their offspring Ls an animal one, and consists of the
same elemiMits, although the mammary product of different ftnifn<^]ff varies
in the iK'nrntagc of these elements.
Assuming, then, that average human breast-milk is the safest standaid
for us t(j copy, we ai-e inipivssed with the fact that although a v^etable
diet woukl oflen s(»em Iar the easiest method of procuring nourishment for
young inliuits, yet natuix,' has |K»i-sisted in providing an animal one. We
should therefniti be very careful not to intHnluce into our substitute dicta
vegtitable element, which, as Judged by our standard, must be a foreign
element. Milk is the KkkI which our reason tells us should be given to Ae
young inlhnt, and a milk whirh will approach as nearly as possible to the
average human milk. That of various animals has from time to time been
rcwmimeiKhsl as the lK»st substitute for human milk, the recommendation
being based on their analyses approaching more or k»ss nearly the composi-
FEEDING.
217
I
tion of human milk. The milk, however^ of all animals has to be modified
to oorrespond to human milk ; and when we begin to modify, it is as easy
to change the propfrrtion^ of the different constituents to a great degree as
to a small. The iket that the milk of any particular animal approaches* in
its analysis nearly to that of the human bi^ast is not of much significance,
other cou.siderations being far more imiK:>rtaut ; and it Ls most iraijortaut of
all that we shrjuld use one which can I)e obtained easily by the i:>eo|jle at
large. This at once settles the question that it is the milk of the cow to
which we must turn our attention » Cow's milk may ditfer in its compjsi-
tion from human milk to a greater degree than docs the milk of the ass or
the mare, whose milk ap]>roarf?hes, so lai* as Ls showu by analyses, most nearly
of that of all animals to human milk ; bnt this in all probability is for the
very reason that t»ow*s milk is so universally used as a ibod for human
beings of all ages.
If the ass and the mare should be employed for dairy purposes to the
same extent that the cow has been^ thert^ Ls every rea«K)n to suppose that their
milk might change in its composition and their comparatively undeveloped
mammary glands increase in size, just as has bet^n the cas<^ with tlie cow, an
animal which for thousands of years has Ix^^n iistHl for the pnxlnction of
milk, and which prol>al>ly did not in the beginning give such an over-pro-
dtiction of the mammary stM^-retion as is the case now\ In fact, on the monu-
ments in Egypt, where formerly there was either no trade in milk or very
little, we find represented c^>ws with only sliglitly develiifMxl udders, while
the generative organs of tlie male animals ai\^ clearly tlepicted, a lact^if some
significance when we remember the well-known tendency of the Egyptians
to realistic rc^presentatit^ns. It is, then, from tlie pnlilic demand, and by
breeding, that cows have Ix^n made t4> prmluce so miu-h more milk than is
necessary for the support of their young. Not only quantitative bnt quali-
tative differences exist in animals a(*ctti'ding to the development of their
mammar}^ glands ; and, as Martiny has shuwn in his collection of statistics
on this subject, the c^^ndition which determines the quantity and the quality
of the milk depends on the devehjpment of the organ which prmkices it.
The question of substitute fettling, then, is rediictd practically to some
modificatioti of cow*s milk, for this is the milk which is pr*x*URHl must easily
everywhere, and, as the milk of all animals must be m*xlified for the human
infant, it is as easy to deal with cow's milk as with any other.
A further exemplification that cow*8 milk is practically the universal
90UiX!e of the sulxstitute food*supply for infants in most civilized ei^mmunities
is the fact that tfie various fijods, put<*nt cm- not, all de|3end for their basis on
cxiw*8 milk, and that withuut this additi<ui of milk they would show but an
insignific-ant percentage of many of the most important ingredients of tlie
fcMxl. Logicjilly we should not sjKv'dv nf tlie various foods as such, bnt
merely as adjuvants to c<jw*s milk. If this is thoroughly understood, much
^ilifiapprehensirm reganling the a)3parently successful results of innumerable
foods will be done away with.
218 PEDIATBI03.
Oiie of the principal reasons for using cow's milk in preference to all
others is tliat the cow has been kept under more strict control than anv other
animal has ever been.
As I shall in a later lecture (liccture X., page 278), when speaking of
home miKlification, have to refer to the necessity of using milk from common
cows on any farm, it will be well for you to know what the average analysis
(Analysis 40) is of milk taken from lai^ numbers of common cows all over
the world. This average analysis represents the work of well-known
chemists^ such as Konig, Forster, and others.
ANALYSIS 40.
Average Cow^b Milk.
Reaction Slightly add.
Specific gravity 1029-1038
WaUr 86-87
Total solids 14-18
Fat 4.00
Siipir 4.50
Pr«»tvid8 4.00
Totiil ash 0.70
Chlorine ••• 18.45
Sul])hiir 0.41
Phosphoric acid 27.98
Irrm oxide and alumina 0.44
Lime 28.17
Magnesia 2.68
Potassium 58.00
Sodium 4.49
The (litren^nct's Ix'twcc^n the constituents of the ash of human milk and
of that of cow's milk are as lollows : in cow's milk there aie more lime,
magnesia, ]K)tas.siuui, much uiore phosphoric acid, and less chlorine and
sul])hur.
THE COW. — Ilaviug chosen the cow for our primal milk-sapply, we
must consider whether any 8]K»cial brt»ed Ls Ixjtter adapted than others for
accomplishing our puriK:)se. To do tliis mc should first examine diemically
and micros<ropir«dly the elements of the milk of tliose breeds which can be
employed Ix'st throughout the civiliztKl world. It has been found that the
finer breeils of cows from the Channel Islands are more liable, when tnms-
j)ort<'d from their home to countries where the climate is more severe, to
<*ontniet diseases, such as tulx^rculosis, than are the animals represented bv
the Durham, Devon, Ayrshire, and Holstein breeds. The characteristic
analysis of the milk of tlic finer breeds, such as Jersey and Guernsey, is
represented in this table (Table 54) in comparison with that of the milk
of other brciK^ls ; the difference* iK'ing mostly in the percentage of fiit and
slightly in the proteids. It may lx> well to state here that the percentage
of i)roteids in the milk of pure IIolst<*ins Ls also a little higher.
FEEDING.
219
I
TABLE 54,
Cbw'a Milk AnalyH6,
Fat . , . -"Tl™ * 6.50 Am
Sugar 4.50 4.-iiO
Pr^jteids , , . . 4.26 4.00
Ai^h 0.f^5 0.05
Total solida . . ....... 14.90 18.15
Wtiter . ..,.., 85,10 8685
100,00 100.00
It is for future research to determine whether there is a qualkati\'e as
well as a quantitative ditference between the fat secreted in the milk of the
Channel IslamU ami that of the more wmmon bnt'ds, hut at prci^nt it
would *et'ra wisc>r, in choosing oar medium for moditittation, to stil^'t the
milk of the hardy breeds of oows*
A cow whose milk is to be used for ptirpo^es of infant fet»tliug should l>e
properly housed and well care<J for^ as the domestic eow is an animal peen-
liarly sensitive to her surRnuidiu^s, and her pn)duct is eorre3|jondingly
liable to be thmwn out of e<|uilibriuni» The milk prfxluet of a herd of
healthy oow^s is mueh less liable to the variations so injurioos to the infant's
digestion than is the milk of any one eow. It is esjjecially to be noticed
how much easier it is by proper care to control exaggerated oervous
influences upt^n the eow^s product than upon the woman^^. This at onee
suggests to us the question, where and how shall cows \n^ taken care of?
The ordinary cow is allowed to range over wide pastures which are
sometimes over-flushed with herltiige and sometimes |iamhed by drought,
and which nearly always contain noxious weeds, which ahe seems eagerly
to seek. Again, she is forced to drink from stagnant pHjls and p*>l luted
streams, and at other times suffers f )r want of water for many houi*s to-
gether. She is also frec^uentl}^ expos*xl to storms. Cows caiTil lor in this
way are not those which pnivide the best milk for substitute teetling.
These are the adverse oonditious which .surround the ortltnary eow during
the summer* In the winter she is crowdtil in the stifling atniosphen? of a
close barn wnth tlic manure of the whole winter kept luidenieatJi the floor
on which she stands* Her head Is usually confined in a narrow stall. The
trxlder intended tor the wiuter^s supijly Is kept alMive her head, and is con-
tinuously contaminated by the foul otloi's of the barn, 8he is turned out to
the watering trough at {Kiriodieal intei'\'als* Thus she cannot be said to Ik-
c*arc^l fiir in a manner cx>nducive to tlie equable function of her mammary
gland.
For cows to be used for the purpiTse of infant feedmg a barn is needed
where each cow shall have at least fifteen huudnxl cubic leet of fresh air.
The food should be kept where it cannot be contaminated. The manure
should be as carefully removed from the barn as if it were a himian dwelling.
The cow should have freedom for her head and limbs in wide stalls all the
A
220 PEDIATRIG&
year round. Large, drj', sunny exerciae-yards should be provided for her.
Her food should always be brought to her and selected with great care. Pure
water should be provided, and suitable cups or troughs containing running
water should be in her stall. The bedding should be fresh and free from
mould or from any soil productive of bacterial growth. This can be accom-
plished best by means of sand or dry soil constantly changed at least twin
a day. Metluxls should be used to get rid of all the usual foul odors anl
free ammonia so commonly produced in barns. Cows should be carefiilly
guarded against fright, the worrying of dogs, and unusual excitements of
all kinds, which caase mtIous disturbance of the lacteal functions of domes-
ticated cows, in contradistinction to those of cows in a more natural con-
dition, as for instance the cows in a semi-wild state on the plains of Mcm-
tana, Texas, Australia, and the Pam{)as of South America. £xdtement
does not apparently injure the lactation of these cows^ while it inevitaUj
throws out of wjuilibrium the milk of the well-cared-fbr dairy cow. If the
same care should be ap]>li(il to regulating the woman's life as is employed
here in this l>am with these cows^ we should encounter fewer difficulties
in human brca.st<-ft?eding.
The fc(Hling of the cows of this farm has for its object the production of
an even, nutritious, digestible milk and the careful avoidance of over-stimn-
lation of the lacteal secretion. For this purpose a somewhat wrider ration
than that cni])](>ycil for tlie production of milk to be used in butter-making,
but somewhat narrower tlian that employed for the production of beef, has
Xkvu found to Ire tlie Ix^st adaptal. For example, a ration for the production
of butter fat up to the limit of the cow's c^ajMicity would be in accordance
with the ratio r>f Wolfe so often employed, — namely, one nitrogenous part
to four and a half non-nitro^'uous. The ration for the prodnction of beef
in its most ec'ononii<*al manner would be that used by English feeders as
prescTilK?d by Lawcs, — namely, a pn)portion of one nitrogenous to eight non-
nitmgenous jmrts. The ratio which has lx»en demonstrated to produce the
l)est milk lor infant fbcdinjr is the mean lx»tween these two, — namelv, one
nitrogenous part to five and a half or six non-nitrogenous parts. A constant
usi» of this ratio in the coniliinations of many fodders and grains appears to
have i>ro<luced a reiu^onably larjxe su]>ply of milk with fair richness, but
w itliout over-stimulation such as would lx» shown by a disturbance of ftmo-
tion. Xitn:)genous focxls for cows inv the k^guminous groups of grasses and
l>lants, such its the clovers, lnc(»rn, Ix^ans and pc^as, vetches, and other plants
of like kind. Resides these fiKlders we have for nitrogenous foods suitable
for producing milk for suljstitute infant feeding, such grains as wheat'-bran,
oil-meal in small (juantities, and pea- and l)ean-meal. Of the non-nitro-
genous fodders the principal ones ixtv maizcv-stover, the hays from timothv
red to]), orchanl grass, Johnson grass, rye grasses, the bents, Kentucky blue
grass, June grass, and oat straw. Most of the grasses in a green state
affonl a fairly balanced maliuni ration for substitute feeiling. Of the non-
nitrogenous grains the most suitable is maize-meal. We also have oat-
FEEDING.
221
^ meal and barley-meal^ whieh oontam less of the noD-tiitrogenoiis elementB
tiian the above, but still must be classed with them. The exact chemical
analysis of aoy one ration used for fetniing cows fijr oiir purpose muj^t 1h3
1 careliilly considered in accordaiit?e with the ratio of the digestible nutineuts
I of the food| and this must of course be arranged practieally from the recog-
nized flxxl tables. A great variety of food Ls necessary in ft*eding cows, but
, in the transition from green foods to dry, or the reverr^*, much care is nwtkxl
L to graduate the change, as dLstiirbauce in the ecpulibrium of tlie mammary
ad is rai>idly folio wtil by injmioiis ctfeets on the consumer* In jwist times,
fore I could rely as I do now on this eart^fully-mauagetl change of rations,
the spring of the year with its flush pastui*age and the fj'esh grass following
I the autumn rains were fruitful sources of iuiantile digestive disturbance in
, my nursery practice.
You will now appreciate how important are all these links in the chain
which constitutes a successfiil substitute feeding. The cows must be kept
clean by gnxoming and the necessary washingj the pn^'antion always Ix^ing
taken to rub the moisteuinj parts dry. The milkers should Ix' di*essed in clean
white suits and caps. Their hands and arms should Ix^ thoroughly scrublxd
before milking. The bauds in milking should Ix? kept dry. The milk
should l>e drawn with S4ime force, simulating the action of the calf, and at
each milking every drop of milk should Ix^ drawn out. The milk should
be drawn into glass-lined pails and eaiTied immediately from the barn to
the milk-house, which should Ix^ a sufficient distance^ from tlie barn to be
free fnim odors. No means yet knowu to science can prevent some few
bacteria coming into the milk during the milking-time, though it is poasible
to reduce the number so greatly as to make the milk practically sterile for
the purpose of infant ieeding^ particularly if tlie s^x'oud half of the pnxluet
of the udder alone is used and milked into sterile tubes. The first half
prol>ably contains many bacteria, which, entering frt>m without, have reached
tlie lower portion of the t€tit.
BiOLfXiY OF THE MiLK. — The experiments on the biology of the milk
of this special henl which I am showing you have b^cu made by Protessor
Ernst and Dr. Jackson, and the results are shown in this table (Table 55).
The specimens examincnl were taken from the mixed milk of the entii'e milk
of tiie herd,
TABLE 55.
Baeterioloffieal eraminatwn of milk from the entire herd milkinff showed six houra after
the milking ifbsty»€ight thousand eoianUs,
Specimen, Heated to Minutes. Developed Baetcria,
Whole milk 76« C. {167° F.) 10 and 20 0
Modified tiiilk ........ TS'' C. (167° F,) 10 and 20 0
Wbole milk and modified milk , 65.65« C. (150° F,) 10 and 20 Nixmeroug.
In strikinjtj ei:)ntrast with thes(* results obtairiefl by exjieri men ting with
the entire milking are mme speeial ex{>eriments made on this same milk by
Dr. Austin Peters and Dr. A. K. Stone, at Mr. Grordon's suggestion^ for the
222 PEDIATBIGB.
])iiqx>8e oi' dcnnding whether it was possible tx) obtain a pracdcallv sterile
uiilk at any part of the milking. The manner of performing the experi-
ments was as follows :
Dr. Peters was dressed in a freshly-boiled white suit and cap, and had
his hands and arms thoroughly washed with a 1 to 1000 bichloride of mer-
cury solution. The cow's udder, teats, flanks, sides, gioinfl, and abdomeo
were washed with the same solution, and dried with a fineshly-boiled cIotL
The milking was then done by Dr. Peters into bottles which had been care-
fully stcrilizetl at the l>acteriological laboratory, with the following result
Of the four cows milked for this experiment and selected without special
choi(*e, the bottle marked 1 in each of the following sets of figures in this
table (Table 56) represents the milk of the first half of the milking and
dniwn by the hand of the milker directly into the sterile bottles. Number
2 in each set of figures represents milk drawn through a sterile canula direcdr
into the lx)ttle, while numliers 3 and 4, respectively, represent milk drawn
by hand after more tlian one-half of the udder had been emptied. A bao-
teriological examination of the milk in tliesc bottles, by Dr. A. K. Stone^
gave the following results :
TABLE 66.
ColonieB. OoloDleB. Ooloniea^ fVfV)«tfn
1 141 167 19 68
2 0 0 1 2
8 0 6 O 0
4 0 0 1 2
The results of Dr. Stone's examination showed, first, that the milk ob-
tained from the first half of the milking contained a comparatively large
nnnilxT of microcsocKii aud fine bacilli of the same general appearance re-
s[xH'tively ; second, that the milk drawn through the sterile nwnnlft unts
j)ractically sterile, and that the milk drawn in the second half of the milk-
ing by hand was so uniformly sterile as to awaken the suspicion that the
isolated colonies might liave been the result of the manipulation between the
" (H)w and the plate."
These ex|K'riments at once provide us with a means of procuring a milfc
j)ractically sterile but not sterilizwl. This experiment also aeems to prove
that the bacteria which are found in cow's milk do not necessarily come from
external sourc^es, whether they be of the cow herself or of her surroundings,
but may also come from some part of tlie milk tract between the udder and
the end of the t<'at. These conclusions, it may be said, are made with refer-
ence to healthy cf)ws.
InfiK'tious mammitis, to some extent, seems clearly to be carried by the
hands of the milkei's from cow to cow. This also points to the fact that
bacteria may find their way to the ducts through the teats.
These ex[K?riments are of \rwiit pra<*tical imiwrtanoe when it is considered
that while under certain circumstances it is impossible to obtain the advan-
tages of such a farm as this and the modification of milk by numtn^ of
FEEDING.
223
I
laboratory processes, yet it may be of great neoessitj" to the infant on account
of sickness to be fed with a sterile fresh milk not sterilized. This could,
of ccnin?e, be accomplished on any farm witli any cow by means of ordinary
care in the milking, and by such i-ules as were carried out by Dr. Peters.
The major part of the bacteria present in the milk are such as cause the
usual acid fermentation which w^e recognize in the wmmon souring of milk,
but there are many sjiccies of bacteria which ought t<> l>e pR^vcutcii from
gaining access to the milk, arising i'rom mouldy hay, straw, or ftidder, jiar-
tially decayed roots, and the natural decay of the w^ood-w^ork of the barn and
adjoining buildings. These latter varieties, w^hich are found to l>e e8|>ecially
inimical to the preparation of substitute ttxjds, cause in some eases the alka-
line fermentation and other abnormal conditions of milk. Kvcr\' barn
apparently has its own set of bacteria, and the flora in Ameriai do not
exacrtly resemble the analcjgous Eurojjean si)ccies which liave so (Ahm luvn
described.
REAcmoN OF Cow's Milk, — It seems to \ye true that milk drawn from
cows fed on the better gnusses in a half-ripe condition is nearly or qtiite
alkaline, while the milk from stall-fed cows, where dry fodder and grain
only are used, is inclined to be acid.
It will jierhaps be interesting to you, inasmuch as gi*ass feeding is not
always practicable, to hear what has been doue to prfiduce a normal cow'S
milk which is alkaline and thus corresponds to normal luunan milk.
The imjKii'tance of the subject lif^i in the well-recogniztHl fact that the
infant's digestive functions have lx*en tinm tinie imracm<»rial better adapted
to the digestion i>f an alkaline or a neutral fluid than of an acid one.
WTiether the m*>dcrately alkaline reaction of human milk is an inijMirtant
factor in the pmbleni of infant tmling is a qnestitm which future investiga-
tion alone can oompletely pnjve, but with our present knowledge we are
not prepared to dispense with even the least important of tlie man}^ factors
which make up tliis problem. At any rate, we should l>e very suspicious of
a breast-uiilk which shows an acid reaction. In the preparation of an in-
fant's fiKKl from cowl's milk, according t^i the latest ex{>erinients by means of
mcKlification, the Ix^st results have been obtained l>y niakiug the reaction of
this iiMxl a^rrespond to that of normal human milk. This, up to the pi-es-
ent time, has been done best by the addition of an alkali^ which Is the only
foreign element that it has Ijeen found nec**ssary to employ.
My attention was first drawn to the pissibility of t»btaiuing an alkaline
cow's milk corresiMmding in its reaction to that of human milk by Mr. G.
K. Gortlon, who, by his extended and intelligent inv4?stigation of this subject
carritKl on tor so many years, has given such a stimulus t<» these que.stions
of clinical interest. Many years ago it was noticc<i that w)ws fed on certain
pastures, such as occurred in Kentucky, represented by the Kentucky blue
grase^ and also in noany other parts of the West, produced at the height of
the season of such gi'ass a pnxiuct which Wiis alkaline ratht-r than acid, and
which remained alkaline for a number of hours ailer milking. It is also of
i
224 PEDIATBIGB.
ooun:»c well kno\\ii that milk iii general, wherever it is produced throughoa
the world, has an acid, or at kiust an amphotcrici reaotion. This infomift-
tion at once incited the investigation of the food values which existed in
these peculiar i>astures. A careful analysis showed that the nitrogenous
elements of this grass bore a certain proportion to its non-nitrogenoDg
ones, — namely, al)out 1 to 4.5. We should naturally suppose that if ve
coml)ined nitrogenous and non-nitrogenous foods in the proportioii of 1 to
4.'") the product of cows fed upon this combination would resemble closely
tlie product of cows fed u])on the |)asture grasses already mentioned. This
to some extent has proved to be true, but not so completely as is to be de^
sired for the precision needed in infant feeding. It is therefore interesdng
to record that the ex{)eriment of supplying the non-nitrogenous proportioD
of the food with sugar-beet8 (ten pounds to each cow daily) of the highest
sacchariuity has ac(x>mplished unlooked-for results. The cows which were
exi)eriniented with in obtaining these results were under observation for
three months, and were cared for in the same bam and mider the same
general conditions. Two-tliirds of this herd were fed on hay and grain
combined in the ratio of 1 nitrogenous to 4.7 non-nitrogenous parts. The
remaining third of the herd was also fed according to the same rado,
but this ration, so far as the non-nitrogenous elements were ooncemed,
was made up partly of Austrian sugar-beets grown for this purpose. No
bt^'ts were given to the first two-tliirds of the herd just spoken o£ During
the three montlis when tlie ex{)eriments were being made, the reaction shown
by the milk to common litmus paper was constantly as follows : the milk
of the cows iW partially on the beets exhibited a neutral or feebly alkaline
reaction, while that of the cows that received no beets showed a somewhat
acid reaction.
A still more delicate test of the reaction of the milk of the entire heid
was made by Dr. Austin Peters, of Boston. Hay and grain without beete,
as previously stated, had been the f(X)d of two-thirds of the herd, and ten
pounds of beets to each cow daily had been fed to the remaining third.
The results of the testing of the alkalinity of this milk at the varioiu
stages of the exi)eriment were as folKnvs. The milk of the oows which had
been fed with Ix^ts, wh(5n tested directly by Dr. Austin Peters as it wm
milked into the jiails and where it had a temperature of 33.88^ C. (93® F.),
invariably gave the following reactions :
Bluo litmus puper i^uve no change whatever.
Red litmus paper was turned slij^jhtly blue.
Cochineal and ammonia paper turned still bluer.
The mixed milk of the whole herd in the vat and at a tempemtate of
6.55° C. (42° F.) was then tested by Dr. Peters, with the following rasults:
Blue litmus papor showed no change.
Ked litmus paper was turnr-d plij{:htly blue.
Cochinual and ammonia paper was turned still bluer.
FEEDING,
225
Finally the mbtetl milk oi* the whole herd, after being carried tw^elve
miles to the LaboniUiiry, was tested by Mr. Gortlon with coehineal and
ammoDia pajx^r ; tlic papiT wa§ found to tnra just a^ blue as when the milk
was tes5te*l in tlie vat at the ikvm.
These experiments are of giTat interest as showing that not only can the
product of the ei>w^ i^i tar as it§ reaction is eoncerned, l>e luailc* to njriTspond
to tliat of human beings by means oi" jjerieetly natural frt^ling and under
perfectly normal eiinditions^ but that this alkaline moditieation can be
produeo<l tc» s^uch a degree that one-tliiiil of the milk is sufficient to destroy
by its alkalinity tlie acidity of the remaining two-thiixls.
THE MILK-HOUSE.— After the cows are milktd, the milk is carried
quickly from the ci.nv Xa? the milk-house, which in this instants is over a
hnndred yards from the barn and is com)>lctely isolated from all other
buildings. To pnn'ent the milkei-s from going into tlie milk-room, the
milk is poured by means of a block-tin pipe tbrongh the wall of the milk-
nwnu into a large ice-lined block-tin tank» whicli is also the mixer tor
the milk of the entii-e herd. In the spaee of lour minutes^ by means of an
ice-jacket, the milk is cooled fmm 33.88° C. (93"^ F.) to Wow 4.44° C.
(40° F.). This is to raj^irlly remove the heat, which Ls c<iuducive to bac-
terial gnmth. The milk passes through eight thicknesses of stcribzc^l gauze
on its way to the tank.
Tlie milk-room is practically clean from a bacteriological stand-point,
lor the walls and tloor am kept wet with clean water, and all dust is ex-
cluded. The milk is drawn into these jars (Fig, 50, |>age 246), in which
it is to l)e traiis]Kirtc<b The jars are then sealed, packed iu ice, and in a
few hours deliverttl at the place where the milk is to be used lor substitute
feeding.
After this treatment of the milk I have had repeated bacteriological
examinations made on its arrival at the Laboratory, with the nnitlirm result
that it has [iroved to be comparati^-ely sterile, and at times it has t.'oiitainecl
either no colonies of bacteria or only one or two.
No antist^ptic can, without danger to the infant, lie nseil about the
cow, while all the mcK-hauical devices heretofore tried to take the place of
manual milking have inevitably tended to impair the lacteal fiinction of
the udder.
CHAEACTERISTICS OP COWS WHICH PRODUCE MILK
SUITABLE FOB INFANT FEEDING. — Some of tlie marks which dis-
tinguish the breeds k'St adapted for infant feeding are :
I. Constitutional vig»»r.
IL Adaptability to acclimatization.
Notable ability to raise their young.
Freedom from intense iuliiTctling.
A distinctly emulsified iat iu the milk.
VI. A prejionderanoe in the fats of the fixed over the volatile gly-
oerides.
I 15
IU.
V.
226 PEDIATRIGB.
You must understand that the volatile glyoerides do not exist in the
maninue, but are lormed in the milk soon after the milking, and tiut in
some breeils this occurs more quickly than in others, such as thofle fiom tlie
Channel Islands.
By means of thi^si* distinguishing marks wc can eliminate fiom liie oovs
which we wish to use* lor infant iet*ding such breeds as the Jeraef, GaeraBer,
and any others in which intense inbn*eding lias been carried on andiniAiA
aeclimati/ation ha'^ not Ix-en iKTtc\*ted, kiiving for our purpoaeB soeh fanedstt
Mr. Gordon has hen^ to show you, — namely, the Durham, Devon, HoIiIbd-
P^'iesian, Ayrshin\ Hretonne, and Brown Swiss. These yon will tadet
stand an' tyi)es of the Imn.'d, though not in all instances pure bred. Tkoe
bi*eeds, (»f coui-s<', do not repit'SiMit all of thc»se available for substitate fad-
ing, for we may mention many others e(|ually good each in itBooantiT,
For example, the Kerry of Irchuid, the B(*d Polled of England, the Dnidi
lielted and the Flemish, also the Flamande and tlie Cotentine of France^
the Norman breed of Normandy, and, besides the Brown Swiss just spoken
of, and which you will pn*s(Mitly see, the Simmenthal, sometimes calkd
Bernesi^, of Switzerland, also the Chianina of Italy, and the Allgaoer of
Germany. I say very little alx>ut the native cow of this countiy, the " Bed
Cow," IxH'ausc? through many generations of neglect- and exposure in winter
she hits undou1)tedIy acquired an iminiired digestion and does not reqNnid
readily to a[)propriate changi»s of KhkI.
Mr. Goixlon will now show you the types of tliose breeds whidi :
lx*st in his heixl the RMpiirements of sul)stitute feeding.
Tlic liiNt cow (Fip:. 'IS) n*pn'si*nt« tbo ]>eist typ? of the milking Durham <yr Ijmu«ii«i
SIu* has <:roat coiistitutiniial vii;nr, tcn*at oa))a(Mty for ftH)d, a perfect digestion, is of apboi
U'lnpcniMioiit, not ('a>ily frightened, and \iv\d& u large quuiitity of rich milk, thffuisfyrii
of which is a.s lollows:
ANALYSIS 41.
F»t 4.04
^*^«Vir»r 4.84
l*r"t.icl^ 4.17
Ash 0,78
Total solids 18-88
Water 86.72
100.00
Tho physical chanicteristics of the Durham arc variety in color, a white note (tUi
especial Durham is a strawberry roan and white), large size, rather small head| laivs udder,
and a placid, intelligent, and rather n'Unetl appeanince.
Tho next cow (Fig. 44), the Devon, htis the same general eharacteriBtios as the DuksiB,
conihined with great gentleness and diKiility. Tho color is, as you see, almost oldfrRiilv
red, with the nose generally white. They are of miklium siee and have
udders. They arc verj' gentle and very vigorous. They come from an old
land estahlishcHl hrec^, and have heen known for centuries. They have never 1
inbred or pampered. They have a fair capacity for food, are not easily frightened| ^M 1
digestion is good. They give a moderate quantity of milk of medium quality, tfc^i aaiMb
of which is as follows :
AKAtYnli «i
till
ad
ire
die
IMTJf* iini»r^ —^ Z^**' ' "^ "^^^^
t JFAi.fW9 #
was
'hes
and
e of
rtiire
Ttl to
228 PEDIATRICS.
ANALYSIS 46.
Fat 4.00
Suicur 4.30
Pniteids 4 00
Agh 0.76
Total solids 13.06
Water 86.94
100.00
Finally, here is a little Bretonne cow (Fij;:. 48), known all over Kurope as the »• cow for
the family.*' Cows of this hri'ed have all the characteristics of the good domestic cov
which I have alnwly mentioned. They are hlue-black or black and white in color, ud
have black noses, whieli are sometimes mottU^ and are rarely white. A distinguiBhin|
mark is that the mueoiis mt'mbrunc of the mouth is always white, while that of 6ome otha
brttvds is black or jjray and white. They are small, but have lai^ udders, which produce a
medium amount of milk, large, howevtrr, in proportion to their size. This special cow i^ oc^ld
from standi nir, and this is the reas(m that her back is arched.
I have nuMitioiKHl tlic natural constitutional vigor of these oows, becaiue
certain brc^ils of cows in some localities do not appear to be able to resk
the attacks of c-oninion diseases, such as tuberculosis. A notable illostratioo
of tliLs is represented by the Jerseys in America.
It is v(Ty in)iK>rtant that certain precautions should be taken to pre^
vent th(» ufie of cows which are affected with tuberculosis. It is probable
that thnK? i)er cent, of the cows whose milk is used for food are tuber-
culous. Whei-e tulxM'culosis is devel()|)ed to such a degree in the cow as
to Ik^ dangerous to the consumer of the milk, tlie disease can usually be
dctcH'tcd by a skilful veterinarian by means of the physical examination
which is cnij)l()ycd in cows. But, as it is a disputed question at present as
ti> when the milk of a tubercnilous c»ow lK*comes affected, it is wiser to adopt
all mciusnrcs of prcciuition known to science. Of these measures the one
whicli is most efficacious in detecting even the incipient stages of tubertni-
losis is that which is used heixi on this farm.
The cows cni|)Ioycd for tlie pnjduction of the primal milk-supply for
th(? Milk-Laborutory have* Ixvn subjected to the test for the diagnosis of
tulKU'culosis. This test is known as the "tuberculin test." The method
of making this test is as follows :
At al>out J) oVlock p.m. the tcMn[)erature of the cows is taken per
rectum with an ordinary clinical thermometer. The temperature in healthr
c«ows may vary from 37.7° C. to 39.7° C. (100° to 103J° F.), according to
age, the weather, tlu; condition of i)i-egnancy, or the period of the day. As
soon as the tcmiK*ratun» of the individual cows is recorded, each one receives
a suIk iitaneous injection of from 2 to 3 <\c, of a ten per cent, solution (1 cc
of Ko<'h\s tul)erculin to 9 cc. of a one-half ptT cent solution of carbolic
acid in sterilizal water), the pn^jmrtion lx?ing adapted to the weight and
vigor of the esixn^ial cow. ThLs fluid, for ccmvenience and unifonnitr, is
introduced in the up|)er part of tlie right shoulder. After an interval of
FEEDING. 229
eight hours — ^that is, at 5 a.m. — the temperature is again taken per rectum,
and this procedure is repeated at intervals of three hours until 2 p.m.
At 5 A.M. the temperature should in healthy cows be slightly lower than
that found on the previous evening. Subsequently the temperature should
not rise above that of the first record at 9 p.m. No rise in temperature
occurs in a cow which is free from any tubercular affection. Where the
temperature rises to 41.1° to 42.2° C. (106° to 108° F.), it indicates disease
and marks the cow as tuberculous, though even a lower reading s<^metimes
marks the presence of the disease in cows whose normal temi)erature was
low.
No water should be given to the cow during the period of the experi-
mmtj because it is found that the temperature, as soon as the water reaches
the stomach, is lowered to or nearly to normal, according to the amount and
temperature of the water.
This test is a very delicate one, and records the presence or absence of
the slightest tuberculous infection, even if the disease has not previously
affected the cow in any way which can be detected by an ordinary' physical
examination.
At the point of inoculation there are marked tenderness and heat in cows
that are tuberculous for many hours after the conclusion of the test, while
in cows that are healthy the skin is not irritated by the use of the syringe.
I have now explained to you what I consider to be a very imi)ortant part
in accomplishing a successful substitute feeding. I shall at my next lecture
describe the characteristics of the milk which is brought from the herd to
the Laboratory, where it is modified.
230 PEDIATRICS,
LECTURE IX.
III. INDIRECT SUBSTITUTE FEEDING.— (Continued.)
Gknkral Kemark.s ox Substitute Fekdixo — Comparisox of Woman's and CovV
Milk— Milk-Laboratoribs.
Ix my last Iwturt* I explained to you at the farm the methods employed
for obtaininji; a primal milk-.supply esjieeially adapted to infant feeding, md
the tyjR^s of cows which exix?rien(»t» hius proved to be the best for this pin^
|>os(». Yon will now nndcrstaiul that where human milk that is suited to
the individual infant csuinot be obtained, or if obtained cannot be pegulawd
by nuKlitii^ation, it is desirable to substitute for it the combination of elements
which sucii a hunmn milk reprenents. To aecompliah this we must have
mati'i'ials which, whiU' closely resembling tlie elements of normal human
milk, are «nisily obtained.
Physiological exix?riment» on the mammary gland show that the albumin
of the milk is not directly an exndation from the lymph-vessels supplriif
the mammary gland, but that it Ls actually modified in the gland itself. We
thus Kv that the mammary gland, l)esides being an elaborator for infant nu-
trition, is also a nuKlitier. This snggests to us tiiat the modification of milk
is not contrary to nature's method of preparing food for infants. Followingt
there fi»rc, natuix^ clos<']y, we have Ictirned that the proper modification of
absolutely pure and iresh milk Ls the vital principle which should underlie
our clforts to jR^rfcct a sulistitute fcHxl. I have already shown you the best
metluxl of obtaining a stable and i)erfectly pure cow's milk. When thfa
milk is ohtaininl, how shall it Ixst Ix? modified?
In ad<lition to the general principles which I have enunciated concemiiig
niatcnial fcn-iling, and which a|)ply ecpially to substitute feeding, there are
certain |)rinciplcs conncc'ttil (SjK»cially with substitute feeding to which I
desire to call your attention Ix^foiv taking you to the Milk-Laboratorv, in
order that you may use the LalK»nitory to the Ixst advantage.
Tlu^ infant at the lircast n^ccives for its nutriment a fluid which is fi«h,
sterile, neutral, or faintly alkaline, which has a temperature of 36.7^-SI.S°
('. (1)8°-1(M)° F.), furnisIicHl in an amount pn)jx>rtionate to the age and sia
of the consumer. It is this fluid which we have to copy in every possible
detail when we undertake to prepaiv a sul)stitute food. We should also
«)nsidcr as foreign matter, to Ix^ carefully avoided, any element which we
know is not to Ix^ found in the milk w(» are copying. Thus, and thus only,
can we arrive at the proi^er solution of this intricate question of substitute
fiH^ling.
The analyses of human milk, which I have shown you in a pzevions
FEEDING*
231
lec'tum {Lecture VII., page 179), teach us that there is a great capacity in tlif-
ferent infants to assimilate a variet^' of prfuxji-tions of the same nutritive
elements. In all piYihability the infiint uetds a variety in its food to some-
what the same extent a^ does the adult. In order, therefore, to c<.»py nature
clo!*ely, we must have some means of pmpariug a ftxMl not only for the mauy
but for the iodividual, and when introdudng new methods tor prepjiring
a substitute fotxl we must ree<jgnize the necessity for providing for many
prescription jKjssibilitit^. In this busy age of scieutitic rational meilicine
physicians all over the world demand, tii'st, means of saving time, and
set\»od, exact methods of work, \\'hich in tliemselves s*xm Ix'come time-
savers. In eveiy brand i o( our art the tendency is growing year by yeai*
to systematize the detailed and laborious work of the individual fi>r the
common pmetieal use of the |)ntfcssion at large. I have long telt tliat in
some way the subject tjf substitute It't'diug should be nxhiwd to a more exaet
system, and that an et!brt should Ix' made to rescue this imjjortant luunch
of jK'diatric^ from the pretensions of tlie owners of proprietary foods and
the hands of ignorant nurses. With this end Ln view, I have given my
professional aasistance to the establishment of a system of milk-lalxmitories
wheiv the materials used shall be clean, sterile, and exact in their j>ercent-
ages. These laboratories have btH?u placed under the c^mtrol of educated,
intelligent men in whom we have tlie same couhdcnec that we have cHineedtMl
to the pharmacist, and we ean write tlirections for iafants' fotxis and send
them to these lalxiratories just as, in the ti-eatment of disease, we write our
prescriptions for tlie division of one drug or the combumtiou of several.
As the pharmacist has nothing to do with the various methods of treating
disease, so the milk-modifier is simply rerjuiRHl to <'arry out the dii-eetions
and ideas of the |)hysician. No s|>ecial S(^h<X)l of mt^lieioe need \m re|ii'e-
sented. No special metlnxl of feeding need be undertaken. An opjxjrtunity
has, however, tor the first time in the histor}' of mcnlicine, been pn?sented
for the physician to carry out his own nietlnxls, and these meth(»ds tor the
fii*st time to l>e judge<J on a fair basis. In this way only *mn each dinieal
obeerver, when lacking in success, be sure that it Is the fault of the fo<xl he
is giving, and not because tlie food has varietl from wliat he supposixl he
had iii-denxL
I have come to the conclusion that even slight changes in tlie jiercentage8
of tlie thr4^ imjx>rtant elements of milk of which we have most anzurate
knowhxlge — namely, the tiit, the sugar, and the proteiAs — ai'c of real value
in the management of the digestion and nutrition of the infant, and that
these* changes are often neoes^sary day by day as well as mouth by month.
With this fact impressed upon us, we c^an well see that no one mixture will
in all cases pnive sua*essful, l>ut that a great variety in the |XTcentagt*s of
the different elements of the milk will be needed in substitute feeding just
m they already exist in maternal feeding. This explains the diversity of
results obtiiinetl in the past with the same fixxl by difierent practitionej'S.
The means for presscribing a diversity in the elements of milk, according
232 PEDIATRICS.
to the idiosyncrasy of tho cliji:estion we are dealing with, is supplied by a
milk-hil:H>niton' apiipped with special niachinerj' and controlled by educateJ
milk-modifiers. From what I have previously said, you will understainl
that purity of the original material is the first object to be attained. This
milk should l3e obtained fn)m wws bred, fed, and cared for in the inannfer
which was dt»scTibed in the hb^t lecture, and, in order to insure ahsuluie
uniformity in the methods which I then explained to you, untiring vigilaiH*
must Ixi used in the sujKTvision of the i'arm, cows, and milk-house, ami in
the trans|X)rtation of the milk from the liirm to the laboratorj'. It i> ak>
necessary that the a)ws should lx» under the medii*al siH)ervision of a skillil
veterinary surgeon. Tluvt* are all questions which to my mind have l>t«n
definitely dwidtnl, but which now ncH.'d time and attention devoted ti» thcui
to insure their Ix^ing systemati(»ally carried out. As in all other advanw*
which are made in practiciil medicine, so also in this one it is well to adopt
at oncv a high standard of work and to demand everj'tliing that can in any
way tend to jKTfwtion. Wc may not always be successful in carrying mil
all the details, but until we aiv so i)erfection will not be arrived at. Bt«T
in mind, then, the chain of facts which I have endeavored to simplifv aiiJ
explain to you, and undcrstiuid that each link of that chain is of vital iin-
jR)rtance, Ikiiuisc, if bn)ken, the value of the whole cliain may be Wt.
One end of this chain is at the milk-farm. We have followed it fn.>m
the stall to the milk-house, and from the milk-house to the laboraton", aud
we must now si> manage* the wntinuation of this chain that it shall onut-
unbmkcn and intact to the infant consumer.
AppAnATrs FOR Fkkdin(j. — Human ingenuity has not yet been able
to devise anything >vhich aj)pn)aclus the ]KTftH*tion of nature's apparatus tor
t(»cding, and tho In/st that wc (\u\ do to oifsi^t this complex mechanism i? to
adojit that which is exactly the; ivvci*se, — namely, an apparatus of absolute
simplicity, — and thus cc^mbat the tendency to termentation by preventing,
through ix.*rfiK*t cleanliness, the ai)paratus from lxKX)ming a source of fermen-
tation. To accomplish this object the rt^ceptacle from which the infant is t»
be fed should Ik* made of glass, in the form which will enable it to be mifct
easily clcauscKl, and, as in the future the question of transportation will un-
doubtedly lj<? a grave one, the rcHt'ptacle should Ix* such that it can be adapted
to transit and not easily broken. For this purpise, what are practicallv
test-tnlxs fulfil these indications l)e>t. These tulx^ have open mouths larger
than those usually j)rovidcd in the ordinary nursing-bottle, and, having no
angles, are i-cadily cleansed. The artificial receptacle is not self-regulating,
and hence we nuist determine tiur amount of fcKxl in bulk which nature pro-
vides f()r the average infant at different ages, and from these average figures
dcduw? the projK^r amount for the esiK.H*ial infant. The feeding-tubes are
gmduat*"*! for the more ini|)ortant jHTiinls i»f gi-owth, for the purpose of
continually impressing upon the mother and nursi» what the physician often
has the op[xni:unity of telling them only at the beginning of the nursing
period, — namely, that the error is in giving too much food rather than too
FEEDIKO.
233
little, an error, abo, which naturally results when, as is wmmanly the case,
the usual eiglit-c*uni^ nui'siug-hottle is providal as the rec'eptacle at the very
beginning of infantik life*
I have foimd that I can easily conviiicx? must mothers of the mistakeE
zeal of nurses who advocate giving tlie young iufaut large amounts of food,
by showing them the size of the intant^s stomach at birth and wmparing tbis
sxuxdl tube which corresponds to the stomach's capacity with an eightH>unce
nursing-bottle.
Pig, 49*
(C
Z::\
Stomach (hjm lafmii five day* old ; capacity 26 c.c
Qlan cylinder, capacity Qbc.tL
(Natural eke.)
I shall presently show you these tubes at the Lalxiratory, and I speak
of them here merely to impress upon you the great imjiortanoe of carefully
attending to the smallest details iu substitute fetNling.
Nipples. — A nipple niiide of 1^ne s<jft rnblxT adapted to the espeeial
infant as to its size and the holes for the milk is substitnted for the materua!
nipple. These rubfxT ni[>ples should fx large enough to Ik> turnwl inside
out and carefully cleansed after each feeding* They should Ijo killed after
being iLsed, and kept iu ecJd water with a little soda in it. They should Ije
renewed frequently, tlie oftener the Ix^tter : preleral>ly a new one sliould
rephwx^ the old one tlire*^ times a week. It will 1k^ found that tfie ruljlx*r
nipple has to Ix :idapt<xl to the taste of the e8j>ccial infant^ and that it often
has to be changed as to its size, texture, and holes before the infant is satisfied
with it and sucks satisfactorily tmm it.
Intervals of Feeding, — I have already shown yon in tins table
{Table 42, page 182) the intervals of ft'cding which should be, as a rule,
adhercHl to iu matenial nursing. These* intervals should also be adoptal in
substitute feetling, but the amount of fcxxl to W given now Ijecomes a pn>mi~
nent feature in the division of the total amount of food which it is ^royet ts*
234
PEDIATRICS.
give in the twenty-four hours, acxHirdiug to the age and development of the
individual infant.
Amount at kach Feei>ino. — The infant*a weight and its ga^^rio «-
]>aeity cjuite frequently do not oorresiK)nd. Yet there seems to be no doubt
that the weight is a (*t>ndition to whieh marked consideration should be given
when we an* attempting t4) determine so difficult a question as the proper
amount of finnl t4) be given at each im»al in the early months of life. The
amount to U* given at i»a<'h fmling must be carefully regulated acoording
to the gastrie cajxirity, and T have stated in a previous lecture (Lecture IV.,
l)age 80) what the gastric cajiacity ia at different ages.
I have arranginl some tahh^ (Tables 57 and 58) to show how the inter-
vals of fi>eding and the amount of KhkI to be given should correspond to
the gastric eaimeity at different jHTiinls of the first year. I think that thev
will pn)ve useful to you when you have to decide on the amount of fo«id
whieh it will 1k» side and wise* to lx»gin with in your cases. It is so im-
})ortant to avoiil stretching so easily distensible an organ as the stomach that
it is wisiT to give t<H) little rather than tcx) much food in the early davs of
life.
TAULE 57.
ircnrrnl Jiuirs/or Feetihifl during the First Year.
The liai/ feedings are mpfntsrd in brgin with the G --1.3/. feeding and to end urith the 10 P.M.
freiiing.
Ako.
Illtrnills.
hours.
NuiiiUt tif
l\tHliiiu"i in
■Jl lump*.
NuiiiIkt of
Nii;ht
Fi*f«limss.
Amount At each
Fciiling.
TotolAiiiODiitizi24
houiK
(liWc
CiiWc
1
(Vntlniotreei.
Otmccs. :Centiiii«>tiaL
Oimi^M.
1 W«H'k . .
2
1 10
1
.SO
1
300
10
1 Wi'ik> .
•»
10
1
45
u
450
15
4 wiH-k-i .
•>
0
1
i 75
2|
675
22i
r» wvok-i .
2*
H
1
90
8
720 -
24
S w^«-k- .
2A
8
1
100
8^
840
2»
o in.»Titli> .
1>*
7
0
120
4
840
28
4 iiHUith^ .
2i
7
0
1 135
4
Mo
311
A inoiitli- .
3"
«i
0
I 1»55
6
990
83-
♦; iuuiiih> .
:i
1 fi
0
176
6
1085
84i
7 iiioiilh- .
8
i «
0
190
0
1125
87l
>< Hii'iith.- .
n
♦J
0
1 210
7
1260
42-
!* iiKHilhs .
3
1 '^
0
j 210
7
1260
42
m ijioiith- .
3
! ")
0
1 255
li
1275
421
11 IMiiTlth- .
3
! .->
0
2»i5
1812
4-n
11* lIlMlltll^ .
3
!
0
270
9
1850
4o^
The tirst month iK'iujj: the wv^i critit'al [leriod for the iniant's notritioii,
as it is the time when the tH|uiIihrium ot* its metabolism is being established
and its rhauii* ti»r liti* is h^ast, esjieeial interest should be attached to the
series of i-an'tiil invest i^rat inns made at the Children's Hospital in St.Peter«-
Inirg l)v Ssnitkin tn di'termine the amonnt of tixKl which should be given in
the first thirty days <»!* lite. As the result of tiu^se investigations he deduces
tlu* rule, *• the ^n-ater the weight tlie pn^ater the gastric capacity." Sauitkin'?
general results (Table o<S) show that one one-hundredth of the imiiat wctight
~ FEEDING. ^^^^^r 235
should be taken as the figure with ithlch to begin (he computation^ and to this
ahoiiM be added oiie gramme for each dfiy of life,
TABLE 58.
Illustratixm of Smitkin-a Rule to aid in adjuating the Food to especially diffkuli Oases in the
fir^t Thirty Dat/a,
AtnouTit at cAch Feeding.
IiiltiAl W«lgbt. Rurty Days. A 1 15 T>ay». At 30 Days.
SOUO gmmmea , . , 30 ^rauimes. 30 -f- 15 =r 45 j^fmmmes. 80 -f 80 = 60 grammea.
(About 1 ounce.) (About 1) ounce*.) (About 2 ounces,)
4500 gmmmed « . - 45 grammes. 45 4- 15 := 60 grauimes. 45 4- SO = 75 trranimes.
(About 1} ounces,) (Ab«-»ut 2 ounces.) (About 2 J ounces.)
6000 gramtnea . . . fiO grammes. 60 4- 15 ^= 75 grammes. 60 -f 30 ==: 90 jfrniiifn^'
(About 2 imnces.) (About 21 ounces.) (About 8 ounce*.)
It ii^ wit^or always to awonijilish first tlie prfj|K'r digt\stion of the f^xd,
even if there* is no gain in wfiglit, and tlion, whuii untit* the infant h digest-
ing well, to inen^se the amount of the [K^reentJige^ of the different elements*
At tinier when tlie infant is tli^estiJifi: well, and eveti ^lining, it will snddenly
crj' so liaixl and with such evident luiDger that an immediate inerease in the
amomit of its food is not only indiented but demanded, no matter what its
r<ige or weight. In these eases the stomach ha5 |>rohabiy grown rapidly and
ont i>f its normal pro|>ortion t<j the age and size of the ehild, and a larger
supply at tlHwl is what is ntMxltHL
Om* elinii.'al exiKTientx? proves to iif^ that the average infant in the early
months of its life docs ntit digest nnmodified eow*s milk. The exct^ptional
instances wIk^r^ it is t*derated have their e«junterjiarts in the sueix*ss t>f many
other foods diverse in their e^imixisitiou, and only serve to pmve that the
human digt^tion (*iin at times Iw^ tani|>en^l with witlnmt niueh appiiiTnt in-
jury, and ti} emphasize the general rule that the ehemistry of the it]n\il whieh
will pnjduce the bt?«t average result should be the ehemii?try of human milk.
Cow's milk, therefore, should \w ean^ fully wmpared with the standard hiunan
milk in order that we should know how* nearly it r^'semliles it. This table
(Table 59) is a eomparison of the avemgt* human tudk and the average cow^s
milk, the figures n*presenting the later and more reliable analyses:
TABLE 59.
Womjm's MUk dircetly from the Cow*b Milk as ordinarily received abcmt
Brv4i»t. '24 houn utd.
H«action Slightly ulkuliiu*. Slightly add.
Wftt^r, 87-&8 86-87
Totiil solid* 18-12 14-18
Pat 4.00 4.00
Milk-sugar 7.00 4.60
ProtiMcle ....... 1.50 4.00
Coagulalkle fiiN)t*idrt . . Small proportionately. Liirg« proportionately*
Coagulation of proteids
by iieotic acid .... Not perceptible in test-tube. Mnrked in test-tube ; pn^nti-^st with
pun.* milk [ IcM with milk diluted
with wat«r, and when 1 to 6 is
not perceptible.
Ash. . . 0.20 0.7
236 PEDIATRICS.
From this coinimrisoii we at once see tliat human milk and oow's milk
(lit!(T as murkitlly th>ni each other in tlieir chemistry as they do in their
cliniml results iis IUkIs ; and, as prac*tieully we must use cx>w's milk in liub-
stitute feedinjr, our wisest course Ls to nuKlify it until we have approached the
(•heiuistrv of human milk as closely as jxissible.
R'fon* siH'akin^ of the various mrxIiKeations of cow's milk which it is
ncMtssarv to make in onlcr that it may corres|x>nd to human milk, it will lie
well to say a few wonls about its proiwrties as represented in the taUe
(Table ")$>,* i)ajrc2;r)).
Rka<ti<)N. — Th(» ri'iU'tion Is statwl to Ix^ slightly acid ; and this is the
case whether it ha*^ st<MKl twenty-four hours Avith ordinary' care or whether
it is testiil dini'tly Irom the udder. This I liave determined by direct ei-
IKTimcut : so that practically the sjune amount of modification will becorml
tor the first twenty-four or thirty-six hours, so far as the reaction is ooncemei
As it is wise in preparing: a mixture for substitute feeding to make such
a mixture appn)a<'h as closely as jwssible in both taste and reactioD to
woman's milk, Ilarrinj^on's ex|)eriments made at my request (Table SO)
with lime water and onlinary cow's milk twenty-four hours old are im-
jM)i-tant. Lime water was the alkali used in tliese experiments because
it is the most simple adjuvant which we can use for making cunv's milk
alkaline, the amount of lime contained in it Ix'ing so small that its additiira
in even cousidcral)le (juantity does not materially alter the amount of tlje
t(»tal minenil matter. As small an amount as one-sixteenth })art, when
added to onlinary milk, will ivndcr it alkaline, so that for making an acM
milk (TJrrt^siMind in its i-cacti«»n to w«>man's milk, limcAvater is of great value,
as it appan'Htly d<K's not j)nKluce any other chanpt»s in the milk. In addi-
tion to tliis, the taste «»f a mixtuiv which is made from ordinary cow's milk,
so as to correspnul to the com|H)sition of woman's milk, is strikinglv like
that of woman's milk if it contain one-sixt<'enth ]>art of lime water.
llarrinirton has made an estimate by a<'tual exi)eriment of the amouot
of lime water which is ncc<l(Hl to i)nKluct» an alkalinity in a mixture such as
I have just mcnti«»ncd which would (Njrivsjxmd to the alkalinity of human
milk. This tabic (Tal)le (JO) shows the results of his ex])eriment8.
TABLK r,().
Reactloo.
Stnmi^ly ulkniino.
Still htnmjjly alkaline.
SIi;,'litly but dUtinctly alkaline, and
corn'spoiuling to woman's milk.
It must Ix' ivmcmlM'red that these ])roj)orti«)ns of lime water are those
re(|uiiXHl for tmlinary milk twenty-lour hours old, a nuieh smaller proportioii
Ikiuj]^ ncixleil to pnMluce the same results when the milk is treated with the
care which I showetl you was employed at the farm connected with the Milk-
Lalioratorv.
Anin^
lint
nf I.iinc
Water in
MixtiiiX'.
*J.J
1"
.Tcriit.
V2.-)
pi-r rout.
r,.'2
5 p
IT (■••rit.
FEEDING.
237
I
I
Water. — There U about one per cent, les?^ of water in caw^s milk thaa
in hiioiun milk. Chemical analyses invariably >shciw m larj^e an amount
of water in hinnan milk that it Ls evitleut tlxat the infant U iutendtd to
take, and can bcist uA-similate, a very dilute ttxid. We must be^i* this fact
in mind in preparing a .substitute ftKxl, m the precaution of supplying a
thorougldv dilutctl ibc*d Ls of extreme im|K>rtanoe in managing the infant's
feeding twth in health and in disease.
Total .Solids. — There Ls alwnit one per cent, morc of total solids in
cow's milk tJian in human milk. Thetse solids in tlie milk are held partly
in S(:»lntiuu, j>artly in semi-solution » and partly in .nusjiension.
Fat. — ^The percentage of fat in the average cow^h milk and in the aver-
age human milk i^ the same. The glyceride^i of the fatty acids c<)m|K)sing
the fat in Ixjth co\v*s milk and human milk have l>een deternuned, yet our
chemical and clinif-*al knowledge of tiie nutritive value and digestibility
of these, separately or t^>llec*tively, has not arrived at a point where we can
practicidly make use of this knowledge, and we therefore direct our atten-
tion to reguhiting in a milk mmlitication the percentage of tlie fat a^ a whtde.
Under this microscope yon will see (Phfitu-micrograph, Fig. 61, page
259) a thin layer of milk which is i'ef>resente<l by a transparent metlium
permeafal with small globules i>f tat. This fat is simply held in sus|»ension,
which enables iis to se|>arate it easily by mechanical means. It is, in fact,
in a condition which marks the milk as an emulsion.
ScdAR. — The Hiu/ar which is present in the milk of all mammals is of
the variety calleil mi/k-stfgar^ or iadose. It Ls a simpk^ and uniform element
to deal %vith. Its |>ercentage in cow's milk Ls 4,5, and hi woman's milk 7.
It is held in s*ilutiou in the milk.
Regarding the kind of sugar which should Ijc iLsed in making up a sub-
stitute food, we have certain questiiins to ctinsider which would seem to be
imix>rtant. Cane-sugar has been, and still is, a favorite form with which to
regulate this part of the solid constituents of the fiwid. The reasons given
for using it have l>een its preservative qualities, as seen in the manufacture
of condensed milk, and the theory that it is not liable to set np excessive
so-ealled lactic acid fermentation, with its consequent distiudiance of digest
tion, as has IwH^n sup|K>setl to Im* the <?a.se with milk-sngai*. Cane-sugar in a
concentrated form, as it is found in wjndensed milk, seems to act as a pre-
servative. But when it Is dilute<l, as in its administration to the infant,
cane-sugar ferments very i^eadily, and in this resp<?et has no advantage over
milk-sugar. Reasoning from analogy, we should say that iis milk-sugar is
the only tbrm of sugar found in the milk of mammals, it is theiT for some
good purjM)se, and that it is nettletl ibr the accompiishment of .some process
which takes place atler the tVnl has been swallowed. Both cane-sugar and
milk-sugar are converted into glucf»se in the intestine. There seems, how-
ever, to be some diiference in the degree to which they can be used for
purposes of nutrition before they are ct»nv*^*ted into glucose. So far as is
knowTi, whether in plants or m animals, cane-sugar is merely a reserve, and
238 PEDIATRICS.
cuniiot be usckI direotly for nutrition. Milk-sugar, on the other baud, is
])n»bably not mort'ly a roscrvo, but may jxiBsibly be utilized in the eci>nomy
also tor nutrition. Thus, Bernard lia^s shown that seven grains of milk-
su^ar dissolved in an ounee of water eould be injected under the skin of a
rabbit without the sul)se<iuent apjK'aranw of Hugar in the iirine, while nnder
the .same eouditions and in the same amount cane-4Ugar was found to be
eliminate<l jis foix'ijrn matter by the kidneys.
Milk-su^*ir underlies n(» diix'ct ale<.>hoIie fcrmeutation, but it change*
n*adily to laetie (|H»ssibly aeetit') acid in the presence of nitrogenous fer-
ments, while i*ane-sujrar easily nndei-goes alcoholic fermentation, but chaug€$
to hicti(^ aeiil hss n^adily than milk-sugar. Cane-sugar, moreover, takeson
the butyric acid fermentation more I'cadily than does milk-sugar. The
ba(:iHu4f IdrfiA (urfKjvnes (Kscherieh) is pn»sent in normal digestion, and ads
on the milk-sugar to pnKluee an oi'gsmic acid which drives out the more
noxious forms of Ijaeteria, which by their pre^euce would interfere with
n(»rmal dijrcsti<»n. AVhen milk-sugar is cfinverted into glucose, we j)hvsi>-
logi(*ally have a gradual conveivion into hictic acid, which may aid in the
digestion of the albuminoids, thus giving us a very valuable addition to the
means at our command for ivndering m<Kliiied cow's milk digestible.
Jeflri(s says, in refeix»iuv to the ditlertMit actions of the various kinds of
sugar in the dig(»stive tract, that it is imiH»rtant to note that starch, dextrio,
inulin, can(?-sugar, and dextn>s(» afford material for the butyric acid fermen-
tation, whik' milk-sugar dm^s this only after completed hydration.
K»*cheri('li, in sjH'aking of Brieger's bacillus, says, "Milk is coagukted
with sour reaction tiivt after s<»venil days (eight to ten) at the body tempera-
ture. With exclusion of air this bacillus cannot grow either in milk or
milk-sugar solution, but will in grai)e-sugar."
We thus see that th(» milk-sugar offers k*ss danger of the butyric acid
ferment, which we know makes mlieh trouble at times in the body, and
that under (certain conditions of the intestine it should be exempt from the
assaults of Brieger's bacillus.
When we consiih-r that by means of heat we can practically put an end
to the lactic acid fermentation, whic^i may have begun to act upon the milk
befoit^ it enters the stomach, it would seem that we are justified^ on both
physiological and bact<Tiologic{d grounds, in using the same aninuil sugar
in substitute fce<ling that is found in the infant's natural food, instead of
intHMlueing a vegetalile sugar, which in milk Ls a foreign element.
The dang(;rs from lactic acid are, at any rate, much exaggerated by
writers (m this sul»jeet.
PnoTEiDs. — The i)roteids of normal human milk have quite a wide
range in their variation ; still, it is now well rec^ognized that their average
normal i^reentage is very nuieh Ix'low that of cow's milk. Aasuming that
the i)ercentage of proteids in human milk is 1.5, or between 1 and 2, it can
be stated that the relation of the iK?rcentage of the proteids in cow's milk
and in human milk is as 4 to 1.5.
FEEDING,
239
The proteicU represent the nitrogeoous elements of milk. They are
partly in scJutioo ami partly in sui^pension, as is seen on filtering through
porcelain, where ueai-ly all the eai^eino^en is left Ix^bind witli the fat, while a
small ijortiuu of the eai*emogen and tlie other proteuls is eiLsily rct'ognized
in the serum*
Of thf total nitrogenons coastituents of milk whit'h mv claastnl lUKler
the general term iin^teid^, and of which the eatieinogen and albumiu am
parts, the coagnlable proteids in cow's milk are proportionately lai*ger in
amonnt than in liuman milk, m that under tlie same conditions a larger onrd
will l>e formed with the iormer tlian with tlic latter.
Coagulation of Proteid8. — In tNjnjunetion with Dr, Harrington and
Dr, Townsend I have made some careful experiments as to tlie relative
coagulability by acids of %voraan's milk, <x»w'h milk, and cow's milk diluted
with lime water and barley water in various piYHMirtiuus. The ci»agidati<»n
by iTimet was not found to be a satisfactory or i^liable tes^t. The experi-
menti? were |KTformctl in tlie following way. Equal volumes of the fluids
teted were platted in a numloer of tcst-tulx^. Ten drop8 of a<_'etic acid were
then added to each test-tube. Each test-tube was tiien inverted slowly
tliri^ times, so as to insure thorough, equal, and uniform nnxing in all.
This table (Table 61) shows the I'esidti* of these ex|ierimente, which may
prove to be of considerable value :
Tesl-tubttB.
L
3.
4.
5.
9.
10.
11.
TABLE 61.
QmffulabiUty pf Milk by Aeetk Acid.
MUttira. Coognlum*
Wonmn's Qiilk , No curd pereeptilik to the eye.
Cow's milk, raw Large curds.
Cow's milk, Ixjiled , . . . Same as 2.
Cow's milk hented by flteum t<i lOO** C. (212* F.) Same as 2.
Cow's milk 2 |>nrt*. \
Water. 1 pun. f
Cuw's mUk 2 pnrLs. >
Lime water ..... 1 ptirt. /
Cow's milk 2 purts. 1
Is. J
Cow's milk ..... 2 partti. \
Finer than 2.
Same aa 6.
8Ughtly finer th&o 5 and 6*
Water 1 1 pmrt.s
^ , 1 Same aa 7.
Barley water . . . . . 1 |mrt.
Cow^.milk ..... 1 part. 1 Finer than 7 and 8.
Water 4 parte. J
A mixture the
cH)[Ti position
of which wo^
Pat . .
Sugar .
Pniteidfl
Ash . ,
Eeaction
Total solids .
4,0
7.0
L5
0.2
Slightly alka^
line (6.25 per
cent, of lime
water.)
12-ia
Cow'ft milk I part, 1
Water 5 paru. I
A very fine cuidi finar than 9.
Same aa 1 : no curd percepti-
ble to the eye.
240 PEDIATRICS.
When a few drops of men'iiric nitrate solution were added to woman's
milk and to cow's milk which had been diluted 1 to 5^ as is represented
in test-tul)e 1 1 in the table (Table 01), a fine coagulum was produced in the
woman's milk, and a still finer one in the cow's milk.
There was found to l)e practii-ally no difference as to the rapidity of the
coagulation of the different mixtures whether the milk was not heated or
was ht^atcd to 10()° C. (212° F.).
Cow's milk taken directly fn)m tlic udder was found to coagulate in juift
as lar^ cunls as when twenty-four hours old. It was found that there «'as
pnictic^ally no dilferemv in the coagulation of raw, boiled, or steamed milk;
also that tiie size of the curd dc]H*nds on tlie dilution of the proteids, rather
than on any esixx'ial proixrty iK'longing to the substance with which the
dilution is made. With lime water the result was the same as with water
in ec[ual amount, and barley water shows only a fractional difierence from
the results obtained with plain water.
Attenuaxth. — In onler to ascertain if tlie statement is correct which
is so oi\vn made, that *' atteiiuants act mec*hanically by getting between the
paHicles of coa^uhim during coagulation and thus preventing their running
togetlier and forming a hirge <'om])act nuLss," I have experimented as follows
with various substances cimtaining different percentages of starch :
In each of six tcst-tuU»s of equal calibre, and containing 5 cc of hot
water, 10 cc. of milk were j)la('ctl. In tcst^-tubes 1, 2, 3, 4, 5, and 6 were
added eijual jwrtions rtsjKK;tiv(»Iy of some starchy foods, eracker-cnunbg,
and bix»a(l-<Tunil)s. The pmteids were then coagulated as before with acetic
acid, and the results were as seen in this table (Table 62) :
TABLE 62.
Test-tiitic. Mixture. Coagnlmii.
1. Hot wator and milk Finest curd of all.
2. Hot wator iind milk and starchy f(M)d Not bo fine as 1.
3. Hot water and milk and Ktaruhy f<K)d About Hke 2.
4. Hot water and milk and starchy ft)f»d Not bo fine as 2 or 8.
f). Hot water and milk and cracker-crumbs .... Not so fine as 4.
C. Hot water and uiilk and bread-cnimba Not bo fine as 5.
There is no doubt that when* no attenuant was added the curd looked
decidally finer, while where attenuants were* used there was not a grcat deal
of difference in tlie result obtained with the substances employed^ except the
|K)ssibly rather larjrer cunl aeeonlinjj: as the attenuant contamed a laraer per-
eeutage of starch.
We may conclude, then, until .something more definite is known concern-
iug this i-ather theoretical meth(Kl of treating the aird, that dilution with
plain water is the most practical and efficient means at our command.
As the predigcstion of the ])roteids is frequently recommended by phva-
cians when the infant's digestion is normal as well as when it is weakened,
it is w(»ll to say a few words about this predigestion in connection with sub-
stitute feeding.
FEEDrXO,
241
Peptonized milk is cow's milk with its pnit<?ick partially or entirely pre-
digested by means of the extract of pancreas and s<xla. There is no doubt
that tlio ]>roteids of cow's milk an^ at times a 8t*iijve of tn)uble to the
infant'?? digestion, and that under (xrtain eireuni^tujiees they can with great
benefit be treated by predigesting them for a time, and allowing a Btoniat*h
which <»tlierwi8e digests well to re^t and i-eeover it^^ entire digestive ]Hi\ver,
It k of uae also where a decided idiosyncrasy of the individual precludes
tlie digestion of tliese constituents of the milk. In many casee the indiges-
tion is attributed to a lack of [K)wer tt> digest protci<ls at all, while in fact
the stomach is 8imply rebelling again,st an amount id' proteitls above the
staudaixl percentage, or against some other c^jnstituent. It would seem
that, for the average infant, this predigesting of the proteids is ctrntrary
t*) nature's teaching. There are t*»rtain natural functions which should }ye
alluwcd to at*t as tliey do on human milk, and it seems irrational and con-
trary to the laws of physiology not to encourage all the functions to act
natnndly, instead of forestalling their actitm and allowing them to fall into
disuse and thus to Ije weakened. The inJant's st^jmach is intended to digest
proteids, and not to have the proteids digested for it. Cliniially, also, the
use of peptijnizeil milk supjx>rts this view, for, 84i far as I knou% no very
brilliant results have lieen obtainetl from its use, except where the infant's
digestion has been in an abnormal condition and one whit^h has cidled for
gome dtH'ided relief from tlie proteid elements of milk. IV|>tHniz*xl milk,
there foi*e, as a fnid for young infants Ls one which consLsts of Uny large an
amount of digeste*! proteids, too little sugar, and a very large over-projMjr-
tion of mineral matter.
Ash. — The (xmstituents of the ash of cow's milk have been analyzed
with tfiniparative care and success. I have already, in sjn^akiug of the
differences which exist between cow's milk and woman's milk, state<l the
differenc*es which exist in their constituents and the elemental |it?r(?entiiges
of those constituents. This question of the |>tTtvntage of the a^h jiracti-
Oally does not enter into the m<xlification of milk at the lalwratory, as our
knowledge has not yet ad vnncetl to that point where we can make use of
what we know of tliese diHerences.
There are a few other questions concerning the composition of cow's
milk in relation to its proper modification for sutetitute feeding which it
will be well to sj^ieak of here.
Cow's milk, l>esifles the elements which I have just spoken of and which
I have represt^nted in this table (Table 59, page 235), is suppftsed to contain
a small |x:>rtioD of fibrinogen held in suspension. I have ado|itcd the terms
fibrinfigen anJ caseiuogen as revonnncudtKl by Hulihnrton* They represent
their respective elements as they actually exist in the milk before anyeJiange
has taken place in them. After the milk has l)ccn tlniwn i'rom the udder
we have certain elements which we call cfrmin, n?sultiug from the cfL'^chiot/en^
and fibrin^ resulting from the fibrivogen.
Cow's milk is also supposed to contain urea and citric acid,
16
242 PEDIATRICS.
lu sul>stitiite feeding, the addition to modified cow's milk of some mib-
Btanoe, siirh as starc*h in various forms, is so frequently reoommended that I
think it will he well to state my opinion of thb practioe.
This brings us to the consideration whether starch should be made a
[)art of an infant's fcKxl. Physiologically, we know that during the first
ten or twelve montlis of life the function of converting starch into sugar
is in the pnxvss of development. It is true that a partial conversion of
the stan*li i*an l)e performed at quite an early age, and, in exoeptional cas«s,
to a niucli greater extent than by the average infiuit. It is rational to
supix)se that wiien a function is being developed it should not be taxed
with a trial of tlie use which Avill later be demanded of it. That is, a
function develoi)s more i)erfectly if its power is not exerted too early.
With these facts before us, and simply recognizing that the best known food
for infants, woman's milk, does not, under any drcumstanoes^ contain staitji,
I believe tliat starch should not form a part of the in&nt's food in the
early months of its life.
The question Avhetlier milk should be boiled or steamed is one whidk
is not of much significtince, and can be settled according to the fancy of Ae
individual practitioner, a greater or less destruction of the bacteria contained
in the milk taking place according to the degree of heat to which it is sub-
mitted. My own exi^eriments in comparing steamed with boiled milk show
that the (xlor and taste of boiled milk are present when milk is steamed,
but to a much less degree than in boiled milk ; also that while a thick scorn
is formed on milk l)oiled for t>venty minutes, which is tenacious and does
not disap|)ear on slinking, only a very thin scum forms on milk steamed for
twenty minutes, and that this is not tenacious and almost entirely disappears
on shaking.
BAcrKiJinLOGY. — A few matters concerning the bacteriology of cow's
milk cjiii Ix'st Ixj considereil in connection with the subject of substitute
fdnling. Kcs{>ccting this question Dr. J. A. Jeffries very aptly remarks
" that it is a ciiri«)us fact tliat, while older ix^ople are chiefly fed on sterilized
fixKl, — that is, cookcKl fiKnl, — infants are fed on food peculiarly adapted by
its c(>nn)«)siti<)n and fluid stat(; to offer a home for bacteria." In some
exiKTinicnts made by Jcllncs agar-agar cultures were made before and after
the (UlVorcnt fluids were sterilized, and the colonies of bacteria were counted.
His results coincide witli those of ]>revious exjjerimenters, — ^namely that
stcaniin*^ for fiftcvn minutes is sufti<*icnt to kill the developed bacteria,
while a second stciuniiig is nt*ccss;irv for complete sterilization. Out of one
hundrcil and twenty li>ts of milk stcaniwl but once, all but ibur or five
showcil distinct sijrns of chanjjco within a mouth, while the majority of those
steamed twice did not (jhangc at all.
JciVrics's exiKTimcnts also sliow that s{K>refl develop slowly, and, indeed,
rarely form, in milk, which, as he says, is an excellent medium for growth,
while spore-formation among bacteria, like seeding among higher plants, is
a phenomenon of impaired growth. He also explains the preservation of
FEEDING.
243
^
^
dome of the milk steamed but once by tlie absenee of any enduring sjwres
fi'om the start. In an article of very great interei^t and value to the prae-
tifling physician **On the Bacteria of the Alimentary Canal," Jeflries has
reviewed, at my recjuest, the work done by the various bacteriologists :
*' Miller, De BariTi and Eschcrieh have i?hown that living bacteria are
to l>e found in the stomachs of men and animals, and the former author
has also clearly proved tliat bacteria can pass through the stomach into the
intestines and live lor a considerable time, . , . Of tlie morphoI<:>gy and
biology of the forms found in the stomach little is known. The field is a
new* one, and the s|>ecies have not been sufficiently di^criljed to enable cithers
to recognize them with cei'taintj% Miller ha-^ found five kinds which give
off earlK)nie dioxide and hydrogen gas, lactic, acetic, and butyric acids being
formed. . . , Of the flora of the intestines much more is known than of
that of the stomach. The researches of Brieger, Vignal, Stahl, and Esclierich
have now proved that a large numl>er of s[>ecies may owur in the fa?ces.
Brieger isolated two new kinds : one a mieroeoccus, which turns grajie- or
cane-sugar into ethyIahx)holj with a trace of acetic acid ; the other the w^ell-
knfwn Briegcr's bacillus. This sj_>ecMes occ^urs in the fsecea in vast nnnil)er8,
ferments sugar, and decomposes albumins. Vignal ist>lated ten spet*ic8 from
the fseceSj six of these also being found in the month. Of these some pro-
duced aeid fermentations and gas, but unfortunately they were not suffi-
ciently studied to show their effects on digestion. . . . Eschericli studicil
especially the faeces of infants, and found a large number of kinds of bacilli,
among them a small bacillus cajmble of converting milk-sugai' into lactic
acid, carlK>uic dioxide and hydrogen gas Ixnng evolveil, cither in the presence
or absence of air, a facultative anaembic si>e€ies, his badilus ladis aerogenes,
Escherich established, by the examination of a large series of cases, the fact
that the kinds occurring in the fie<:***s vary w^ith the frHxl, — that is, the in-
testinal contents* . . . Starting at biith with the sterile meconium, c*»nslst-
ing of nincns, epithelium, and the like, infectirm by the mouth and rectum
quickly occurs, and in a short time almost any form may be found, but
chiefly such putrefying forms as proleus milffaris.
*' With tlie suckling of the infant and the 6ul>stitntir>n of tlie refuse of
the milk and secretion of the digestive tract for the mtH:'onium, a sharp
tnoiBtion occurs. Instead of the generally distribiitt^l forms causing de-
comiX)sition, only two kinds a?*e regidarly found, baeinus ladw aerogenes
and Brieger-s Imcillns ; the first chiefly in the npf)er parts of the intestine,
the second in the hiwer parts. Passing on to the j>criod of mixtnl diet,
quite a number of forms ajiin^ar, among them the drepiocoeeus coU graciiw,
the putrefying green fluoremhu/, a (drad cocch^, and several Idndji of yead.
This brings us to the pith of the subjecrt: Why are the flora so limited in
the milk-eating infants and so diverse in others? What drives the forms
found in the meconium out? That they can live there is clear, as sho^^l
by their presence the day l*efore. Again, what prevents forms so cfunmon
with meat diet fmm gaining a footing? It is not the milk alone^ for mUk
244 PEDIATRICS.
is an almost universal food for bacleria, and all the kinds found in the
intestines thrive in it.
*' Acieonling to Ksoherich^ the bacillus ktctis aerogenes and the milk diet
keep out the other forms.
" Formerly," continues Jeffries, "even before the action of fermeutg and
putrefactive pnK-esses were clearly understood, the significance of this ques-
tion was si*en. The chyme is a mass admirably adapted for putrefaction or
fermentation, yet ordinarily but little of either occurs. It is an alkaline or,
as in the milk-fed, acid mixture rich in albumins, fats, and the starch group,
amply provided with water and warmth. Such a mixture outside the body
at an ecpial tem|X'rature would (|uiekly decompose. It was generally held
tliat some jireservative action was exerted by tlie digestive juices : Bidders
and S<'hmidt's dogs with biliary iistuhe were supposed to explain the whdk
These dogs, depriv(>d of tlieir bile, became emaciated, and 8u£fered firom diai^
rhfpa and deiKjm|xjsition of the intestinal contents. Thus it seemed clear that
in the absence of the bik> dc»<»om|)ositiou occurred, — that is, that the bile was
a ix)werful giTmicide or giTm-inhibitor. During the last few years, however,
different n^sults have Ixx'n obtaiiunl in cases of biliary fistula. Rolmiann's
dogs did not suffer from diurrhiea or putrefaction in the intestines, hcnoe
it is ck»ar that the bile is not the cause of prevention. The diarrhoea, if
present, is due to the largt^ anu»uut of fat ])assed on to the lower intestines.
" Maly and Eniich ascrilxil vahie to the bile acids, especially the tauio-
cholic, basing their results on crude methods; and Lindenberger, really
leaving the subject, attributed tlie action to the oi^nic acids in combination
witli the bile.
*^ All this argument and l>elief in the det'ided germicidal action of the bile
o<"CuiT('<I in the face of the well-known fact that bile itself will decompose.
*' From a l)acteriologicjiI stand-])oint, Miller has shown that a ten per
wnt. solution of bile, if anything, favors growtli. Macfadyen has studied
bil<% l)ile salts, and l)ile acids in varying strengths. The only positive
results wen* got with the acids ; these am»sted the development of bocteria
if sufficiently strong, es{)ecially taurocholic acid. Neither acid had much
ellwit, and least of all on the* forms causing putrefacrtion. jPro^eu« vulgaris
was only am^tt^l by a stivngth of from one to two per cent. The patho-
g(»nic forms were arrest<H:l by a much smaller quantity, from one to one-half
per mille.
" It is thus clear that other causes must 1^ sought for. One of these
is to l)e found in the lack of oxygen in the intestines, as pointed out bv
KscJierich and stningely forgotten by others. There is certainly very little
free oxygen in the cliyme, if any ; not only is it scarce in the food at the
start, but is taken uj) by the chemical (•hanges during digestion, and also bv
the intestines. This clearly must be a jM)tent facitor, for the nugoritv of
bacteria recpiire a fair supply. Ac<*ordingly, many l^acteria are found in the
fte(x?s which will grow in the air, as shortly stated by Macfadyen, and the
mass of those isolated in tlie air are able to grow without it.
FEEDISO.
24a
I
" This apparent coutradictifm, the absence of oxygeu in the intestines,
and the presence of both aen>bic and anaen>bic b^w^tcria, is prnbably expluin<xl
by the ability of the ai^robie kiiidrf to draw oxygt:'n from oxyhtemoglubin.
They thns birathe throngli tJie intestines, as it were» when in close a»ntaet
witli tlie walls, while the anaerobic kinds live in tlie mass of the cliynie, and
do not, so ikr as we know, rtKlnee t>xyhiemogl<*hin.
** Esclierich, though he ptjints ont the al>s4?nce of oxygtni, doe?? not seem
to give it fiill value, or rather forgets the siibjetl in tre^iting of the action of
Ids lactic add baci/lm. As before stated, this fn rrn is iN?gidarly ihimd in
great numbers in the iipjier pait of the intestines of milk- fed children*
Here it converts a eonsidci^able part of the milk-sugar into lactic acid, and
thiii* prevents the other forms from grow lug, — most forms Ixnug susceptible
to an acid rt^a^-tion, and cs|RKually to the organic acids. The action of sali-
cylic acid is kuiiwu to alK and rcctnt expcrini(*nts» of which Maeiadycn's
(the last) arc the best, show acetic, butyric, and lactic acids to be efficient
germ-inhibitors in strengths of from one to one-half mille according to tbe
species.
** In milk-fed infants another point is the c(»niparative inability of liao^
teria to attiick castnn, so that the Imctcria arc literally starvt^b
** We may thcretbrc* conclude that the bile ainds, lack of oxygen, lack of
suitable albun)ins, and tJie presence of organic acids art^ the causes of immu-
nity from the putn'fying and fermenting kinds of liactcria to which we are
exi)Ose<l. f ertain lurms art^ pp>bably limited l>y the lack of water,— that
IS, of a fluid state, — doing poorly if unable to swim fnxly alM>ut. It must
not, however, be snpptsctl that l>actcria are scai^e in the intestines ; on the
contrary, tliey form a large part nf tlic tljy snbstani-e of the fieces.
" The ferments act by the* prrMJuction of various acids, chiefly derived
from the milk-sugar. In small amounts, as in the t^se of the hacilhm ladis
atrfH/rtH'fit^ the a<^id s^'cms to l>e of Iw-ncfit, and certainly (li>cs n*i harm, as it
rt»gularly fM-rurs in healthy breast-ii-ti fniants. In large anmnnts, however,
it must tend to over-aciilify the Cf>ntents of the intestines and interfcix^ with
the action of the digestive Hnids,"
MILK-LABORATORY.— I shall rt-fl r agjiiu to this tmalysis (Analysis
4*J, pjigc 21 S) of the average milk <>f Ileitis of cows when I am explaining
the methofl by which those who arc Umi far away from medical centres to
make its4^ of milk-laboratories may Ix* cnabk^l to modify milk with n*as<»n-
ablc exactness from ln-rds of comm<iu cows. Where, however, rn<Kliticati<»n
at tlie lalxiratory Is used, according to the methods which I have descriljed
to yon, nrnstant siK^cial examinations of tht> milk-snpply from the jwii-ticiilar
herd employinl arc necessary.
I shall flrst desc*ribe the mixlification of the milk by meaas of the
mechanism of the lal>onitorv, and lafci* spak of the more inexact methrids,
which may he designated as ** Home Mixlitieation' * (Home McKlilicatioD,
page 276).
As milk is one of the best means for the cultivation of bacteria, the
246
PEDIATBICS,
lalxjratory mhoulil \ye ^;itiiatixl m a healthy locality. It should be as free s^
jKiftfiible fmm contaniioatiti^ inflaeot*^, should be kept absolutely clean, m\i
every as*'i>tit' jirtt^mitinii ugamst the* harlK>ring or development of patbog^ue
urgaiiL^ois should be takoii.
From the moment that the milk i** delivered from the farm at a t4*mf»«
ature of about 4.4*^ C. (40^ F* ) it should be watched over and cared for wij
8«ieDtifie aot^uracy duriug the whole pn.Hx^^ of die mi>difieation which it qimJh
gfjes in the laboratory. The milk-rooms shoidd be cool and free from du
and iiM>lated, m far as possible, from other jiarts of the lab<3ratory.
Fio. 60.
Mflic-room.
Tliei-e i^hould also 1^ an entirely separate mora where the retumixJ jmck-
ages and all artit-l*^ I'eceived fmm the homes of tlie wnsumers 8hnuld lie
directly hrouj^^hl from the street or wagons, and where tht*se articles c3Ui be
immediately sterilized in apparatus reserved for this purpose.
The mtxlifyiug materials n^<\ in tlu' hd»oratr>ry should be carefully kept
for use in glass vessels, and at a tem|>tTature of alMiut 4.4*^ C\ (40® F,), to pre*
vent the growth of bacteria. The rciison for this is that milk modified from
materials fi-ee from bacteria is V»ettcr for the infant than milk in which the
baeleria have been destnjycd by heat. Therefore the ntmost care in nt^x'^
sary in all parts of the pr^xvss and in ever}^ depart ment of the lalx>nitory,
A special room should be pi-ovidc^d for the milk-modifiers who are t»_
put up the mixtures nxjuired by eac^h prescription*
FEEDINO.
247
There j^hould also be a room where the milk is eqiarated by means of
machmery and where it can be tested and steamed.
The office at the lalxjratory should be entirely se|i4irato from these work-
roonts, so that customers cxmiing to leave their orders shookl not go near
the materials used for moditicatioo and thus possibly contaminate thcni*
It 18 necessary » also, that all odors should be excluded from the work-
rooms, as milk absorljs mlors very quickly.
VentHntimr-fan.
Fio. 61,
Water-«tU].
It is hardly neceseary to eay tliat the employees of a laboratory, whether
they be in the ofliGe or in the work-rooms, should be intelligent and interested
in their work.
I have explained to you in a general way the chief requirements of a
niilk-Iaboratorj'. I wnll now take you to the Laboratorj^ and exphiin to you
on the spot the varituis details which must l>e imdci-st^KKl by the physician
8o that he can intelligently onler what is l^est fitted for the infant under his
charge.
Milk-Room, — We are now in the niilk-nKjm (Fig, 50, page 246), where
the milk is received on its arrival from the farm.
The milk from the farm is delivered here in the milk-room within a few
hours from the time of the milking. Yon saw how it was aerated at the
248
PEDIATRICS.
m
farm and cooled to alM)iit <3.()<)° C. (44° F.), and you now see that on its ar-
rival at the milk-r(N)ni its tenii)eratiirc is found to have been held by meao.^
of ice durinjr the transi)ortation Ik'Iow 7.22® C. (45® F.). You see how it
has Ixx'n traus}X)rtiHl in thesi' l)oxes and Iioav the man in chai^ of the room
Im^ had it placed in the tanks of ice-water.
This milk, as a result of the e8])eeial manner in which the cows have
lx>en f«l and cjiretl for and the sele<*tion of them according to the proper
hret^I, may U* said to have an almost uniform ])eroentage of its elemeot^
Even at tliose times of the year when the percentages of the di£ferent ele-
ment< of milk commonly vary from changes in the pasturage and in tlie
hal)its and surrounding of the animals, the milk of these cows, which hsn
their food supplied to them in stated rations at one time of the jear as vdl
as another, is not subject to the elemental variations which occur in the milk
of onlinary <*ows.
Haviufr siK'u here in the milk-room the methods by which the milk ii
treatcil and is kept unc^intaminat^il, we will visit the aepaiating-rooniy
the milk is taken to pivpan* it for the modifying clerk.
Skpakatix(;-Ro<)M. — This nnjm (Fig. 51, page 247) is
cartnl f<)r in very much the siune way as is the milk-house at the farm.
walls aiv of white tile, and the ceilings aiv of material which can be^
and scrul)lM'<l. The Hoor is of asphalt, im|)enetrable to water^ and is hflft
tlioroughly moistened and inn}, from every kind of dirt and dust.
Ventilator. — In addition to the ]>rec*autions against pathogenic gtfH^
whicli 1 have already (>xp]ained to you, the air of the separating^iooni is
kept fresh and pun* hy means of this nntHator which you see in tfae(
of the nH»ni. It (nmsists of a large steel fim^
n'volvcs at the rate of two tliousand times
and by the fonv of its current carries away any torn
or partieh's of dust which may come within its mob.
Separator. — Here is a piece of machinery of gmt
delicacy, calKn.! the Cerdrifivgal Separator (Pig. 6SQ.
This S4'parat4)r is made to revolve six thousand eight
hundnHl times in a minute, and Avorks with such search-
ing ellcct on the milk that only a small percentage
(O.i:]) of fat n*mains in the sei)arated milk.
Tlie utility of the st»parator, however, does not con-
sist wholly in its absolute withdrawal of the iat from
the milk and in providing cream as fresh as to time
as is the separatcid whole milk : it accomplishes two
other very imiH)rtant nwults. First, by its great oen-
trifupil fonv it separates from tlie cream and the
separated milk any dirt or foreign matter of any kind
which nec(»ssarily gets into every milk, and thus pro-
vides at once a practic-ally clean milk, a most important result from a bac-
teriological jxjint of view. Secondly, the Resulting cream has an almost
Ym
Centrlfii^'iil K'p^ir.itor.
FEEDING.
24^
stable percentage of fat, — sixteen |)er cent.,- — tlie unp^^rtiiuce, of course, of
this being in its stability, and not in its sj^ecial iK-rceutage.
StiD.— We also have in this n>oin (se[>arating-rooni^ p. 247) a still for
freshly preparing;: eaeh day distilled water.
In thLs next rcKimi you will see the steam-power (represented to right of
separating-room, p. 247) which runs the ventilating-fan, the seimmtor, tlie
water-still, and the sterilizer whieli I shall presently deserilie to you.
MoDiFYiNG-RtXJM. — We aiv now in the nKHlifyinM^-niom, where tlie
milk 18 tested, where the materials tor preparing the !Vmk1 aix? brought fmin
the different rooms when needed, and when* the mtKlifieation of the milk is
cMimpleted.
Flo. 53.
I
Moflifs"irii;-r^i
Babcock Milk-Tester, — Th l»e dmil^ly sniv thnt the chemistry of the
milk is what we 8uppr»se it to Ix? from the uniform natun? of the primal
milk-supjily, we take advantage* of the kuowlKlgi- ubich we have tinje<*rn-
ing the ehanges most likely to take platr in wrtaiu eleniL'Uts of the milk.
The pen*entage oi the priDteids, of the sugar, and of the mineral matter
in the milk of a herd of this kind, when:- onififroiity in the fee<iing is the
rule, is nL*t apt to Ik* appre^'iably atleetecL But the pret^ntage of the fat in
individual wws diftei's ihmi day to day, and thus slightly affeeti^ the jier-
centage of the fat in the milk of the henJ.
The fat, then, Ixang the elem^ut by whieli we know whether eaeb milk-
ing givt»s a unitbrra pnKlu«jt, we test this element by means of what is (*alled
the "Babeix^k Milk-Tester*** I have here on this table the Babax^k
250
PEDIATRICS.
machine, and I will have the percentage of the fat in a Bpecimeu of thfe
morning's milk tested for you.
The |jc*eiiliar feature of this method of a**certainiDg the peret-^ntageotfat
in milk, as desiTilx^ in the \Vi8<x)n8in Ex[>eriment Station, Bulletin No.
24, July, 1890, coasists in plaeiag these test-bottles contaiaiug the acidi-
ticxl milk in a centrifugal nmehine, by the rapid revolution of which ih
fat i.^ matle to separate tjuickly and completely . The milk is acidifieii in
oixler timt the proteids, ea^i'in and fibrin^ may lie changed to soluble acid
albumins, which offer less n^j^iji^tanw to the rising and aggregation of tlie
fat-globules.
Approximately equal volumes of milk and eomraercial sulphuric aeid
1.S2 specific gravity ai^ uuxed iu a tetst-bcjttle with a long graduated aeck.
This pi{>ette, delivering about 17.5 ex. of milk, and this measuring ey
Fin. 54.
Balx-ock Tnilk-t€»t<jr
for the acid J are us<?d. The acid is in tliis hirgc bottle to the right of i
machine. The lx>ttk\s are whirltHi for several minutes at a teni|)emture (
9ti° C, (200° F.) iu a iHjrizontal wheel making fnnn seven to ei|rht hund
revolutions [xt minute. This w^heel is siirroundeil by a ropj>er
w4iir!i may Ix^ filkd with hot w^ater for heating during the test. The
ration of fat by gravity alone is not complete even when the l>ottles are
standing for seveml hours. By centrifuge, however, a jx'rfeet sejianition j
accomplished in a few minutes. If whirk^l at once, no h<:*at need be applii
as that caused l>y the strong acid an<l milk is .sufficient, Af\er whirlii
the iHjttlcs are filled to the iKH^k with liot water, returned to tlie maehi
and w hirled for one or two minutes longer, after which they are filled with
hot water to ab>ut this seven j>er e^^nt. mark, and the machine is
turned for a sliort time, the tem|x*rature l>eing kept np by means of a
or by filling the jacket with hot whaler. The fat separates and its peiDeotage
ia noted while still liquid, pi-eferably at about G5° C. (150^ F.), the reading
FEEDING,
251
itage of fat directly without calculation aud beiQg easily
giving tlie pereent
taken to 0,1 per cent.
This daily testing of the fat enables the modiiier to preserve the aceuincy
of h)8 material, and to eorreet any variation in the percentage of the cream
as it comes friDm the separator.
The milk thi^ morning shows four per cent of fat, and therefore we
conclude that we are dealing with the usual uniform milk exjiected to
c<ime irom the farm. The average and almo.st stable aoaly.sis of this milk
throughout the year shows a percentage of fat of 4.00, and is the Imsis on
which the office clerk makes the calculation by which the |>erceutage of the
fat calkil fiir in the various prescTiptions is exactly obtained. Knowing the
exact percentages of this milk, the office clerk can, by a simple mathematical
formula, give the required directions on the mmlitying clerk's fiirmiila for
obtaining whatever jMjrcentages of the other eleraeijts tJie physician may
call for.
Here are the figures (Analysis 46) which have Ixx^n found to result from
tnauv analyses of the milk of the herd whicli vou saw at the farm :
ANALYSIS 46.
Fttt ...
Sugar . .
Aub . , .
TotJil solids
4.00
4.80
4.00
12.95
Water . , . . 87.06
100.00
I have al^o had placed ben^ on another tahh* for yfiur ins|>ecti(>n the
modifying materials n^*d for making up the prescriptions.
Fio. 66.
In this large glass jar on the left side of the table is the staljle cream
obtained from the separator, which is used in obtaining the pres(^ril>ed |x*r-
Gentage of fat On the right side of the table i.^ another large glass jar
252 PEDIATRICS.
which (X)iitiiins tlic soimrated milk, also of stable percentage, obtained from
the seimrator, and which is used for obtaining the difTerent peroeatageii of
the proteids as called for in the prescription.
We must, of course, allow that the ci-eam as well as the separated nM
contains its own definite iK»rci»nt4iges of sugar, proteids, and mineral mattfcf.
This analysis (Analysis 47) shows the peroentages of the fat, sugar, and
proteids in this cream and separated milk :
CrPHin . . . .
ANALYSIS 47.
Fat
16.00
0.18
Sugar.
4.00
4.40
ProUrWl.
8.00
S<*i>iiruU'd milk . . .
4.00
To pn>vide the means for adjusting the percentages of the sugar which
are calltHl for, a can»fully pr<»i)arcil twenty ix?r cent, solution of milk-sugar
and distilled water is uscil, and is kept in this large glass jar which stands
beside the cream-jar. The n'action of the food is adjusted by means of the
Uvw water which you irAv in this lai-j^ glass jar beside the separated milk,
and which is freshly prcjMmHl every day.
The other jars on tlu? table contain 8i)ccimens of cream of difierent per-
centjiji^'s, and ]>n*i>arcitions of oriM, barley, and tcheaty which are freshly pr^
l>an.Hl at th<^ Ijal)<)ratory each day, and which can be iiscd for infants when
they nrv old enough to have stan'h added to their food.
With th(»se iniHli lying materials the modifying clerks combine earii
infant's f«MMl su'coi'ding to the jiit^criptitm l)cfore them, and poiir it into the
glass tulx's Irnin which the infant is to nursi*. These tulx^, which you see
standi ing in their baskets on the modifying clerks' table, have been especially
<levise<l as the most pnirtieal ior gcMieral use, are adapted both for transjwr-
tation and lor !is<» as niirsing-ljottkv, and are easily cleansed,
Theiv ai-e two sets of elerks. (Se<^ \)i\^v. 249.) One set is eng:aged in modi-
fving the milk aeeonling t<» the pn^Tiptions. As s<Km as the tubes are filkd
by the uKxliiying clerks they mv passtnl on to the stoppling clerks, who im-
mediately seal them with aseptic non-al)sorlx*nt cotton especially prepand
for this ])ur]H)S(^, and place them in these baskets adapted as to th^ com-
partments to the numlKT of fiKnlings onlered for the special infant. Here
an* some baskets which hold eight, some which hold ton, and some which
hold ibur t!ilK*s. The tulns an» kept on tul)c»-racks within easy leoch of the
UKHlifying clerks. Each basket has its own label attached to it, with the
address of tlu* |)crson t(» wli<»m it is to lx» sent.
The rule of absolute cleanliness is carried out in every possible detail,
fn)m the table on which the materials arc combinwl to the dress and hands
of the clerks.
When the milk has l)ecn sepanited, rcM^ombinetl according to the pie-
siTiptions, stopi)leil, and jjlactnl in the i-esiH»ctive baskets, the baskets are
taken from the m(xlitying-room to the s(^parating-room.
Stkkii.izeil — We will now return to the separating-room (page 247)
FEEDING.
253
and see the baskets placed in tlm large sterilizer (Fig, 56), which has a
capacity of 240 kilogrammes (500 pints).
The sterilizer is so arranged that the steim which pa**ses through it can
be regulated m as to pi^oduoe any degrtx^ of heat re^inircil up to 100° C\
(212** F.). This is aitT^mplished by a regulator atUichtKi to the ^team-pipe,
and, m you see, the man in charge of the hmting of the food, by keeping his
hand on the regulator and his eye on the tlierniooieter which is fitted to the
Bterilizcr, can subject the l>asket^ and the tulx^s in them to whatever dc^i-ee
of heat is ordei-ed, and of course for tlie length of time required.
After the ffwHi has Ixt^n heat*xl, the ha^skct^^ are taken out of the steril-
i2er and placed in the cooling-tank, where the temperature of the food is
reducx?d to 13.3° C. (38^ F,).
Flo. 66.
Cftpactty.fiOOiifott.
Flo. 67.
Sterlliaer.
Spedsl rterillaej.
I
The baskets are then placeil in the delivery-wagon, which quickly
ooDveys tliem to their various dcs^ti nations.
Where a s|>ecial prescTiption at an unusual time of the day is called for,
it Is heated in this hood and sptx-ial sterilizer (Fig. 57)*
When the Ijaskets are d<4iveiied at the homes of the consumers, the
btiskets and tul)es of the prt'vious day are n^turned to the Laborat4»ry.
When they reach the LaljM3rati>rv they are tiiken dinx'tly from tlie street to
the wash-nx>m (Fig. 58), which is entirely shut otf, as I have Ijefore told
you, frf»m the rest of the Laljoratorv.
WAsii-IifiOM. — Here in tlie wash-ro<im (Fig. 58), in r>rder to carry out
alisolutely the aseptic precautions, the biLskets and ev^erything which has
been returned to the Laboratory are placed in this special sterilizer belonging
254
PEDIATRICS.
to the was
taken out ^
*mom. I
f the steril
Fio. 58.
Aseptic pncAQtioiiB.
obsorv^e that the baskets and tubes are j
. The Ijottles, after being sterilized, are th
wajvlittl in these tubs, which are especially
adaptid tor this purpotae, in a solution of hx
and water. All the tags and stoppers
destroyed atler sterilization. The
are of woven willow^ and are easily k^
sterile.
In this way, always guartling again^
I>o8rtible infeetion of all kinds, the L«abomt«jrT
enables us to make Uise of the chemical and
bac*teriological knowledge which we have i
qidrcxl in e<mneotion with the feeding of
fantis, and fulfils the re<|iiireraent8 of
system of substitute feeding which up to i
present time has proved to be the best,
Yim will now have an oppirtnnity
seeing the returiud baskets and tubes? actuallv
steamed in the sterilizer (Fig, 59).
The dm)rs of the sterilizer are tight
clamjied, and Mn Gordon has just or
the steam to be tiirne<l into it
Modification* — We w^ill suppose tliat ytm wish to prescribe J5S
modified milk ibr an iniant tour niontlis old, with normal digestion an«^
Fia. 59.
Wftsh^room ind ilcilllier for retunie<]
. uiitaiiiing jietumed boskets and tubfis.
normal weiglit and general development. The regular prescription-bl
issueil by the Lalx>rator>^ can be used if you have one» but, of wiurse, a_
milk-prescription can be written as you would write a prescription fori
FEKDlNa.
255
drug. Here is one of the pref^cription-blanks tliM I am iii the habit of
using at this special Laboratory, and which I will fill with some .^upj)os€d
directions.
PRCSCRlFTtON BlX\K.
H
Fut . .....
Percent,
4tOO
Reaction .
Number of Feedings . . ,
Amount at each F^ing »
Heated for
. Slightly iilkaline.
; 185 c,c. (1 4})
* 5iC> minutes.
Milk-Sugar.
Pmteidfi . , , , .
3Ihieral Matter
. . 1100
1 ao
Lirae Water . , . .
Hf»ftted at
76** C.
M^ .»»t^^ wv .*>.... 4 , itjy^ ^,
Specia] Directions.
Remarks.
Infant's Am?
Infant's Weight? ♦ . . . .
Signature.
For Wbom
Pate.
Ordered.
. 4 mfmthf,
. 14 {xiunda.
M.D,
I shall direct the percentage of fat to be 4, that of sugar 7, that of the
'proteids Ko, I slrnll order the reaction to be slightly alkaline.
In ix'gard to the ([UCtition of the reaL-tion, it can \)q left to the niilk-
modilier, a^ we leave to him the carrying out oi' other directions contained
in the pre?s*Ti lotion. If the milk bnmght to the Laljoratory on the .sj>ecial
day when we ai'c sending nur prescription Iuls l)ei'ii produced frrim cows
I fed, as I have previoiLsly descrilr^l, *tu rtugar-bt^efc^, the milk may be already
sufficiently alkaline for an infant's digestion when normai If, on the con-
trar}% the milk luis its usual acid or amphoteric reaction, the milk-modifier
will make it slightly alkaline, in actN>rdance with our prescription and
aooording ns the milk of the si>eeial day has a greater or less acid reaction.
For this pur|K)se lime water should he used, as being the best material
and as least likely to do harm. If, however, the infant's digestion is not
normal and we \rish to prescribe a precise amount of lime water, we can do
s<j by writing fi»r whatever |K*rcentage we choose, as wc do for the other
elements of the milk. In mixlifying tlie milk which wimes ir^jm the farm
I isomiected w^th thies Lab*)ratorv% as a rnle^ one-twentieth part of lime water
(five |>er cent,) is sufficient to make the n:*action e<irres[xmd Ut tliat of nor-
ma! human milk. By referring ti» this table {Table t]0) you will see what
the percentage of lime watcT should be in order to obtain a greater or less
degree of alkalinity. The hydrate of lime Is said to be soluble to the ex-
tent of 1 jMirt in 778 \mrts of water at a temjierature of 15.5^ C. (60° F.).
This would make one oun*x» of lime water to contain rather more than
0.03 (1 gmin) of CbO^H^ (hydmte of lime).
256 PEDIATRICS.
I shall write for seven feedings, and make the amount at each feeding
135 c.c. (4 J oiinees).
I showcnl you at a previous lecture (Lecture VIII,, p. 221) that the
milk fnmi the farm cx)nuected with the Laboratory has proved to be com-
luiratively free fn)ni batrteria, and tliat it would probably be unnecessary to
destroy the iew bacteria whicli exist in it if the infimt could be imniediatelj
iUl here in tlie Ijaborator}\ As this is not possible, and as the milk ha< to
Ik* tninsi)<)rtcd fn>ni the Laboratory' to the homes of the consumers at varioas
distances, I have found it better to heat the milk to 75® C. (167° R).
This temperature, as I have already explained to you, is sufficient to kill
those* devoIo|XHl Imcteria which would be of any harm to the digestion of
the infant, and at the simie time is below 77.2® C. (171® F.), the pm
at which coagulation of the proteids is supposed to take place. We thus
obtain a practically pure fresh milk, uncooked and sterile. We therefore
write in our i)res<Tij>tion 75° C. (167° F.). If, however, the milk is to be
sent a long distance, if the w(Mithcr is hot, or if the milk-supply has to last
more than twenty-four hours, a higher degree of heating can be used,
acx.'onling to the wish of the pn»scriber. Thus, 100° C. (212** F.) is a tem-
perature us<m1 tor these pur|)oscs at the Laboratorj'. Where, again, ire
wish the milk to Ix? al)solutcly sterilized, as may be the case when we are
preparing it for an (H%nx\\ voyage or fi)r a trip across the continent, not
only a high d(^rec of lu'at, 100° C. (212° F.), but two or three heatings,
with intiTvals of some hours, are necessary for this complete sterilization,
and this can Ik* called lor in our prescription. The lenjjrth of time during
whi(*h the milk should l)c hcat<»d, as a rule, can Ix? left to the judgment of
the sn|H']int<'n<lrnt. I have aln»ady shown you in this table (Table 56) that
ten minutes is ol't<»n sufficient to kill the deveh)}x?d bacteria and to make
this esiKvial milk practically sterile. Kxi)erienoc, however, has proved that
during transiM>rtation the milk is often ex}XM5ed to temperatures conducive
to the fni-ther development of bacteria, and that practically the bacteriologi-
cal results which we obtain in the Lal^jratory do not entirely hold when
the milk is expos*^! to these varied conditions of transit. As a rule, thew^
fore, from twenty to thirty minutes is the projXT time to heat mixtures of
modified milk sent from the Lal>onitorv.
I shall also, for reconl in the Ijalnn-atory and for reference later, state
on the preseriptiv)n th(* infant's a^e and weif^ht.
Finally 1 shall date the pirseription, write on it the addresB where the
f<KKl is to Ix* delivered, and sitrn it.
This preseiiption is now handcnl to the clerk in the office. The dert
coi)ies it into this lx>ok, which n^^onls each <lay's fcwling of each individual
infant, and then translates the ])hysicianV prcs<Tipti<m into such form as cud
l)e n*adily underst<MMl by the modifying:: clerks. Of course this fi>nn mav
vary in different parts of the world, a<*cording as the metric or the apothe-
cjiry system is in use. In the work of this (^jHHMal Laboratory, although
tlie prcscri])tions are writti'n by the physicians in the metric aygtwwi it has
FEEDING.
257
heen found more convenient, when delivered to the patrons of the Labom-
tory, to have tiie amounts expressed io oimces and drachraH. The office
clerk, after translating the metric j>ereentiiges into ounces aud draehnis,
copies it on to a blank of tliis form, which h enlled tlie mmiifying elerk*8
preiscription :
MouiwYusQ Olkrk'b Phescriptiok.
I
Na..^
Name of Infant
Ae^ of Infiint .
Weight of Infant
Addreas
4 moe.
14 lbs.
wkf. djiyi.
I Send by...
..at.. „,......, .o'clock.
Phymckm'a Pteseription,
Per Ceot
Fat
Milk-Sugar . ,
Proteids . .
Minenil Matter
Lime Wiiler .
Cterk^B Formula.
Ox, Br.
Modifying Crvam .... 717
Modifying Milk . . . . , 4 17
Sugar S^ilution 8 1 8
Lime Water 1 i 5
Water BjO
Total 81 : 4
Nr». of Feeding 7
Amount Ht €uch Feeding * 4j ouncen.
Heatt^d at 167^ F.
Time in Sterilizer tiOtainutes*
Kemarka
Put up by
Date
Month..
17
18
8 19
20
21
6 22
7 28
8 24
9 25
10 26
11 27
12 28
13 29
14 ao
15 31
16
Copied 189...,,.by.
This preacriptioD is then placed in the hands of the modifying clerk,
who combines tlie diflert^nt elements of the prescription by means of the
elemental materials winch have been brought into the m<xlifying-iT»om from
a dilferent part of the Ijaborutory, and which I have already described.
I have requet^ttd pliysician.s to write their pi'cscriptions within certain
limits as to the percentages i>f the fat, sugar, and proteids, and to allow the
mineral matter for the pn^ent to regulate itself. The limits which up to
the present time the Laboratory has fiinod it necessary to place on the pre-
scriptions for the milk -modifiers, and within which the modifying clerk
is supposed to put up the pretscriptions, are as is shown in this table
(Table 63) :
17
258
PEDIATRIGB.
TABLE 68.
Fat ttom 0.08 to M.00
Sugar fiom 0.87 to 20.00
ProteicU ftom 0.22 to 4.00
There is not much doubt that in the future more and more exact resobs
^dll be obtained, representing definite percentages of still wider limits. The
results obtained from combining the modifying materials used hy the modi-
fying clerks have so often been proved to be practically oorrect, that we cu
assume tliat when we write a prescription we shall obtain in return a prodna
which in its various elements comes within a fraction of one per oent
I have arranged in this table (Table 64) figures which will aid you in
writing ibr such percentages of the fat, sugar, and proteids as can be ob-
tained at the Ijaboratory :
TABLE 64.
Practical Limits of Milk-Modification which can be accompliMked im ike Laboraioty.
I.
Low Fats.
Fat 0.08 0.04 0.08 0.12-16
Sugar 2.00 8.00 4-«.00 6.00-7.00
Proteids 0.76 1.00 2.00 .8.00^00
II.
Low Sugars.
Sugar 0.87 1.40
Fat 2 00 8.00
ProteicU 0.75 1.00
III.
Low Proteids.
Proteids 0.22 0.84
Fat 2.00 8.00
Sugar 2.00 8.00
2.12 8.804.80
8.60 4.00
2.00 8.004.00
0.46 0.68
4.00 4.60
4 004.00 6.00-7.00
Fio 60. You see that in I. I have taken the
lowest percentage of fiit which can pncd-
cally be used at the Laboratory and have
combined it with various peroentageB of
sugar and of proteids. In II., in like
manner, I have taken the lowest peroenti^
of the sugar which can be combined ^di
these various percentages of fat and pro-
teids. Finally, in III. I have made ^
same calculations for the proteids.
Otlior materials can also be obtained at
the laboratory on the physician's piescrip-
tion for older infants and childreny notaUy
preparations of oats, barley, and wheat, which you see this young womaa
(Fig. 60) ])reparing in a special apparatus devised for steanung these oeieal&
When a physician orders cereals to be prepared at the Laboratoiy, he is
FEEDING.
259
enabled by tliLs apparatus to obtain exact preparations as ttj the ixTcentages
of the mnfttitueiifcs of any cereal fixyds, Thifi i^ atTtjnipIished by employing
I an analysis of the spetnal cereal ordered, and, with tlistilied water a^s a
[diluent, regulating the time the heatiug shall be maintained with '* live
[ eteam^' around the porcelain crwks.
The question having arisen whether the emulsion of milk which is used
! for modification Is interfered with or destn:»yed by modification^ I have
I answered it in the following way :
Under each of these four microscopes there is a drop of milk strongly
finagoifietL
Under the first microscope (Fig. 61) you will see a drop of milk as it
Pio. 61.
Cow's milk.
, came from the cow, unmixlified and unchanged, except m it might have been
, affected by transportation i'roin the farm.
The analysis (Analysis 48) of the milk from which this drop was taken
ris as follows.:
ANALYSIS 48.
(hw's Milk.
Fat ... .
Sugar . . .
Proleidfi . ,
Anh , . .
Total ftoHda
Water , .
. 4.01
. 4,5&
. 4.15
. _o.n
. 13.46
> 8(3.55
100.00
260
PEDIATRIOS.
Under thii* second microscope (Fig. 62) is a drop of a mixture
has been m treated as ti> rL*prL>;ent the same analysm (Analysis 48) f
Fi«. »V2.
Cow's milk flefMffttof! imd rooomiiowd
HumflD milk.
FEEDING.
261
e original wliule milk, and whirfi in fart is the origiiui! whole milk m
in Fig. iily which has Ijut-n soparatetl aod imM.nnjKisttl.
oil will notic'e that tlie emiikion of the recoiuiKJsed milk is ignite as
as that of thv original whole milk from which it was separattxl.
inder this thin! microjjcopt! (Fig. iio) 1 have placed a specimen of
in milk.
he analysis (Analvi^i^ 49) of this milk wa.s si-nt to me in order that I
d have a fixxl mcHlifiLHi to corresjxmd to it, to he ur^I for the purpose
mixed feeding :
^ ANALYSIS 49.
Fat
HutfiOH MUk.
2.67
Sugar . , . . .
Protoida
6.S7
2.69
Aflh
. . 0J6
Toint eolicU ....
. . n S8
Wat^i-r ....
mA2
100.00
Fnder t\m ibiiith mieroscope (Fig. fi4) i.s a specimen of eow^V milk modi-
0 c?orrf*8[>QDd to the human milk which is mider the third microBcx)pe
63).
Fm. 64.
Modified milk.
on i*ee that tlie emtd.sion <t>rrt»siK>nds almost exactly : so that there is
lestion that it is not injiirioiL*^ so fur as the emulsion is tonoemed, to
ate the elements of milk and then recomlnne them.
862 PEDIATRICS.
I shall now take you back to the office and show you the varioug (bnm
of apparatus which are provided for feeding the infant id its hotne. I \mf
had some of tliem plaoed on this table (Fig, 65).
Fio. 65
In ibe left of the picture is & biiskcl holcjlnif eJjrbt tubes <>( u vm^tuiiy t»r #ix oiui€^e« cja/'ii- bi fruax <(
tliiB basket U a fottr-oimee tube Iq & wlr? Mtond, !□ the ini<l(Ue ^>t the pietiire is o tin *p^am^-tf ^
warmlitg the milk at the time of feeding, Ati ulecalKtl lutiip i» nhnvm beneaili the wanner, and « tzibe
of TTiltk and a thermnmet4>r for (eetlo^ the U'lnperatun? of the milk Afe in tti« tio-wttnaer. K«xt 101*^
to ttie rtght i>f the tin- wanner t» • tube with a cjijiaolty uf eight ouncea. It Is eodoaecl ill • wtill* wamA
oozy, has the rubber ulpplc in plaoe, and is vupfiortetl in a wire stand. In Clw rt^t of Uie pktatt h 1
taflket contalDlng itx tub«t with a capacity of eight ouncei each. In ttaiai of llUa bttikel are ill iffli'
oimoa tube and a f(iur<i>QDoe tube.
This ap|iaratU8 is very simple and practieal for traiisportatioiL A
wicker basket, divided into a number of eompartmente oorre^pciading to
the nuiiiljer of ft^'diugs which are to be sent tcj the iufant, ha^ been foimd
t*j be the mo^t praclieal. These baskets with their tubes can be placed^
as you saw, direetly in the nterilizer, and are not harmed by thi» heat to
which it is nax^s^ary to exjx)8e the fii<^.
This tin receptacle can l>e ])lactHl ab^ve an alcohol lamp ; the water 1
18 to be on a level with the height of the milk which is contained m the tufa
and the tube is submerged in the water. It has l>cen found neoeagarvj
take the temperature of the food by means of a thermometer plac«*d dii
in tJie tube. No rule can Ix* laid down by which the temperature of
water-lmth determines that of the milk, unless the tubes are iif unifoQ
thickness and the milk uuifoiTn in qnantit}' and teni|>emtnre when platnl i
the bath. The therm<jmeter must Ije washe*! in sterilized water witli
greatest c^are, both before and after it is used. The fijtKl when given to thf
infant should have a tempemture of from 36.6° to .*I7.7° O. (98^— 1<^<1^ Fi
As in dii^ect feeding from the breast the fotxl which the infant receive h^
the same tejnperature at the end of the fee*! in g as at the Ix^inning, we should
copy this provision of nature and not allow the temperature of the fixxl t<>
vary during the time it is being taken. To att'omjilisli this end, this white
worsted csozy can l3e used. The cozy is warmed at the same time that tJie milk
is being heated, and the tube when placed in it is prevented from oooling^
FEEDING.
263
I
Thus the infknt receives a food of unvarying temperature throughout the
whole of the feeding- ^
1 have here al.so to
show to you the various
means which are ut*ed io
trans|Krrting the fixKl
when it ha^ to Ik? sM^nt
long distantM:»s. Here is
a traiisportation-lK)X (Fig.
66), which is ust^l in eold
weather^ wlieu ive Ls not
necessary to preserve the
freshness of the milk.
This b..x (Fig. 07) is
one which can be ys4.Hl
in hot weather, and liajf*
prt^vwl to l)i" of gi*eat pra<*-
tieal iitility. It admi-
^t 1 * Ai- TFampOTt»iioa-^ijox, LoiiUkiniiy? ba^iket &Jid tubes.
rably serves the pnr poses
of an express box and of a home refrigerator. The iee^ as you see, is
packed in a metal crtmpartment in the middle of the b<:)x, and the tubes are
placetl, each in its own compartment, around the sides of the ice-receptacle.
Fio. G7.
kt-boi, holding twelve tubes. Receptacle for Ice In centix* of box* laboratory ppescriptlon-bliink
l^oat of box* AQd packlug-pttper under end of open lid.
I shall DOW call your attention to tv^o cases w hieh were fed nnder my
dirc^'tiun at the Milk-I^borator)' dnrin^ the first year of their lives, and
which merely illustratt* the ehaojjes which naturally wonki be made during
tim peri<»d in the food of a healthy Infant.
264
PEDIATRICS.
The first cw^ (C'a<v 91) was a male, bom November 18, 1892. Thk
tahle (Table Go) sbows the reeord of its weight and food during its fini
year :
TABLE 65.
Showinff Mtmagemnit of the Food and Increase in Weight of a Healthy Infant {Cue 91)
during the First Fi/tif^Two Weeks of its Life.
Wi-ikji
Life.
WWtGWT
Amount
■LeAch
PvBosfTAines <»r Fooa
Date^
F^tliUf-
FU.
8u»„.
|Fxii«eid^
lixoeWAkr.
Nfivcmber 1
**
ti
Dt'combor 21
Januttiy 13
14
February 17
it-
H
HiirL-h 17
ApHl 2] !
May 1H !
IE
8
1
2
8
4
5
6
7
8
9
10
11
12
IS
14
16
in
17
18
la
20
21
22
:f3
24
25
2fi
27
28
2f*
:w
: 81
a2
5i3
84
S5
1 37
38
' m
40
1 41
' 42
■ 42!
44
4a
4t\
] 47
! 48
' 49
GO
51
GruuL
8753
6944
6048
M748
7308
7504
LbL
8
9
is'
i8*
15
Id
IG
V
8
"7
1
12
8
11
80
46
76
90
io6
120
185
160
166
180
210
ISO
225
Ol
1
P
H
4
H
6
6*
6
7
6^
7i
2.00
8.00
4.00
4.00
4.00
4.00
4.00
3.50
4.or
4' 00
4.00
Wh
6.00
6,00
7.00
7.00
7,00
7.00
7.00
I 6,50
[ 7.00
8.m
\ 5.00
olc mi
olc mi
1.00
1*00
1.00
2.00
2.60
8,00
2.60
1.60
2.00
'2.60 ,
8.00
Ik. ,
Ik and
6.00
10.00
6,00
13.60 '
10 00
COO <
WM
12.60
10.00
6.00
<mt Jelly.
si
e
r-
-J
h
r-
1
J
'Ml
Junt'22 '
n
li
El
AtiifUfil 17
u
1 j
IE
?Cnvcnili<'r 1*
7840 1 17
■ ^ ' I ' ■
8820 W
1
9870 22
3
£
1
1
fid
The ^ruiiinios in the third co\u\\m Vv«.\^ \)S5!fu Tv^M^itid \a ^undi and ounoea <m tha }iarii
or i^8 irniminot} to the ounci;, and the fracXAvm* o^ \Xvv o\iwc»\vw^\s««i\ Q^Kc^^nMi.
^^r FEEDING. 265 ^H
H The next case (Case 92) was a female, born November 1, 1892* This ^H
■ chart (Chait 4) shows the line of growth in its weight from birth U* the ^H
B fifty-setTind week of it^ life : ^H
^.
1 —
t9,
bU
^IW^
r
i
t>at**lf Birth y^rUt.
^1
1 1
in
I
1
1
t
§
t
i
S
§
1
i
1
i
g
1
1
§
i
1
g
§
1
i
t
1
1
i
Aefwtl Wtight
1 '
&ntm'B
&
*•
1
s,i8a
1
XVY
1
2
a.180
1
"
fl
3
iiao
1
^ lis
\
4
S,I9U
ID
i»
22
^M
"^
5
3,3W
14
•*
29
\
6
3.730
5
p«o.
6
s
7
%9m
14
«
13
^
s.
H
4,100
9
4
If
ao
>
V
9
4340
10
•1
zt
N
f*W.
10
l^iM
10
4 )J«-i 3
\
\
11
4,970
10
14
-
10
1
L
L2
5.080
4
17'
\
13
5,270
U 12
di
s
14
S.3<W
12
«
V
31
V
Sta
Iff
^870
13
1
Itb
7
(
1
L
16
tjm
13
B
«
14
s
k
17
8,900
14
1
M
21
v
18
4J70
14
4
s
L
19
MliJ
14
8
Mm
7
\
20
«^«0
14
13
14
%
■^
31
•.aao
15
7
¥>
21
A
22
19EIU
15
9i
.,
2S
L
23
7.150
16
15!
Apr.
nr
\
24
T,340
le
2
»
11
S
25
7,560
16
H 1 '<
IS
v
26,
7.800
18
15
-'
25
N
\
37
7.300
n
9
pi»r
2
J
?
28
7,730
17
4
9
%
\
^7,Bia
17
8
^
16
y
L
30
S.U70
IB
0
.-
23
1
\
31
8,l«a
18
3
"
30
1
32
8.1»0
la
4
lima
6
^
N,
33
8.490
IB
15
'►
13
7
94
a,470
IS
14
«
30
^
Si
95
a.iuo
19
6
M
27
1
36
$,m
19
e
JbIj
4,
V
37
B.fii24
19
11
-
U
1
33
8.950 ,
19
14
•■
18
I
99
S^fW
ao
0
*-
25
1
40
8J80
30
1 j
All«
1
L
41
».0«Q
20
4
If
S
V
42
9.110
20
€
H
15
\
^
43
flJIO
20
13
M
33
/
r
44
f.I1D
30
8
"
29
\
45
•JSO
2}
12
p«p.
5
I
46
8,110
20
13
^■
12
V
47
9.470
21
2
19
^
i 1
48
».«I0
21
9
"
2e
\
49
St8»
21
B
OcC
3
\
50
9,140
21
to
"
10
\
SI
9.dr70
22
0
"
17
11
69
^,9m
22
1
,♦
24
^1
' -4
a»
CB
CO
(O
o
o
C
-
ci
13
12
c^
;?
<s
t;;
at
at
-a
ts'
S
s
Ep
B
»
e
B
I
k— ^
^H
> m
o
m
o
m
o
Bl
o
<s
o
C
Ol
c
»
c
o
ti»
ts
«
X
■4
s>
fp-
lk»
^
*
^
?
u.
11
M(A^
41
fMi
Em^
-
1
»r<
•yA
^H
Ai
,.*[,- f
w
7f
JO
UHk
C
^^^^^^ ^^
^^H
266
PEDIATBIOB.
I Iiave also arranged a table (Table 66) leoording the quantity and
quality of this infant's (Case 92) food during the first year :
TABLE 66.
S/iowing Managetnent oj the Food and Irtereate in Weight of a Healthy Infant {Cue 9f)
during the First Fifty-Two Weeks of its Ufe,
1
1 Weeks
Amount
or Foodl
X/ATE.
LlflB.
*T ■
Sogmr.
FroteldaL
Ume Water.
T"
Uraxna.
Um,
Ox. C.c.
Oi:
November 1 . .
1
8180
7
1
N<)vemlM>r 8 .
2
8180
7
1 60
2 2.00
6.00
1.00
6.00
November 15 .
8
8180
7
1 60
2 4.00!
7.00 j
1.00
November 22
4
34:U)
7
10 90
8 4.001
7.00 J
1.00
November 29
6
3520
7
14 76
2} 8.00 i
7.00
1.00
December 6
6
8730
8
6 . .
. . 8.00!
6.00
1.00
December 13
7
8980
8
14 . .
. . 8.00!
7.00
1.00
December 20
8
41H0
9
4 90
8 4.00
7.00 1
l.OO
10.00
December 27
9
4840
9
10 105
8| 4.00
7.00 i
1.26
6.00
January 8 .
10
4690
10
4 , .
. : 4.00
7.00 j
1.60
January 10 .
11
4870
10
14
January 17 .
12
5060
11
4
JanuaiT 24 .
18
5270
11
12
January 81 .
14
6560
12
6
'
-A
Febniarj' 7 .
15
6870
18
1 ao
4
• • •
• • •
12.60
%
February 14
16
6070
18
8 1S5
4 > '
• • •
• . •
10.00
^
Februarl' 21
IT
6800
14
1
■ • •
6.00
e
Fcbrunrv 28
18
6870
14
4
^^
March 7 . .
19
6610
14
8
:i
March 14 .
20
6650
14
18 150
6 4.00
7.00
2.00
S)
March 21 .
21
6920
15
7
r*
March 28 .
22
6980
15
9
t
April 4 . .
23
7150
15
15
f
April 11 . .
24
7240
16
2
>»
April 18 . .
26
7560
16
14.
s
April 26 . .
20
7600
16
15 1
-
May 2 . . .
27
7800
17
6
d
MaVO. . .
28
7730
17
4
J
MaVlO . .
29
7840
17
8
J
May 23 . .
30
8070
18
0
180
e
2
May 80 . .
31
8160
18
8
June 6 . .
32
8190
18
4
1
Juno 13 . .
83
8490
18
16 196
d| 4.00^ 1M
2.60
June 20 . .
34
8470
18
14
=
£
June 27 . .
35
8700
19
6
•3
July 4 . . .
36
87»i2
19
8
1
JulV 11 . .
37
8824
19
11
h
July 18 . .
38
8950
19
14
JulV 25 . .
39
8970
20
0
August 1 . .
40
8980
20
^
August 8 . .
41
(KX»0
20
d
August 16 .
42
9140
20
6
Augupt 22 .
43
9340
20
13 1
August 29 .
44
9170
20
7l
September 5
45
9290
20
1
Septemb'T 12
46
9340
20
13
September 19
47
9470
21
2
September 26
48
9640
21
9
October 3 .
49
9630
21
7
October 10 .
50
9740
21
10 . .
. . 4.00 i 6.00
8.00
Octol)er 17 .
51
9870
22
0 . .
Whiole mi
Ik.
October 24 .
62
9890
22
1
• •
. . Wh
ole mi
Ik and
oat jelly
The grammes in the third columu Yiove \i^x^"t^>ice^ Xo ^^^oMwda tod oanow on the 1
of 2^ grammes if) the ounce, and tbc fwucWoTift ot \.\ivi o>3LTv»&\^N^\«m^9
FEEDING.
267
I shall also mention a few cases which have a practioai bearing on the
ineth«»d of substitute feeding by means of milk-lah)mtories»
The first case illustmte!^ how importaut it m to be able to vary the i>er-
oentages of the cliHei-ent elements of the milk, and to know that we are
abtainlng thetie variations exactly as they are oixJeretl,
An infant (Caae 93) was being nursed by it« mother, who waa heflUhy and who had on
abundance of bretii<t^milk. Their gumm<*r home wua by the a^a'^ide, in a bealibj situ&tioii|
and the infant wiw surrounded with everything that could be desired for perfect hygiene.
Tlie infant during the first two months of its life nurised well^ throve, and was perfectly
quiescent in iti* diiily life^ When it was three months old^ the mother waa very much
worried by some trivial fainlly matters and did not take nmeh exercise. The infant now
began to have colic, and, although it gained in weight, it was very restless and cned con-
tinuously* An analyfliji (Analyfiia 50) of the mother's milk at this time gave the following
result:
ANALYSIS 50.
Fat 2,69
Sugar .»**•*.•*,.....* 6.15
Prt>teidg 8.71
Ash 0.17
Total soHda 12.72
Water ...,,. , 87.28
100,00
The indications for treatment were^ of courae, to lessen the amount of ment^il disturb-
ance in the mother and tc* make her exercise more. The mother having followed these
directions J the symptoms in the infant s*x>n became less severe. AlVr a few days, how*
•ver, the unfavorable symptoms returned, and it waa found that thf^ mother had not been
exercLsing and was again menially disturbed- Ajb it se^^med imjKisj^ible to regulate the fimc*
tioti of the mammary gland under these circumstances^ it wa^ decidi?d to feed the infant
from the Milk-Laboratory. The following prescription (Pre«cription 6) was ordered:
Pbescription 5.
B Fat , _ . . , 8.60
Sugar ..,........*» 6,50
Prttteida 1.00
Reaction Slightly alkftUno.
Healed to 75" C. (167'' F.).
Eight tubee^ each holding , . . . 90 c.c. (8 ounces).
The infant digested this food perfectly, had no colic, and again became tranquil. As,
however, it only made a flight gain in weight during the first two or three weeks of this
iubstitute feeding, I changed the prescription to the following one (Prescription 6) :
^pRKSCRIrTIOK «J.
a Fat . 4.00
Sugar 7.00
L Proteida 1.60
On taking this food the infant began to make regular gains in weighty and continued
to thrive until it was four months old, when it was brought back to its city home, where it
was subjected to many of the annoyances which you will so frequently see occurring in tha
J
268 PEDIATRICS.
families which you tako care of, and which, though somewhat diaaatroui to the infant, tend
tr> advance our knowledge of substitute feeding. The annoyances which I refer tu were, ia
this especial case, as follows. The infant was surrounded with too much excitement, aod
was exposed tu unnecesjsary changes of temperature in its home. During the procesi of
removal from the sea-side to the city it caught a slight cold, and had intestinal sympUiWi
characterized by Unisc discharges from the bowels and undigested food. This condition vit5
easily obviated in a few days by simply changing the prescription at the Laburatoir to tk
following one (Prescription 7) :
Prescription 7.
B Fat 2.50
Sugar 6.60
Proteids 1.00
Lime water 10.00
Under this treatment the food was again fairly well digested, the dischai^ges leseenoi
in frequency and tliey were of a better character. The infant, however, during this sick-
ness had lost over 224 grammes (about } pound) in weight
At this juncture the grandmother of the infant so influenced the mother that she
insisted upon having a wet-nurse procured at once. Although I did not approve of thii
change, the family were so urgent in their demands for a wet-nmie that I procured one for
them. This wet-nurse was nursing her own infant and another iufiuit at the Infkote'
Hospital. Both infants were thriving in every way. An analysis (Analysis 61) of thii
wet-nurse's milk gave the following results :
ANALYSIS 61.
Fat 2.92
Sugar 6.20
Proteids 4 62
Ash 0.16
Total solids 18.90
Water 86.10
100.00
The milk for this analysis was taken from the middle of the nursing, ^le percentsge
of proUtids was so high that I did not dare to allow the foster-infant to be put to the Incut
at once. I therefore endeavored to regulate the percentages of the elements of the we^
nurse -s milk in the usual way. At the end of two days another analysis (Analysis 62) of
her milk was made, with the following result :
ANALYSIS 52.
Fat 8.89
Sugar 6.96
Proteids 4.78
Ash 0.21
Total solids 14.88
Water 86.67
100.00
The extraordinarily high percentage of proteids in this analysis made me absolutely
refuse to allow the foster-infant to begin with its nursing from the wet-nurse. The ftmily,
however, were very impatient, and argued that, as the other two infknts were gaining in
weight, digesting well, and looking remarkably ruddy, it must be a good milk which Uiey
were receiving from the wet-nurse.
FEEDING*
269
Two days later, although the fuster-infant waa decidedl^r improving on the subfititute
food froni the Laboratory^ it happened to lose 30 ^unmea (about 1 ounce) in weighty and
the ikmily then inaisted that tbia wet-nurse should be tried. Another analysis of the wet-
nuise's milk was then made^ and showed that the percentage of the proteids had been
reduced to between 3 and 4,
I had already endeavored to find other wet-nuraes whose milk would better oorreepond
to what the infant needed, but wm unsuccessful in obtaining any the analysia of whose
milk showed the percentage of the proteids to be below 8*
I have here the analyses (Analyses 53 and 64) of the milk of two of these wet^nufses^
which you may perhaps like to see :
ANALYSIS 6a.
Fat . . * 8.88
Sugar . - , . 6.65
Proteids , , , 3.14
Ash 0.14
ToUl solids , . * 18.71
Water 86.29
100.00
ANALYSIS 64.
Fat . . SM
Sugar .,..*. 4.50
Proteids 4.70
Ash 0.18
Total solids . . • 12.77
Water 87.23
lOO.W
The first wet-nurse wa* then brought to the foster-infant's home, and the infant was
put to the breast. It absolutely refused to take the breast for twelve huurs, although it
was crying with hunger. Finally it was induced to minse, but immediately at^er the
nursing had an attack of colic. Tbe^e attacks of colic were more or less severe «nd oc-
curred after each nursing. The infiitit soon appeared to like the milk and took it eagerly
at the regular nwrsing intervals. In twenty-four hours from the time when the infant
beigan to nurse its bowels were again aflected. The number of dWharg^^s l>ecame fre^juent,
fend the milk evidently was not being digested well. The^e conditione lasted for several
days, when it was found that the infant had lost over 480 grammes (alxjut 1 pound) in weight
As the severity of the colic was increasing^ and as the infant had lost its c<»lor» the mother
agreed to have the feeding by the wet-nurse discontinued. I then wrote the following pre-
scription (Prescription 8) to be put up at the Laboratory ;
PRESCRrPTION 8.
B l^t 2.00
Sugar 6.00
Proteids . . 1.00
Lime water . 10.00
To bo heated to .... . 76« C. (167" F.)
This mixture was given to the Infant. In twenty-four hours the number of discharges
from the bowels grew less^ and in a few days became almost normal. It began to gain in
weight, and, though seeming very hungry, looked better and ceas(*d to have colic.
Tlie prescription was then changed to the following one (Prescription 9) :
270 PEDIATRICS.
PBK8CBIPTI0H 9.
B Fat 8.00
Sugar 6.00
Proteids 1.00
Lime water 6.00
On taking this food the infant began to make rq^ufaur gaini in weight, but still eeemcd
hungry, so that ut the end of another week the presoription was ohAnged to the foUowing
one (Pret»cription 10) :
PBKaCBlPTION 10,
B Fat 4.00
Sugar 7.00
Proteida 1.50
The infant now improved steadily. It made the normal tLvermge daily gains in weight,
and soon recoven-d its color and former streng^. From this time it continued to thrive.
This cuse in interesting in many ways. It was very evident that a per-
centage of proteids over 3 was more than this especial infant could digest
It therefore had to be weaned from its mother. The wet-nurse's milk,
which was agreeing perfectly with her own infant and with another uifknt
which she was nursing at the hospital, had a percentage of proteids between
3 and 4. As I knew from my experience with the mother's milk that this
high percentage of proteids would not agree with the infant, I was not sur-
prised to find that, instead of agreeing with it, it made it sick. This cue
substantiates the statement which I have made in an earlier lecture (Lecture
YII., page 180), that, while there are many varieties of good milk, there are
also many infants who cannot thrive on them all, but only upon such as
suit their individual digestive iH)wers.
It is interesting also to record in this case that, as the infant grew older,
it was found that the percentage of the proteids could be incr^tsed in its
fo(Kl without harming its digestion, and that by the time it was eight months
old it was having in ite food pertx^ntages of proteids between 3 and 4, tibe
very percentages which caused such serious digestive disturbance when it
was yoimger. When it was ten months old it was able to digest 4 per cent
of proteids in its fo(Kl.
This case as a whole so well illustrates the use of the Milk-Laboratoiy
tliat it is hardly worth while to multiply instances of its value. I will,
however, give the record of the treatment of some twins (Gases 94 and 95)
that have recently come under my charge, showing the utility of feeding by
means of modified milk.
These infants were bom ut term, but were as weak and emaciated M though they had
been prcmuturo. One of them hud u convulsion when it was a few houn old, and the
other's circulation was ver}'- deficient and showed evidence of a cardiac souffle oyer the bsM
of the sternum for some days. This class of infants is very apt to die unleaa thdr fbod ii
carefully regulated at once, and the great luck of equilibrium of the peroentMget of the
elements of the mutcmal milk in the early days of life is often most diiMlw>u» in iti eflecti
on the hypersensitive condition of the gastro-enteric tract at this age.
Here is a table (Table 67) showing the condition and the treatment of these in&nti ia
the first fifty days of their lives :
FEEDING. 271
It may be instructive for you to look over a few of these prescriptions
which I have sent to the Laboratory at different times, as they will give you
a very fair idea of the simplicity and precision of substitute feeding.
Pbsscbiptioh 11.
A girl 6 years old; duodenal jaundiee (funetional),
a Fat 0.60
Milk-fiugar 6.00
PpoteicU 8.00
Lime water 10.00
Send 12 tubes, each 4 ounces.
Pbxscription 12.
A boy 6 weeks old; healthy.
B Fat 8.00
Milk-BUgar 7.00
Proteidfi 1,60
Reaction Slightly alkaline.
Heated to 76«> 0. (167«> P.).
12 tubes, each 2 ounces.
Pbsscbiption 18.
A boy 6 months old; healthy,
B Pat 4.00
Sugar 7.00
Proteids 2.00
Beaction Slightly alkaline.
Heated to 76«> C. (167«> P.).
8 tubes, each 6 ounces.
Prescription 14.
A girl 4 months old; proleid digestion weak.
B Pat 4.00
Sugar 7.00
Proteids 0.76
Lime water 6.00
Heated to 76«> C. (167«> P.).
8 tubes, each 4 ounces.
Prescription 16.
A boy 6 months old ; sugar digestion weak.
B Pat 8.00
Sugar 4.00
Proteids 2.00
Lime water 6.00
Heated to 76«> 0. (167«>P.).
8 tubes, each 6 ounces.
Prescription 16.
A girl 4 months old; summer diarrhoea. Food has to be sent to a distant town by express,
B Pat 2.00
Sugar 6.00
Proteids 1 00
At time of each feeding add lime water 8 drachms.
Heated to lOO^ C. (212<» P.).
20 tubes, each 1 ounce and 1 drachm.
272 PEDIATBIOB.
Ill this case the diarrhoea had not been suf&dentlj studied to determine
whether it was putrefactive or fermentative, so that a safe general preacrip-
tiou was sent to begin with. The lime water had to be int3t>duoed at each
foe<ling on account of the 100° C. (212° F.) heating, necessitated by the
hot weather and the distance to be sent. If the lime water had been mtro-
du(^Hl at the Lalwratorj- and heated to 100° C. (212® F.) with the food, a
rea(*tion would have taken place between the lime and the sugar, and the
mixture would have turned brown and have had a peculiar taste.
Feeding of Average Infants Born at Term. — When an infant is
bom at term, is of normal development and wei^ty and is healthy, I am
in the habit of regulating the quantity of its food aooording to the figures
which I have arranged in this table (Table 57, page 234). These figures,
however, are intended only to be provisional until by experiment the proper
amount for the individual has been ascertained.
The quality of the food which I begin with is usually as shown in the
following prescriptions (Presc^riptions 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,
27, 28, 29). Where these prescriptions are used the infimt is supposed to
be digesting well and gaining in weight progressively.
Prkscbiption 17.
For the first twenty-fovr to, thirty^aiuB hour9 of iife.
R Milk sugar, flvc-pciH^nt solution, in Bterilized distilled water.
Prescription 18.
First week.
B Fat 2.00
Sugar 6.00
Pn)t«id9 0.76
Keaction Slightly alkaline.
Heated to 76® C. (167» F.).
PRESCRIPTIOX 19.
Second week.
B Fat 2.60
Sugar 6.00
Proteids 1.00
Kouction Slightly alkaline.
Heated to 76» O. (167* P.)-
Prescription 20.
Third week,
B Fat 8.00
Sugar 6.00
Pruteida 1.00
liraction Slightly alkaline.
Heated t^) 76® O. (167* P.).
Prescription 21.
Four to six weeks.
B Fat 8.60
Sugar 6.60
Pn»teid8 1.00
Reaction Slightly alkaline.
Heated to 76^ O. (167» F.).
FEEDING. 273
Pbxsgbiptiok 22.
Six to eight toeeka,
B Fat 8.60
Sugar 6.60
Proteids 1.60
Reaction Slightly alkaline.
Heated to 76° C. (167o F.).
Pbescriptiok 28.
Two to four months.
B Fat 4.00
Sugar 7.00
Proteids 1.60
Reaction Slightly alkaline.
Heated to 75o 0. (167o F.).
Pbescriptiok 24.
Four to eight months,
B Fat 4.00
Sugar 7.00
Proteids 2.00
Reaction Slightly alkaline.
Heated to 76«> C. (167oF.).
Pbbscbiption 25.
Eight to nine months.
B Fat 4.00
Sugar 7.00
Proteids . 2.60
Reaction Slightly alkaline.
Heated to 76° C. (167° F.).
Prescription 26.
Nine to ten months,
B Fat 4.00
Sugar 7.00
Proteids 8.00
Reaction Slightly alkaline.
Heated to 76° C. (167° F.).
Prescription 27.
Ten to ten and a half months.
B Fat 4.00
Sugar 6.00
Proteids 8.26
Reaction Slightly alkaline.
Heated to 76° C. (167° F.).
Prescription 28.
Ten and one-half to eleven months.
B Fat 4.00
Sugar 4.60
Proteids 8.60
Reaction Slightly alkaline.
Heated to 75° C. (167° F.).
18
274 PEDIATRICS.
PBSSGBIFTIOir 29.
Eleven to eleven and one-htUf months,
B Unmodified cow'b milk.
At about the tenth or eleventh month I usually b^;m to give at first
one and then two meals daily of equal parts of oat jelly, prepared at the
I^ilwratory, with plain cow's milk heated to 75** C. (167° F.), and a little
salt added aooording to the iniant's taste at the time of the feeding. (Prep-
aration of cert^als described in Lecture X., p. 281.) Freshly prepared barley
or wheat can, if preferred, be given with milk at this age.
In the tweltlh month I usually accustom the infant to taking a little
bread one day old with its milk, and tQ be fed from a spoon, so that bv the
time it is a year old it is taking bread and milk for its breakfast and supper,
and oat jelly and milk for the tlirce middle meals.
COLOR OF F.iiCAL DEJECTIONS AS INFLUENCED BY THE PERCENTAGE
OF FAT IN THE FOOD.
I have considered it of some scientific interest to record the color of the
fa?cal discharges which corresjwnds ap])arcntly to the percentage of lit in
human milk and in the corresponding modified milk. On these two nap-
kins (Plate III., 3 and 4, facing p. 112) are the normal yellow dejectirais
of two infants (Cases 96 and 97) who are being nursed by their healthy
mothers and are themselves digesting well and thriving.
Here are also two napkins (Plate III., 8 and 9, facing p. 112) on which
are the normal yellow dejt»ctions of two infants (Cases 98 and 99) who are
lx»ing fed on a modified milk which is supposed to correspond to average-
human milk. The [XT(x?ntaj^« of the fat, sugar, and proteids in this modificti
milk are resiwctively 4, 7, and 1. The infants are digesting well and thriving.
You will notice the striking resemblance in color and consistencir
lx^tww»n tlicsci fjeoal discharges resulting from human milk and from modi-
fieil milk, where tlie percentage of fat is 4.
I have hert> also to show you the fsecal discharges (Plate HI., 7, facins
p. 112) of a healthy infant (Case 100), fed on a modified inilk having a
])ercentage of 3 for its fat, 6 for its sugar, and 1 for its proteids. You see
how much lighter the color of the yellow is.
This cliange of color is still more strikingly illustrated in this Dapkin
taken from this fourtli infant (Case 101, Plate III., 6, fisusing p. 112), where
its mwlifitH^l milk was comjwsed of fat 2 per cent, sugar 6 per cent, and
proteids 1 j)er wut., and where you see the resulting fiecal discharge has a
very much lighter yellow aJor than is the case with the others.
During the last three yeai-s I have been able to test the value of this
laboratory by the feeding of nearly three thousand infimtB, and my experi-
ence has Ix^n controlled in the practical use of this system by about four
hundred physicians. The numlxir of infants that have been fed fiom the
Laboratory each day was about two hundred.
FEEDING. 275
I myself believe that by the establishment of these laboratories a new
era has been entered upon in the province of infant feeding, and one which
will enable us to produce results which have never before been obtained.
Before leaving the subject of milk-laboratories^ I should like to impress
upon you that the establishment of laboratories for the modification of milk
has to so great a d^ree been accomplished by the extensive knowledge of
the subject^ the great experience, the unwavering determination, and the
enthusiastic effoi'ts of Mr. G. E. Grordon, that physicians, as well as all
others who are interested in the welfare of infants, must always acknowl-
edge their indebtedness to him for the great work which he has carried
to so successful an issue.
The first milk-laboratory for the exact modification of milk that has
been established in the world is the one which I have just shown you, and
was opened to the public in 1891 here in Boston, under the name of the
"Walker-Gordon Laboratory.
276
PEDIATRICS.
LECTURE X.
HOME MODIFICATION.— GENERAL REMARKS ON ARTIFICIAL
FOODS FOR INFANTS.
HOME MODIFICATION. — I think that you will now agree wttli me
tliat the ini|M>riarKv of nu*tlifying milk with the mi»st exact precision is sclf-
evi*h^iit if we exiH^^t to \n}riivt a .sulit^titutc tlnKi* Maiiy j>er8ons are m<t
near enough to n)ilk-!;ilM>rat<>ries to have their infants' fcx>d prepared by thU
nieans. It h there fore neiMi'^^^ary b> pmvifk* for the pre[xiration of the fuid
for thi8 rla^s of (ust\s in their lioiiies. Under thetf^e eircu Distances I hare,
in nuijunetiuri with Mr. GoitioJi, umde a nn-ent 8tmly of the l>est mean^ i^>
aetximplisli thi.s end, and I will dcserilx? them under tlie term of ** Home
MfHlititatitHK'* I |)jv>iU|)jKj>i4:» tliat absolute siiuplii-ity as to the raatcriak
u.hhI atul sui'h as ran l)e ubtairuxl racily is nttrssary, and als<_» that tht*
method employed shindd lie such as any |>hysieian I'au explain to a motltff
of oixiinary iutelligenee.
steriliser and themiometer. Stand for tubes.
Rerilia«?r cdVctuHl with cozy aSlur ivmoviU fr Jtu tr-.!
Materials,— I Iiave Iit-n' tn show ytni the materials which will make
possible the home uicHlilii^iition r»f milk inr substitute* feeding vrhh an
accui-acy clonely approximate, though n(»t tHjual* to that of the Lalxiratorv*
All thi.4 apparatus and tlie same fee(liu|r-tulx^ that I have already
8criJ)eil can l>e priwuret! at the Lalxiratory ftir the uri^iual outtit.
Home Sterilizer. — ^Thi.s 18 what ib called the ** Home Steriliz.er'* (1
68). It is sim|)ly a tin can supjK>rted on legs so that it ean be heated by a
^
FEEDING,
277
lamp; or, if preferable^ the legs ciui Ix^ it^moved aud the cniD plaeed on a
stove.
Thermometer* — It luMy a Ikl, to which is fittod a tliermometer by which
the degree of heat within the ean Ls indieated.
TubeB. — Tiie tiilx\s, varying in iiomlKT iKx*ordiiig to the miml>er of
feedings wliieh are required in twenty-four lionrs, are platxHi in this stand,
which can be lowered into the sterilizer and Ik^ inimerstHi in the water in
the ^sterilizer, which is mailc to rise a^* high as the level of the milk in the
tubes.
Stoppers. — You see that the tubee are stoppled with cotton-wool,
aeeording to the usage at the Laboratory.
Cozy* — I have alno hei'e another sterilizt^r, w^hieh has been covered with
a tlijck cozy, througli which the thermon liter imm t!ie lid jiasses and indi-
cates the degree of lieat retained within the sterilizer aiter the ihime lias
been removed.
Gh'aduate, — The other articles to be procni'ed at the Laboratory am this
250 cx\ (8J onnt*es) glass graduate (Fig. 55, p. 251), divided, as you see,
into halfnlmclinis.
Cotton- WooL— Also a n>ll of aseptie noD-al)sorbent cotton-wooL
Milk-Sugrar, — Also st>me milk-sugar,
Sugar-Measure. — ^Uso this siigai*-measiire, which holds 13.5 grammes
01 drachms),
Fm. m.
This measure obviates the expense of having the milk-sugar put up in
packages by the ajK>the€ar}% and h sufficiently exact to regutate the sugar
jxTCi'ntage in the mixtur(^s which I shall sjieak of presently. It is well to
rc^meniber, however, ttutt a jHjund of milk-sugar e<jntains 404 granmies
(7000 grains), and that if you prefer to order the sugar in packages of Vl/j
grammes (3 g draehms) dijXH^tly frmn the apr>thiH'ary, in jitaet^ of using the
measure, you eao simply tell him to make tliirty-five [jai'kagt^s from the
pf)nnd, and yon can then direct a package of milk*sugar to be useil instead
of a niPJisiireful.
Siphon* — Finally, they must have tliis glass .«iiphon (Fig. 70), O.O em.
(l inch I calibre, Tlie sii>hon can l>e used in any quart glass jars which the
family ]iap|)en to have.
The siphon should be a glass tube one-fjnarter to one-half inch in
diameter. It can be bent in a gas-Hame. The end out of which the milk
18 to flow should be at least six inches longer than that which is to Ix* in-
sertctl in the jar. To operate the siphon, fill it with boiled water, close tlie
huiger end with the finger, invert the siplion, and phuv the shorter end in
tlie milk. Then withdraw^ the finger, and tlie water, followe<l by the milk,
278
PEDIATRICS.
Fig. 70.
will run out of the long arm of the siphon. Do not oae the xnoutli to start
tlie flow of the milk through the siphon, under any circumstaiioes.
The mother is to be told tliat extreme precautions are to be taken to
follow your directions to the minutest detail, or otherwise a nnifi^rmly cor
rect result will often be lost. You must ex-
plain that the milk from a herd of coit^ is
preferable to that of one cow, for many reasons,
but esjieeially because the elemental percentages
arc less likely to vary in the mixed milk of a
herd than in that of the individual, and because
tlie mixing lessens the deleterious effects on the
milk arising from occasional distorbance of
health in an individual member of the heri
The cows should be of a common breed, and
such as give a moderately rich milk. The
milk should be drawn with dean hands. The
udders and teats of the cows should be cleansed,
and tlie cows should be milked in as clean a
])laee as possible. The milk should be thor-
oughly strained. You will now have a milk
fairly uniform in its elemental percentages and
cx)mparatively free from bacteria and foieigD
matter. The composition of this milk will
usually correspond to that which you see in
this table (Analysis 40, page 218). The milk
is then set in a vessel containing ice and water
with some salt, in the proiK)rtioii of 5 grammes (1 teaspoonful) to 960 c.c
(1 quait) (»f water, and the vessel is set in some clean place.
(Dr. S(»ibort, of New York, has recommended a system of filtering
through a funnel containing aseptic cotton, and asserts that the bacteria are
reduced in numbers one-half by this procedure. The fats, however, acconl-
ing to my cxjKricnce in the use of this method, are also somewhat reduced,
though not to any great dcgixx'. With the precautions taken, such as I have
just stated for obtaining tlic milk-supply, the cotton filter wiU probably not
be ntK.'ossary, but it c-an l)o use<l, as Sciliert intends it to be, where there are
known to Ix? mucli dirt and many l>acteria in the milk. Dr. Seibert ha?
had carefully j)r('j)arcil cotton disks and funnels made for filtering milk in
this way.)
You should always endeavor to prevent impurities from getting into the
milk in i)rcfcrcnaj to trying to cradicjite them after they have begun to alter
the normal com]X)sition of the milk.
A clean, invlily l)oil(d (»otton clotli is next thrown over the uncovered
quart jar. The mouth of the jar is kept oj)en for about fifteen minutes, to
disjwse of the animal heat. The jar is then sealed tightly, as you would da
for preserving, and is left in tlie ice-water for six hours, care being taken
Jar CGiitAiiiiii)? milk, cream, and
siphon. C, cream ; M, milk ; 8, sl-
[>hon.
FEEDING.
279
that the temperature of the water does not fall below 1.66^ C. (35° F.).
At the expuution of six hours you are to siphoii out carefully from the
bottom of tlie jar with tliis .siphon (Fig, 70, page 278) 720 cc, (24 ounces)
of the milk into a clean glass vesseL
You will now have your various materials ready for any oombinatious
which you may wish to make in preparing the food for an especial infant.
These materials are : the milk which you have siphoned from the jar, the
cream containing ten per cent, of lat which remains in the jar, the sugar,
eitJier in packages as I have just described or in bidk» to be used when
uee<]ed with tlie sugar-measure, some fresh lime water, and some clean
di4n king- water which has been boOed for five minutes*
I have arranged in these tables (Tables 68 to 80) figures by means of
w^hich you can make the various combinations which you will l^e likely to
need» and which correspond somewhat to the prescriptions that I have
already shown you at the Laboratory :
TABLE 6S.
Flit 025
Sugar 4.00
Protdda 0.26
Lime writer , * 5.00
To obtain this combination mth our nmteriab, and to provide a snflS-
cient quantity of food to last for twenty-four hours, you should give the
following orders.
Set enough milk to raise cream sufficient for the mixture refpiired. For
each twenty ounces, or part of twenty ounces, use the following formulfle :
Cr(*am .,*..,.,.., * . . | ounce.
Milk 1 ounce.
Lii!>e water . . . . • • . . 1 ounce.
Water ,.,.•,..... 17J ounoea.
20 ounces.
Milk-eugftr 2 measure!.
The niilk-eugar is to be thoroughly difisolved in the water of the mixture before the
other materials are added.
TABLE 69.
Pat 1.00
Sugar 6.00
Pmteidfl 0.75
Cream . 2 ounces.
Milk 2 ounces.
Lime water *...•••. 1 ovtnce.
Lime water 6.00 Wuter 16 ounces,
20 ounces.
Milk-eugar . 2 measuree.
TABLE 70.
Fat 2.00
Sugnr . , , . ♦ 6.00
Froteidi? 0 76
Lime water 6.00
Cream 4 ounces.
Milk None.
Lime water . 1 ounce.
Water 16 ounces.
20 ounces.
Milk-^ugar 2 meMurea.
280
PEDIATRICS.
TABLE 71.
Fat 2.00
Sugar 6.60
Protcid8 1.00
Lime water 6.00
Creum 4 uuncee.
Milk 1} ouncts.
Lime water 1 ounce.
Water 18 j ounces.
2U ounces.
Milk-sugar 2^ moasuro.
Fal
Sugar 6.00
Prutoids 1.00
Lime water 6.00
TABLE 72.
2.60 Cream 6 ounces.
Milk None.
Lime water 1 ounce.
Water 14 ounces.
20 uunco>.
Milk-sugar 2} meaean&
TABLE 78.
Fat 8.60
Sugar 6.60
Proteids 1.60
Lime water 6.00
Cream 7 ounces.
Milk I ounoe.
Lime water 1 ounce.
Water 11 ounces.
20 ounces.
Milk-sugar 2( measuxu.
TABLE 74.
Fat 4.00
Sujrar 7.00
Pn)teid8 1.60
Lime water 6.00
Cream 8 ouncee.
Milk None.
Lime water . . • 1 ounce.
Water 11 ounces.
Fat
Sui^ar
Pn.»telds L>.00
Lime water 6.00
20 oune».
Milk-eugar 2| meat^UKs.
TABLE 75.
4.00 I Cream 8 ounce«.
7.00 Milk 2J ounc».
1 ounce.
Lime water .
Water . . .
Fat
f^u^ar 7.00
Protcid.s 2.60
Lime wuter 6.00
• . . 8} ouncM.
20 ounces.
Milk^ugar 2} meaeorei
TABLE 76.
4.00 • Croam 8 ounces.
^lilk 5 ouDceL
Lime water i ounce.
' Wator 6^ ounces.
I
20 ounces.
Milk-8ugar 2J-
TABLE 77.
Fat 4.00 ' Cream
^"^u^'ar 7.00 i Milk
''r^'teids 8.(X) i Lime water
Lime water 5.00 i Water
8 ounces.
7^ ounces.
1 cNinoe.
Milk-iiu^ar
90
2
ounces.
FEEDING,
281
TABLE 78.
For weaning.
Fat 4.00
Sugar, 5,00
Proteidf , , , 8,00
Lime water 6,00
Cnjam 8 ounce*:
Milk 7J ounces.
Liiue water 1 ounoe.
Water , . 8| ouncea.
20 ounces.
Milknsugar 1 measure.
TABLE 79.
For weaning.
Fat 4,00
Sugar 6.00
Proteida 8.25
Lime water . . , . 5.00
Cr^am 8 ounoea.
Milk ........... 8 ounoei.
Lime water , . 1 ounce.
Water S ounces.
20 ounces*
Milk-«ugar {
TABLE 80.
For weaning.
Fat. . .
Sugar . ,
Proteids ,
4.00
4.60
8.60
Cream * . , , 8 ounces.
Milk . 12 ounce*.
20 ounces.
After the various nmterials have been mixed, in the proportionw which
I have shown you in these tables, the mixture U prepared for tlie *' home\
sterilizer.*' The rerpiisite amount of foixl for one fettling is fwnral into
each of the tubi«. They are stoppled with cott*m-wo<>l, care being takt-n
to have a renBonably tight stopple in and a dry neck to the tubes. The
tubes are then plaet»d in the rack and lowerrd into the sterilizer, and the
water in the sterilizer is adjusted to tlio levtd of the milk in the tuljes,
[Heat, by nieanw of a lamp or stove, is then applied to the sterilizer, which
IS watehal, with the cover off, until the thermometer shows that tlie water-
bath has reachtil a point of 77. *2*^ C. (171*^ F.), The lamp is removed
as soon as this tenn^erature ia reached, the cover put in place, and the cozy
over it. TIxe thermometer should mark a tem|Terature of lietween 75*^ C
(im^ F.) and 77.6° €, (170° F.) for thirty minutes, at the expiration of
which time the tubes are to be removed from the sterilizerj and are to be
kept in a c*>ol plact% preferably the ice-chest, until needeti.
OATS. — For the prcjiaration of oat jelly the following method should
Ije employttl :
120 grammes (4 ounces) of coarse oatmeal are allowed to soak in a quart
of (x)ld water for twelve hours. The mixture is then Iwiiletfl down bo as to
make a pint, and is strained thn>ugh a fine cloth while it h liot.
When it cools, a jelly is formed, which is to be kept on ice until needed.
Dificrent projmrtions of this jelly «in lie used, but u.sually it is Ijestto In -gin
with t»c|ual i>arts of jelly and mw's milk. When neede*!, this mixture is
warmed and a little salt is addtHj,
BARLEY. — Barley water is made by boiling 150 grammes (5 ounces)
282 PEDIATRICS.
of granulated barley in a quart of water until the volame is reduced to a
pint, and then straining.
If a barley jelly is to be made, 120 grammes (4 ounces) of barley fioar
are employed, and the same process is gone through with as for the prepa-
ration of oat jelly. The resulting jelly is treated in the same way with
milk as I have directed for oat jelly.
WHEAT. — Wheat can be prepared by the same method as that de-
scribed for oats and barley.
PEPTONIZED MILK. — For peptonizmg milk, tiie followmg mks
are the most practical and sim])le :
In a clean glass jar containing 4 ounces of cold distilled or boiled water
dissolve 1 gramme (16 grains) of bicarbonate of soda and 0.25 gramme (3
grains) of pancreatine (extractum pancreatis)^ to which add 12 ounces of whole
milk. Set the jar in a vessel of water at a temperature of 41.6** C. (107® F.)
for from seven to ten minutes. Cool immediately, and keep on ioe until used.
To {)e]>tonize modified milk an amount of the powders should be used
corresponding with tlie percentage of the proteids in the mixturey taking
the standard of whole milk to be represented by four per cent, of the
proteids.
SWEET WHEY. — Sweet whey is best made by the following method :
For each pint of whey nce<lcd take one quart of whole fresh milk,
heated to 37.7° C. (100° F.), to which add 8 c.c. (2 drachms) of the essencv
of pe|)sin, or one s<iuare inch of rennet. When the proteids have been
precipitat<il, break the ciml finely with a fork, and pour off the fluid,
straining it through two thicknesses of boiled clieese-cloth.
This removes such of the i)roteids as are coagulable by acids.
Placx3 this strainer! litjiiid in a clean ix)rcelain pot, and raise the tempera-
ture to the lK)iling-iK>int by a stove or a lamp, but do not aUow it to boiL
Strain this hot liijuid through a cloth as before.
This reni()V(»s the proteids coagulable by heat
Cool the resulting fluid slowly to a temperature of 10^ C. (50° F.), and
keej) on ico until nwded.
ARTIFICIAL POODS FOR INFANTS.— It would seem haidly
necessary to sngj^^st that the projKT authority for establishing rules for sub-
stitute f^Hilinjj: should emanate from the medical profession, and not fiom
non-ni(Hlieal ('aj)italist8. Yet, when we study the history of artificial
ieeding as it is r('[)r(^s(»nti'd all over the world, the position which the familv
pliysician oocujjies, in eoni{)arison with that of the venders of the number-
less ])atent and j)r(>prietarv artificial foods administered by the nuTBeSi is a
humiliatinji; one, and should no longer he tolerated.
If we an» ahn^ast of tlie times, if we but recognize and do justioe to the
work which has lately Ik'cu done by our own profession, we sniely will
not hesitate to n*le^te to oblivion the statements of the food proprietors,
which on l)ox and can, on lx)ttlo and printed circular, attempt to stem the
slow but inevitably i)rogressing wave of scientific investigation.
FEEDING*
28S
It may be weU to bear in niiod that the attempts whieh iu the past have
been made to niaiiiifaetiire cheap focjds Lave l^een markedly iaihires. We
must first, regardless of expense, leum to produce by mcNJifi cation a per-
fected substitute food, and not endanger the success of our undertaking by
allowing the mercantile side of the i|uestton to cripple us in the use of costly
metIi(Kls, which, however, we know tfy be the l>est. We should^ in fact,
remember that the human milk, which we are endeavoring to copy, far
fi'om being a cheap pnxluct, is a very expensive one.
My own opinion in regard to patent ilwds^ as a whole, is that they must
necessarily be unreliable. They are thrown on a market where the eomj>e-
tition Ls extreme, and w^hen once they have Ijeen advertist^l into public
notice I cannot but feeJ that irregularities aud changes — slight, {wrhaps, in
the eyes of tJie makers — may uninteutioually cri'<^p in and carry tlieir com-
position still further fmm that of the standaril, human milk.
Analyses show that there is a lack of uniformity in these foods from
year to year, and that original claims are apparently forgotten or allowed to
give w*ay to cheaper production. In fact, ns ray ex|>erience in the feeding
of infants inci'eases^ and iks I examine year by }'ear the effects of the diflerent
foods on infants, I am strongly imprc«^sed witli the lieUef that with our pres-
ent physiological, chemical, and clinical knowledge all the patent fiiods are
entirely unnecessary. The claims made for them are not supfKUted by in-
telligent and uoprejudii^i investigation. Those who manufacture them are
not in a position to judge cf>rrectly eoneerning tliem. The merit at times
of their apparent success does not l^elong to them, but to aiM^'ompanving
circumstances. They do great harm by impressing upon the public the
false idea that a cheap, easily prepared food Is for tlie good of the infant and
is better tlian anything which can be procured elsewhere. They vary too
greatly in their analyses to keep even within the acknowledged varying
limits of human milk. It is therefore high time for physicians to ap*
preciate exactly how inefficient in themselves and how misleading iu their
claims arc these artificial foods, and also in what a false jKJsition, as the
protector of and adviser to the public, our profession is placed whenever it
lends itself to even a tolcnition of their use. I s[>eak of them here simply
because there is no doubt that tliey are kept in the market by the physi-
cian rattier than by the manufacturer. The latttT is only doing what any
capitalist in teres t4,d in a business venture would do. The former, it seems
to me, is, jjerhaps unintentionally, aiding the business interests of others at
the expense nf his own future reputation as a scientist. It makes little dif-
ference to physicians as to what is claimcKl for these foods when they are
plaocil in the market. It makes a great difference what the mixture con-
tains when given by the mother to the infant according to tiie directions on
the label. For instance, a ftK)d may show by its published and certified
analysis a fair pTcentage of fat or sugar, and yet this same ffnA when
diluted for the infant's feeding may have these constituents reduced far
below the rea^nable limits of nutrition.
284 PEDIATRICS.
LECTURE XI.
THE SECOND AND THIRD NUTRITIVB PERIODS.
SECOND NUTRITIVE PERIOD.— During the eleventh and twdfth
montlis of life the amylolytic function of the in&nt has become almost Mt
<lcveloi)ed. In aeeordanoe with the rule regarding the use of the different
functions, which I have already 8|)oken of, — namely, that a function should
not he taxed before it is developed, but that when its development id abnost
complet^l it should be brought into use, — ^we should in the latter part of the
first year begm to use tliat function of the digestive tract by means of whidi
the aniylac(^)us elements of* the f(x>d are converted into sugar.
In .sjK'akiiig of weaning I have already explained to you the value of
using ])re])aratious of oats or barley mixed with milk. I have also shown
you how to re<hice gradually the percentage of sugar in the modified milk
which is being given at the tenth and eleventh months and at the same
time to inc^reiise the |)ereentagi^ of the proteids. The reason for ohanging
the n'lative iK?reentages of these elements is that the power to digest proteids
has mu(*h inen*sLsed during the latter part of the first year. The capacitr
for (li^'r^ting a high ]H*reentage of sugar Ls just as great at this period as at
an earlier one, but the aint)unt of sugar, given directly as such, which is n>-
quire<l in the later is not so great projx>rtionately as in the earlier period.
A large j^ortion t»f the sugar which is needed for nutrition in this later
jxTiiwl is inten(le<l to 1k' introduced into the economy by means of a new
element in the f(Kxl, — starch. A certain amount of sugar is, as before,
dirct'tly introdiuxnl into the gastro-enteric tract from the milk-sugar of the
milk, and the starch when converted into sugar supplies the remaining por-
ti(»n of supir nee(le<l il^r nutrition. In a normal infant with normal digestive
i'unctions a (•onsi<l('ral)le jXTcentiige of starch can be digested and absorbed
with U-netit in the eleventh and twelfth montks.
I am thor(»fore in the habit of giving preparations of oats or barley
when I have decided that stan*h should be intn)duced into an infant's food.
There is a larger jK'reentage of starch in oats than in barley. It is also
more nutritions in every resjKX't, as it contains a considerable peitsentage of
fat. The starch in oats takers a somewhat longer time to be converted into
sugar than does tliat of barley, so that in the case of an infant whose
amylolytic function is not fully develojKKl or is somewhat weak, piepan-
tions of barley will l)e In'tter to Ix^gin with, because they do not intoro-
duee so high a |)ere(Mitage of stan*h into the food, and also because the
starch will Ik» more readily i'onveit<Hl into sugar. Preparations of oatB
seem to Ix* the lx*st form of fixxl to lx» added to the modified milk when the
FEEDINO.
285
I
infant has reaclit'd a [ieriod at which it needs a ohange in the character of
its foocl.
When the infant has rear-hed the thini nr tuurth month of its life it nor-
mally should \>e able to digest four per cent* of fat in its food. This percent-
age of fat eorresix)nds, as I have already shown you, to tliat which exists
in average cjow^'s milk. It is natural to suppose that at the eleventh and
twelfth months a still further increase in the amount of fat which is jiro-
vided in the infants ftwKl is ret|nired, as well lis the new eltnicnfr, start*! t.
This fat is supplied, aa I have already told yon, in LTmsiderabte quantity
from the oats.
We have theix^fore, in preparations of oats, both for purposes of weaning
and for estahlLshing a new regimen of diet for the infant, a food which in
combination with cow's milk satisfies cooiijletely the demands which the
digestive functions at this period are making tor a i)erfect nutriment
The second nutritive j>eriod may be re<:*kone<l to la<5t from the twelftli to
the twentj^-eighth or thirtieth month of life. That is alx»ut the second half
of the {KTiixl which we are in the habit of calling intancy. It also in-
cludes the time when the last tour teeth of the tirst set ajjjx^r. In this
second nutritive period the element of variety in the food becomes imjwrtant.
It is nndoubte<lly imjxjrtant tluit the actual nutritive values of tlie food whic4i
it is l>t^st to give to infants in this [jeriod l>e con.sidercd,, but it is much more
important that special attention be paid to its variety. Foods should be
given which while containing a fair jx^iventage of nutritive elements yet
differ io the C(»mbi nation of these elements to such a degree that they i hi til
the ret|uirt*ments of this i>erit»d of life. It is best to increast* gi-adually the
variety of articles of diet from the twelJith to the twentieth month, always
adapting the food to the esjiecial infant. Thu.s^ some infants may be able
to digest and assimilate profKirtionatcly large c|uantities of stan-h ; ot lid's
may both need and digest larger proportions of the proteids or of sugar than
the infants first S|x>ken of.
Between the twel fth and thirteenth months I am in the habit of giving
the infant five meals during the day. At this time it is well to accustom
it to take its footl from a spocjn, and as soon as possible to omit feeding from
the lx»ttle. The five meals should be arranged in tlu^ fi>lUiwing maimer:
For breakfast, bi'ead and cow's milk, slightly warmwl.
For luncti, ecjual [>arts of oat jelly and cow's milk, warmed, with a
little salt addetl ac(X)i^ing to the infant's taste.
This meal of oat jelly should be repeated in the middle of the after-
noon.
In tlie middle of the day, broth of some kind, either chicken or mutton,
carefully prepared so as to be free from fat on its surface, can be given with
some bread.
The fiftli meal shotdd be given in the latter part of the afternoon, and
should ix>nsist of l^rcad and milk.
In some cases it is impossible to make infants swallow broad for a
286 PEDIATRICS.
long \yenod after the usual time of twelve to thirteen months. At times il
is not until tliey are two and one-half to three years old that they can be
induced to take bread. In these cases we must feed them aooording to our
judgment of the individual case.
When the iniant is fourteen to fifteen months old, some thorongUj
boilctl rice can be added to the broth in the middle of the day, and if it
digc^sts this well it can also have bread given with this meal.
When the infant is sixteen montlis old, it can have a small amount of
butter on its bread. When it is seventeen to eighteen months old, it can
have a thoroughly baked white potato, mixed with batfcer and salt, added
to its mid-day meal of broth. When it is nineteen to twenty months old,
eggs c^n become imrt of its diet
There are not many fruits which should be given to the infant m ite
second year. A Imked apple can be given at the evening meal when the
infant is fourteen to fifteen montlis old ; or, for variety, the apple can be
made into a simple sauce, never, however, having the sauce made with
much sugar. When {x^ches are in season, a ripe peach can often be given
with benefit, esi)ecially if the infant is inclined to be constipated. Other
fruits should be avoided, as they are not necessary for the insult's nutrition
and at times produce serious trouble.
This is the diet which is sufficient for the infant daring the second nutri-
tive peri(Kl. It is im])ortant for the subsequent int^rity of the infantas
digestion and general nutrition that the parents should insist that no odier
articles of food Ix; employed, except such as are similar to those whidi I
have sjK>kon of, — namely, the cereals in a variety of forms, according to the
taste, judgment, and knowk^dge of cooking which exists in the spedal
h(>us(.4)old. For instance, preparations of wheat and barley cooked id
various forms may be given in place of oatmeal. Bread also in diSerent
forms may Ix^ given. The crust of French bread is easily digested, and is
su[)p()sc(] to have k^s starch in pro]X)rti()n to its gluten than the usual home^
made bread. It Ls well to begin with some form of bread of this kind
when we ant getting the infant accustomed to take starch in the form of
bread. If it is i»onstii)ated, Graham bi*ead and preparations of rye will alao
Ik» found usei'ul. Fn^h bread should never be given, and bre»d one day
old is the ])reierable form which should be provided.
The iniant should never Ix* given cake or candy even to taste. I f-^inlc
that it is ne<*essary to state this very decidedly, because it is an erroneoos
view which is held by most mothers that it can do no harm to give occasion-
ally to an iniant in its second year of life, or to a young child, a little candy
or a little cake. This may be tnu» so far a.s the immediate effect these articles
may have on the digestion is concerned, but it is of far more importance that
the infant should not liave its taste jxTverted from those articles of diet
which are best for its nutrition. Thc^ new articles appeal more strongly
to its sense of taste, and allow it to know that there is something whidi
tastes more agreeable tlian tht^ food which it is accustomed to have. When
FEEDING,
287
l&n infaot has acquired a taste for cake or candy, it will cease to enjoy the
1 focxi by which its development will bi^ best j^rfected. It is, in fact, kinder
to the infarit never to allow it to tiiste cake or (■andy. When the.se articles
I are withheld, it will eontimie to have a healthy apptite and taste for ntn^e^-
[eary and proper articles of food. •
I am so oiieo aske<l by mothers wliat is the liest meth<:>d of preparing
[fiimple broths for their infants that jierhaps it may be well lor you to know
I how these broths should he made.
CHICKEN BEOTH.— A fowl weighing ab«>ut five jmnnds should be
boiled Ibr about twelve hours. The fluid should Ije strained while hot
through a fine sieve. It should then be allowed to eool in an earthen jar
for alxjut twelve hours in the ice-chest The ix^snltiug jelly can be used in
fnll strengtli or diluted with water. When the jelly has been thoroughly
I cooled^ the fat <^n be either partially or entirely removed from the top.
MUTTON BROTH, — A shoulder of lamb, when it can be obtained,
^ — otherwise of mutton, — weighing from five to seven pounds, is treati»d in
the same way as is the fowl for the preparation of chicken broth,
THE THIRD NUTRITIVE PERIOD,— The thii-d nutritive period
I have arbitrarily made to Ix^gin at about the thirtieth month of life.
At this time it will be well to begin to accustom the child's digestive
fiinctions to a still greater variet)' of food. In summer the more easily
digestible vegetables, such as squash, young \wns^ and young beans^ can be
given. The variety of fruits *^n also be tnereasetl at this jxn*iod, but they
should l>e cooked. The principal change which is to be made in the diet to
which the infunt has been accustumed is a very decided iucrt*as<^ in the pro
portion of the pi\>teid element oi* its fcMid. This is at*eomplL«hti:l by means
of giving the child meat The quantity of meat which should be given
towaixls the end of the third year should be small at first, and should be
given at intervid> of a day or two. Meat jis a n^gular article of diet for
,eac)i day is not, as a rule, requirt^l until the child Ls ImHwwu three and four
t years old* The kinds of meat which should be given in this early period
i of childhood are eliicken, mutton-chop, roast beef, and beefsteak* These
meats should be cut into small piec-es, and a little salt addc^ according to
the child's taste. It is w^ell, durini^ the latter part of the thii'd year and tiie
first half of the fourth year, to give the child an egg on one day and meat
on the next
When die child has reached the age of five or six years, we should allow
it to have a somewhat more varied diet, but during the whole peritxl of
childhood up to the age of pul>erty the closest attention should be given
to the i-egulati^tn of the kind and the amount of fiwjd to l>e given to the
child, and any deviations from the niles which I have just laid down are to
be deprecated.
DIVISION V.
PREMATURE INFANTS,
LECTURE XII,
I SHALL next Apeak of that elass of in&ntB which is deBignated as pre-
mature, I)ecause tliey are bom prior to the usual two hundred and eighty
days whieh represent tlie normal duration of intra-uterine life. I describe
this elass of eases direetly after what I have just told you about infant feed-
ing not only IxK'aiisi; it is essentially the proper management of the fiwd
which pn^serves the lives of tliese infants, but because I consider that the
lx»st way to 1ml prt»niature infants is by means of food carefully prepared at
milk-laboratories. This method of feeding premature infimta is fiir superior
to even bn^ast^fcHnling, and, in my opinion, the use of milk-laboratories in
these eas(^ will result in a dwided reduction in their mortality.
Very few east\s art* reiH)rted, and none of them appear to be ahsolutelj
authentic, when* an infant has survived which was bom much before the
twenty -st^veuth or twenty-<'ighth week of intra-uterine life. The premature
infant in its intra-uterine development is unprepared to meet the conditioDS
of extni-uteriiH^ life, and often dies within a few days, and usually within
a few lioui*s.
A sufIici(Mit luiinlKT of careful investigations regarding the characteristic
a|)|M'arances and the development of the foetus during the last four months
(li* intra-ut<Tine Hie has not yet been made and recorded to enable us to
stat<i (lefiniti'ly what a<re the infant represents when it is bom. The few
facts which we |m)sscss concerning this subjecrt must, however, be made use
of, and, though not absolutely correct, are sufficiently so to be of great value
to us in our management of these cases. One reason for the difficulty which
arises in every case in determining tlie age of the foetus is that the condi-
tions which influcn<*e its growth during intra-uterine life axe veiy varied.
Tiie health of the mother and her hygienic surroundings, together with die
influence of heredity (»n the size* of her ofrs])ring, present good reasons far
decided variations in the gn>>\^h of the foetus in different cases at the m"M>
jKTi(Kl of intra-uterine lite.
I f the infant is living when it Ls born, wc should at once cany oat the
28H
PREMATUIiE INFANTS.
289
Tules for preserving its life which have proved to he best in the case of any
infant bom prematurely. These rules shoulJ Ix' insisted on even if the
infant lias been lx»rn at a much earlier ^ta^e of development than is» accord-
ing to our present idea^^ compatible with its viability. This is necessary,
becaiiise s<i many errors in our caleulatiou as to when the impregnation took
place ail! liable tc* arise, and also because a foetus may have arrived at a
jx^riod oi* mtra-uterine development which is {perfectly compatible with life,
and yet fn>m ita small weight and general chamcteristics have the appear-
ance of one whose development is incompatible. Whatever advances we
may make in the future in preserving the lives of premature uifante born
at an earlier date than Ls supiK>sed to he compatible with life, — namely, from
the twenty-fourth to the twent^^ -eighth week, — it would hardly be practical
at this time to dfscuss tiie treatment of infants bora before the twenty*foui*th
week,
TWENTY-POUR WEEKS.— A fcetus born at about the twenty-
fourth week of iotra-uterine life usually breathes feebly, and dies in the
course of a few hours, apparently from an inability to acc-ommfxlatc itself
to conditions for which it is not prepared. At this stage of development
it may still have fine hair (lanugfj) over the whole of its brxly, but it is
often the caj^ that this hair, commonly Ibund from the sixteentli to the
twentieth wt*ek, has disappeared. At thi.s age it still has very little deixusi-
tion of iat in the subcutaneous t^elhilar tissue, and it has a decidetlly emaci-
ati-d ap[)earance. In other resi>ec*t^, except it8 size, it does not diiler very
much in its appearance from the foetus of stmie weeks.^ later development.
Its eyelids have separated, though it is so feeble that, as a rule, it cannot
open and shut them.
The estimatii>n of the length of the foetiis is difficult to make, and, on
the whole, uusatisi'actory and inexact. These measurements, in all proba-
bility, differ very much when made by ditreroiit iuA'cstigators, owing, as
Mi not has p<:>intetl cmt, to the many changes in the curvattire of the longi-
tudinal axis of the human embryo, which make it impracticable to employ
any f>ne system of measurement in ol>tainiug c^nnparable rt^sults ihr all ages,
Hecker\s figures, however, ai'e prohably as reliable a^s any we know of.
According to this author, at about the t^-entA^- fourth week the ftetus meas-
ures 28 to 34 cm. (11 J to 13| inches). Its weight, accxjrding to Lusk, is
about 690 grammes (23 ounces).
TWENTY-EIGHT W^EEKS,— By the time the foetus has reached the
twenty-eighth to the tw^enty-ninth week of intra-uterinc existence its con-
dition, so far as its development is fxincernixl, is such that there is no neces-
sary contra-indieation to its living if it hap|M»us to lie bom at this time.
It has been stated that an infant liorii pivmaturely at tlie twenty-eighth
week is more likely to live tJian one which is \mrn at the thirty-second wt^ek
of intra-uterine life, and that this has been proved l>y j^tatlstics. If true,
the reason for tliis, I believe, is l?ecause much greater care is taken of the
former than of the latter. It is reasonable to believe that an earlier stage
19
290 PEDIATRICS.
of iutra-utoriiic development is less likely tx) insure oontin nance of life tiler
premature birth than a later stage, provided the same precautaons are taken
in each ease.
Keeker's and Liisk's figures, in a general way, state that when the fcEtOB
is born at alxnit the tweuty-i^ighth to the twenty-ninth week it measures frmn
85 to 88 om. (al)out 13| to 15 inehes) and weighs about 1170 grammes
(39 ounecs). Tlie skin is still wrinkled, is of a dull red oolor, is covered
with veniix ea«^>sa, and there is very little deposition of subcutaneous &l
The infant can move its liml)s slightly, cries feebly, and often dies in a few
hours or days. Yet it is tliis class of prematurely bom infants whose lives
I ex]XK*t t^) see preserved in tlic future, when all the precautions which 1
am about to descTibe against external and dangerous influences have been
taken and improved ap])aratus has been employed.
THIRTY-TWO WEEKS. — Again, using Becker's and Liusk's figures
for the thirty-second, thirty-sixth, and thirty-eighth weeks, at about the
thirty-second week of intra-uterine life the foetus measures from 39 to 41
cm. (about 15^ to 16| inches) and w*eighs about 1560 grammes (52 ounces).
The hair of the head by this time has increased in thickness, and the lanugo,
which in many erases is pronounced from the twenty-eighth to the thirty-
second week, has either begim to disappear or has entirely disappeared from
the face. The nails, which between the twenty-eighth and thirty-second
weeks are often not well developed, now present a normal appearance, though
they frequently do not quite reach the tips of the fingers. At this age,
also, in boys, it is oftt»n ix)ssible to feel the testicle in the scrotuin. There is
usually, also, at this age, in a healthy fcctus, considerable deposition of sub-
cutaneous fat, and the senile asixx^t of tlie earlier periods of intra-uterine life
is miu'li le.ss<Miod.
THIRTY-SIX WEEKS.— At about the thirty-sixth week the length
of the fd'tus is from 42 to 44 em. (about 16f to 17J inches) and its wdght
is alK)ut 1 920 graninies (64 ounces). The lanugo has usually at this period
disap]>oare<l, and the infant, although less energetic than at ftill term, is
d('<'i<l('<lly stronjrer than hi the i)revious periods which I have mentioned.
It skM'{)s a ^reat doal, and is still in a condition to die easily unless carefiilly
lookcsl al'tcr.
THIRTY-EIGHT WEEKS.— At about the thirty-eighth week of intn-
utorine liir the infant measures alnnit 45 to 47 cm. (about 17|f to 18} inches)
and wci^rlis alxmt 2310 jj:raninies (77 ounces).
WEIGHT. — It is ini]K)rtant to ivnienilxT that the weight of premature
infants of the same ajr<' varies at birth, just as we have seen that it does in
the casc! of infants horn at term.
Ill treating these eases, obsen-anec* of their weight is of the greatest
importance, and until we have ohtain(Hl a regular progressive daily increase
in their weight we are never sure that they are thriving sufficiently to live.
The daily gain whieh the premature infant should make has not yet been
determined, but it is much less than Ls ex|)eeted when. an infant is bora at
PREMATURE INFANTS.
291
full term, and may be stated to l>e about 10 to 20 grammes {J to J oiinoe).
Any decided loss in weight, such as 30 to 40 grammes (1 to IJ ounces),
l>eyond what would occur from natural causes, should make us look upon
the iofant as being in a critical condition and impress iif>on us the Impor-
tance of taking active measures to prevent further tos,s. This loss in weight
must, as it is relatively so small, be carefully adjusted to the loss ^liich
naturally occurs from the ftecal discharges. Thus, the total anioimt of loss
in weight from the ftecal discharges may amount in these premature infants
to from 30 to 60 granmaes (1 to 2 ounces) for each fiec*al discharge, and this
may entail a considerable loss of the infant's weight in the t^^eoty-four
hours beyond that occasioned by defective nutrition.
I have here to show you an infant (Case 102) prematurely bora at about
the twenty-eighth week of intra-uterine life.
Case 102.
InTKDt prematura ftt leventh mcmtU.
Binh-weiKht^ 1"-^ gtmnune§ ; pretenl weight, 1540
a«e, ID days.
KTUUDifii; fireieiit
lt« weight at birth waa 1740 grammes (about 8| pounds). It U now ten days old and
boa JoBt about 240 E^ramtiips (about } pound). You see that it is in a very fiomnolent con-
ditifUi^ that it baa very little hair on lU bend, and very little subcutaneous fiit. You will
also notice the penile expression of its face, that there is no appeurunce of lanugo^ and that
the nfdU are well formed. The small size of the infant will be «till more appreciated if you
compare it with the hand of the nurse » which, for comparison , u placed bedde it.
There have been so few obser\^ations recT»rded of the development of the
variouB [Ku-tri nf the fcetns in the later ninntlLs of intm-uterine lite that I
am not pivparcil to deserilx* Bystematieally the ilevelopnient of the prema-
ture infant m I have ah'eady done that of the infant at term (Lecture III.,
page 54). There are, however, some facts which I have obser^^ed and others
which have Wu retH)rded.
HEAD, THORAX, AND ABDOMEN.— Looking at this infant (Case
102) critically, we uotiee that all thot^' anatomieal conditions which I have
empha^i^.e*! in my dej^^tTiption of the infant at term na Imug esi>ei^iaUy
prominent ai'e still more marked in the premature infant. Thus, you will
notice how lai*ge the head is in comparison with the thorax, and how very
large, in prr>portion, is the aljdomen. The alxlomen is in almost every case
much distended in premature infants, owing to the large pRuxjrtionate size
of the liver. This distention of the abdomen lasts for many weeks, and
292
PEDIATRICB.
••»»
even moudis^ and its gradual return t*i the normal size and appearance
m one of tlie signs that tlie infiint is dcjing well and is gradually acquiring
tJie normal auatoniical developimait
Pio, 71. of the infant bom at term-
8KEN* — The various changes in
the e<»lor of the skin, which I have
aheady deaeribed as represented bv
ervthema neonatorum and icteju*
ntHmatorum» I have notic€?d to ooair
ill thr pnematui-e iiifatit as they d«» to
tbr infant at tenn.
SWEAT - QTiANDS, — I liaxe
told you that the fiuictioti of the
sweat-gland.'* is, ai; a rule, not Je-
veloped at birth, and that we do »Jt
ex[>ect the infant in the carlr wwb
of life to |)erspire* I have also told
you that there h a great \^ariatioD a£
to the time of the development of the function of the sweat-glands. In ao
Fig. 72.
Tmclngn of fc£taL feet (nutiiral itie), seven moiitlii
old.
internal m-.h. PuniaJly <il**e<'ted UKtalai**>iilialaiigeal Juini of f^m&t u^ m kIuuIow. lufctlor c*Ux 'f
stapliokl shows Rfi ii Hhnded line,
infiiiit premature at seven iiimI nue-half mtmtlis I have noticed fre<
ration take plac^ after it had l>eeu born one wet^k.
PREMATURE INFANTS.
293
^
PEET. — I have already told yoii how few obsen^ations have been made
on tlie developmeot of the various parts of the foetus in the later months of
intra-oterine life, and I think all facts determined at this period of existence
should be recorded, I therefore con.^ider Doners oUservatioiis on the instep
of a seven months' foetiis (Case 103) born alive to l>c of value in eonneetion
with what I have already j^aid about the feet of infants btjm at term (Lec-
ture IL, p, 50)* These tracings (Fig, 71) represent this premature intaut^s
feet, and you see how aLlmimbly the presence of the instep is showUp
The infiiiit died a few hours after birth, and I have hem to show you (Fig« 72) it« feet
and lower legs?* The skin of the right leg h bitdl}' wrinklwl by the aleohol in which it waji
preserved. It looks Btrikinglj like the foint as it appears in adults, and its arch atands out
plain! Jt unmasked by any pads of fat. The k^ft foot has been dissecU^ down to the lit^a-
nient^. The arch made by the os ealcis* ciil>oid, and fifth raetittarsal bones represents the
lower edge of the cut On the inner l>order uf the foot the metatarso-phulangeal joint of
the grent toe 18 seen partially directed. Behind thiji the enlargement at th^^ tarso-nirtatareal
joint forms a considerable bulging. Behind aiid above the latter the interitkr t'dfje of the
scaphoid shows as a ehaded line.
Fnim tliest* spetiiiieii8 and from the traeings we see that the f«x>t at
seven niooths ehjR'ly apj»n)aches in external ap|>earau(i38 the well-develoj>ed
foot of the adult, and that when the infant wa^ 9upj^)orted with its feet on
smoked pa|MT it k'ft an excellent im|)ression. The dissection also shows a
remarkably well eoustnieted bony framework,
GASTRIC CAPACITT.— As the question of the proper amount of
food to be given to a premature infant is of the utmost importance, it is
well to know aljont what the avera^ ^stric capaeity of the fretus is during
the kter mouths of iutra-uterine life. No ^Ties of complete and reliable
observations on this (xant have been made, that I know ot* and the rules by
whif^h we ai'e guided nuist for tlie pi-esent !x* very general ones. The less
tlie weight of the infuut, tlie less, in many eases, is the gastric capacity, I
have here to show you some foetal stomachs.
The first stomach (Fig. 73) h that of u frt'tus riWut four and one-half months old, and
ia intereiting merely as sbowinir the relatively udvauoed development of the leaser and
Fio.
Fio. 73.
Cfr/)^
vtmi ^Cucouob (uAtuml
e), fiiiir and one-half
InonthB old.
FcctAl fltoDuieh (iiamral Mm), leTen and one-half rooDChi
Qld« Weight of fitiim, 1^20 ^nunmes. Gastric capaeity,
greater curvatures at thU age, as well ss the rapid gn^wth which take* place between the
fourtli and the seventh month.
294
PEDIATRICS.
The next stotnaoh {Fig, 74» p. 298) waa taken from ftn Iii£mt bom preouitiiTelj (
aT»out the tweiUy-ninth tcj iho thirtieth week. It U of a mther peculiar ebape^
epnidin^ t<t that which I havK* described to you in ii previous lecture (Lecture IV.,
2i*, p 89). Tho wiOght of this ra>tari wiw 1920 grammes (about 4 pouncU). lu gaeltie
oaptiojly wa* 18c,e. (about 4^ dmcbm*).
Thw next itomach (Fig. 76) was tnkeD from a fa>tua at about the tbirty-eecond wpfk,
which died in farty-flve minutes frum the time of its birth. Tbe gastric capiudtj vai
c.c (5J drachms). The weight of thw inlkiit waa 1230 gratmnes (2 pounds 9 ounce*).
FcBtal itoomch (naeuml aUie}, eight months old. Weight of fbetuB, 1230 gmmmea. Oastiic caiiaclty. S i
The next Btomach (Fig. 76) was taken from a foetus bom at about the thirty-i
week of intra-uteriuti life, and weighing 1440 gramme* (about d poundB). lu ga&uk
capacity was 8 c.c. (about 2 drachms).
Fig. 76,
floatal itoiEtach (natural slae), eight moathj old. Wei^t of fiftua, 1440 KrammoL OmmiTie ^mpmdtf^ % c
INTESTINAL CONTENTS*— The moraainm in premature mi
presents the game appearance as is seen in miants at term. When the fo
is pmperly regulated, the fecial discharges assume the consistency and
eolur which are seen in thase of infants who have l>een bi>rn at term. Thii
color in its iieual varieties Ls well represented in this [>late (Plate 111.^ 6^
7, 8, 9, facing p. 112). "' J
AMTLOLYTIG FUNCTION,— The amyloMie function of the mfanr
at term is so slightly develoj>ed that we may safely Eussume that it should
not be depended upon for the digestion of starch in the premature iu&at
under any circumstanoes.
PBEMATURE rSFANTS.
295
I
SUOAB, — Altliough we must assume that tlie fimction of absorbing
sugar is not developed to the sanie extent in the premature iiilant as iii the
infant at term, yet» in all probability-, it is more highly di'veloiMKl than the
otlieT functions of digestion. Sugar is needed to keep op the animal heat
of the premature infant, which is so very much more readily lesacnwl than
in the infant at term. Sugar^ therefore, is an important element in tlie
premature infant's food, but should be given at tirst in a much lower
percentage tlian later, when the eriuilibrium of the gajstm-enteric tract has
been aequirefl.
PAT AND PEOTBID DiaBSTION.— The function of digesting fat
and proteids is in a much more undevelo|>ed w>nditiou in the premature
infant than in the iniant born at term, and should, therefore, not Ik? dc«
pcodcd u|>«>u to the same degree as can safely l>e done in arranging the fixxl
for the older iulaut. Much smaller percentages of these elcmcnt^^ should
be given to the premature infant than to the infant at term, both for pur-
poses of digestion mid of absorption, for, in all probability, the |x»wer of
absorption of the gastro-entcric tnict in premature iulanti^ in in a very im-
develojMx! condition.
KIDNEY. — We should ex(>ect, from the lack of development of the
kidney in premature' infants, to find a considerable deposit of uric acid^ such
as I have descrilxtl as a[>|x^ariug in the early days of life in infants at term
(Lecture IV., page 111, Plate IIL, 1). This is, in fact, the case, and the
appearance of uric acid on the napkins of premature infants is, therefore,
not necessarily to he looked uihiu m denoting an abnormal ojudition. It
should, however, be carefiilly watched, for where it becomes excessive it is
ail indieati*_»n that the infant's food has not l^een proj>erly adjusted to its
digestive lXl^vel*s and tliat the intant may s*>«>n l>egin to fail.
CIROIJLATION. — The heart in premature infants has not yet arrived
at the complete stage of development nee<led to render it a relial>le central
force wliich can fulfil the demands that will l>e made on it in the exttTnal
world to sustain the ec^uilibrium of the cireulation. Therefore as little
work as is possible should lie thrown uj>on tlie heaii, and the intant
should be kept quiet, and not be carried alxuit, as is customary ivith
infants born at term.
In a number of cases which I have carefully examined I have failed
to detect a cardiac murmur, wldch leads me to think that the f(»ramen
ovale closes s<w>n after birth in the same manner as it df>es in the infant
at term.
ANTMATi HEAT, — The animal heat of the premature infant is much
more easily re^chR-etl, and is even more inii>ortant to its vitality, than it is in
the infant at terra. Following the rule that the smaller the size of the
human Ixung the greater proi)ortionately is the entire surfatx^, and, therefore,
the gi"eater the opportunity for lowering its tem|x^niture, an atmosphere
which is suitable for the infant at term is too cold for the prematiu^
infant.
296 PEDIATRICS.
Prc»niature infants shonld be thoroughly protected from changes of tem-
perature of the atm<j8phere in which they live, and this temperature sbuuld
lie raised to a jxjint which will corresiwnd in some d^ree to that of intrir
uterine life.
AIR. — Just as a necessity exists for the premature infant to live ibr
some wwks in an atmosphere where the air approaches in its temperature
the warmth which exists in intra-uterine life, so is it almost to the same
degree inqiortant that the air which it breathes should be free from dust and
micro-orfranisms. The lung Is in a very undeveloped condition, and although
it may h'. sufficiently develoixd to carry on the function required of it in
extni-utcrine life, yet all its tissues are exceedingly sensitive, as are those of
the nose and naso-phar^-nx through which the air must be introduced to the
liuigs. The air of the ordinar}' room where infants live when they are born
n(H*essarily contains many impurities, botli irritating and morbid. This
irritation of the respiratory ])assages may of itself be sufficient to reduce the
vitality of the infant Iwyond the limits of life.
TOUCH. — PrtMuature infants have to be carefully handled, as they die
easily fn»m influences which would have little or no effect upon the infiut
lx>rn at term. In intra-uterine life they are floating in a fluid which prao-
tically prevents what in the external world corresponds to handling. While
they arc^ living in the anniiotic fluid they are almost completely protected
from the influence <»f touch, which necessarily affects them as soon as ther
are lM)rn. Touch, then, is an ini[M)rtant element, to be as much as possible
avoided when tlu; premature infant is bom, as it has a decided tendency to
lower the vitality.
An instance of tlie caiv whicli is needcKl to preserve the lives of the*
infants canK' to my notice in tlie casc^ of an infant (Case 104) premature at
eight niontlis wliich wiis in my service at the City Hospital.
Diiriiii: till* first wcok <»r ton days of it;* lift* this infant was in chai^ge of an unusiuUy
cart-ful and <xjMri.ii(<-d iiurn", who appn?(.iatwl tin* risk of handling it. It was gainiogin
wriirlit and wa< doinir xv.-H : but uiif(»rtunat<'ly another nurse was substituted who did not
uiidciNtaiid lid- cla>.< of infants ^^o \v«*ll. Sht* allowed the patients in the ward to handle
tJH- infant, tr» talk to it, and to .-iirroiind it with various i>imUar deleterious influences. Fw
ft fpw day> it lost in wi.'i;cl»t. and thrn it >uddi-idy ditxl. There is no doubt that it wwnn-
ul»N' to withstand tlio amount of handlini; which would have done no harm to an older
infant.
LIGHT. — Tlic premature infant shonM live in comparative darkness
(lurino: the early weeks of its life. Li^lit is not reqnisite fop the develop-
ment of the infant in the earlier stages of its existence, and too much light
will ini])air its vitality. It is im|>ortant to adapt the light to the stage
of its ilevelo])ment, and gradually to aeenst4»m it to more light as it grows
older.
SOUND. — In the normal intra-uterine conditions the iniaiit is veiy
slightly exposcnl to sound, and all its funetions are adapted to silence rather
than to the many noises which unavoidably surround it in the extonai
PREifATURE IXPANT8.
297
Iworld. We should tlierefore arniogie that from the minute it is born it is
[protected from noise.
PULSE, TBMPEBATUBE, AND BBSPrRATION,— I have not any
Ivery exat*t reectixlr^ ui* the average pulse, teii]|>erature, antl rt*spiratiou found
premature iniaot*?. The^e infants seem tn jji'ej^^nt rather irregular tj^jea of
[temjx^niture aud pulse, as well as of respiration. They have to be ho eare-
I fully handk'd that observations as to these physit^al ^igns must be made witJi
[great eaiitiuu. The main jioiut in iTgard to these thrt^ eouditious of the
premature infant is that they are all represented by irregularity. The tem-
pemtHrc of tlie premature infant, when it has onee beguu to gain in weight
auil to thrive, m usually a little above the normal temper'atiii^^ of the infant
lat term. Before it has begun to gain in weight and when its vitality is
mueh depressed, the tempc^rature, as would natorally be exjjeeted, is rather
, below tlie normal standai'd ; aud we should watch this sign with the greatest
leolieitude, as a decided and continuous depression m often indieative of
Ideath.
The puke is dlffieidt to take in the pi-emature infant, aud, as a rule, is
[6<:)mewhat quicker than in tlie iufaut at term*
The respinttionrS^ irregular in the infant at term, are still more irregular
[in the premature infant, at times Ijeing rapid tor a few seconds, aud then
I beet^ming almost imjieret^ptible ibr some uiuiutes.
This infant which 1 have had brought here to show you (Case 105) was prematurely
l1>om at the thirty-second week, and illustrates the fact thi*t a prematurt! infant, if it«
[weight is not extremely small and if its devt^loprn^nt is somewhat alxjve the average ex-
pected for iU age, can live und thrive without all the precautions being taken for its
preservation which I have alr*.-udy ^spoken (jf. Thtrse cases, however^ merely emphasize the
[ fact that if we are guided by them in *>ur treatment of premature infants in general^ we
lihall make many fatal mistake* niid far fewer lives will l:>e saved.
This infant wpijLjh*^! at birth 2954 grammes (nbnut 6^ pounds). This would indicate
j that its chance-^ for living were go<>d, the otht^r conditions of iu development being normal,
I '§£ you will undersUind by referring to this table (Table 2, p. 49) of the relation of weight
[to vitality. You see that the weight of this infant is between 2500 and 3000 grammes,
showing that the vitality haa risen above what is designnted a* low ; in fact, it is within 49
grammes (about I J ounces*) of the SOOO grammes which repre^ient a fair vitality. The in-
, fnnt wtus kf'pt in a room where the temperature woa 23.8^ C, (75** F,), The air which wa»
J;^ftruiind it* bc<l, which was in a baj^ket, wa* h^^ated to about 29.4° C. (85° F.). The infant
I wmpped in frcah absctrbent cotton. During the tirst twenty-four hour» one tea«poonfu!
* fbod was given every hour. After that time it wua fed every hour during the day, and
[©very two hours during the night. On the third day the mother had a gufflcient supply of
«l-milk^ which flowetJ easily. The infant was therefore fed with the breast-milk from
%^^oon for a week, wan then put directly to the breajtt, and continued to nurse unUl the
nd of the third week, when, ub its mother's udlk failetK it again had to be placed up*>n a
Jcarofuliy regulated *ubpiitute fc^fd.
There is nothing eUe especially interesting to record either in \U history or in it6
l^hyFieal ccmdition, except that it had a small umbilical hernia, which did not cause any
[diBComfort, and which clewed at the end «tf the third month.
With thi^ attcntitm to \U warmth tind Iwd it tbr<.ive as any infant at term would have
done, and has since been well and &trr>ng.
Here u a table (Table 81) which represents its weight for jiixty-tme days^ and here
I the reooni (Chart 6J of its tempemturi' and puUe during the tlrst three weeks of its life«
298
PEDIATRICS.
TABLE 81.
\Vrifj/,i for Hixty-Onr Days of Infant Premature at Thirty^Two Weeks.
I>ay f»f Life.
Birth-wt'ight
Thinl . ^. .
Sixth . . .
Ninth . . .
Thirtri'ijth .
Sixti'«'iith .
Twriitit'th .
Tw«'iity-third
Tw<*nty-jj«.*venth
Thirtieth .
Thirty-third
Thirty-Htvfiith
Forty-tirst .
Forty-f<»urth
FortyH'iirhth
Fifty-tiivt .
Fifty-fifth .
Fifty-riirhth
Sixty-first .
Tummtfi. (I\)unds. Oz.)
2i«i4
1>724
L>H14
L>'.«)4
3178
3888
3.V.I8
381*2
4110
423<i
4476
4r,()()
4840
4U00
4094
r>()84
r>L>34
.'>324
5384
( <i
( 6
(«
( 7
( 7
( 7
(8
( 0
( 9
( 0
(10
(10
(10
(11
(11
(11
(11
(11
8)
0)
8)
8)
0)
7)
l-i)
«)
1)
'">)
13)
2)
10)
12)
0)
8)
8)
11)
13)
Bemarks.
Cow's milk, with spoon.
Mother's milk, with epoon.
(( i( (t a
Mother's milk direct from breast
Modified milk.
CHART
V
•
Dags of Life
F
m"
95*
l»
140
90
1
ri
3
n
5
n
T1
,.
10
II
12
13
14
ra
IS
l;
rr«i
^
20
2\
c
ij 1*
r ■
> •
10.3*
•00*
so 3^
7
L
/
'^
/
1^ i
r\
/
/
3rr"
J? a*
/
/
\
^
f
i
^
/
\^
u^
i/
/
I.
■ - ^
-
-
V.
--
"
ifj
t?
r
1^
J4.®*
s
^
A
'
i/
v^
\,
A
J^
A
/\
^^
/
1/^
-
— 1
\
^
/
S/
^
^
f 1
r>
/
V
A
^
N
^
^
^
=
=
=
=
--
^
^
=
_
All the |M>ssil)le causes which may reduce the premature infant's vital
must he th(>r()U<rhly undcrstcxKl and <>bviate<l. You must also appred
tliat a faihire t(> recognize and ohviate one of these causes may deftat
benefit whicli may aris(» from atten(lin<j: to all the others.
The premature infant should, so lar as is i>ossible, be restored to
PREMATUEE INFANTS*
299
ondidoD that it has been forced out of, — ^immely, a condition of darkness,
ilenoe, and warmth.
You see, therefore, that there are a great many points to he considered
rhen you undertake to tR^at intellii^ently an infant prematurely Ixjrn, and
t is this treatment which I shall eudeavor to explain to you.
AMOUNT OF FOOD AT EACH FEEDING.— I have already stated
hat the amount of ftxxl to be given at eueli Reeding 13 very imiwrtaut. By
referring to the weights and gastric capacities of the premature infants
llready described (Figs. 74, 75, 76, page 294), you will see how^ misleading
the weight of the infant if we take it as an exact, iiidex of the gastric
ai>acity. We must, however, take the weight into account, as, from even
tie very imperfect data at our command, the weight of premature infimts
appears to bear a dwidtxl relation to their gastric cajmcity. We should
It least be more inclined to increase rapidly the initial amount of fo<xl
fiven in the case of an infant of large weight than in that of a small onet
tt is better to begin with too small rather than t<30 large a quantity. By
matching carefully for signs of hunger, a desire which the infant expi-esses
jy feeble but continuous cries, which stop when the food is given to it,
ire can gradually increase the amount until it seems to want it at regular
iter\'als, is satisfied, and sl^ps quietly during die intervals of feeding;
By referring to these ftetal stomac*hs (Figs. 73, 74, 75, 76, pages 293,
294), you will understand that it is safer t(j begin witli 4 or 0 c.c, (about 1
imrhni) and gradually to increase:' the amount up t4> a jM>int where our very
imiKHicct knowledge on this subject, derivt^l paitly from the weight of tlie
afant, makes us believe that the stomach is full, than to begin at ouoe with
the largiT amount. It is absolutely necessary that we should avoid undue
stention of the stomach, jis this may prove tataL
INTEKVALS OF FEEDrNQ-. — The premature infant's stomach is
small, aud is, in all pmbability, emptietl quickly, and, as ffiod is necessary
[for keeping up the animal heat i-cfpiinxl for the maiotenance of its life, the
itervals of teetliug should lie much shorter than those required for the
ifant at term. In the early days, and in fact weeks, of life, I have found
at it is better to feed the prematuix^ infant regularly everj^ hour. Four or
[five weeks after birth, if it is gjiiuing in weight and is digesting well, these
[intcrv^als can be so lengthened that by the time it arrives at term we can
f usually make the feeding intervals one and a quarter to one and a half
ibours, and a few weeks later t\vo hours.
COMPOSITION OF FOOD.— The careful adjustment of the pre-
[imiture infant's food to its digestive organs is of even greater importance
in the case of the infant at term. There is no doubt tliat if we con-
the hypersensitive condition aud the iindevelo|)ed state of tlie digestive
lorgans prior to birth, the most exact adjustment of the food to these
f digestive organs is absolutely necessary. This adjustment is best accom-
tplished by means of carefully prepared prescriptions at the Milk-Lalxjratory.
Through this instrument of precision three important advantages are gained :
300 PEDIATRICS.
(1) wc insure a clean food free from micro-organisms ; (2) we can obtain kv
and properly balanced {x^rcentages of the constituents of the milk ; (3) «i
have, at any time, the iK)wer of exactly varying, to within a fraction of on^
half of one i)er cent., the percentages of the three most important elemom
of the milk, — namely, the fat, the sugar, and the proteids. In addition to
thet^c latter two advantages })0S8essed by the substitute over the maienal
method of feeding are others of almost equal importanoe. One adN-antageK
the al)sencc of variation in the substitute food arising from emotional cum
and another is that the infant need not be taken fix>in the incubator to b
fed.
This prescription (Prescription 30) is the one which I should b^m wid
ui feeding an infant premature from the twenty-eighth to the thirtr-axtl
week :
Prescription 80.
R Fat 1.00
Sujcar 8U)0
Pn»toid8 0.50
24 meald, oiich 4 c.c. (1 drachm).
Hfat to 760 C. (107O F.).
Reaction faintly alkaline.
If the infant is over twenty-nine weeks, or if it is unnsually laigeii;
its age, and es}>ecially if it is unsatisfied, it is well in a few days to ^Hi";
the prescription to this one (Prescription 31) :
Prescription 81.
B Fat 1.50
^"^".i^'-'r 4.00
^*''"t*»<l=' 0.60
24 im-aN, oaoh S c.c. (2 dniolinis).
If tlio infant is over thirty-two weeks, vary the prescription in a &
days, under the same conditions as in Pr(»scription 31, to-^
Pkkscription 82.
B ^'"t 1.60
'^"-^^^ 6.00
i''"tei<l.< 0^75
24 im-als, each 12 c.c. ('A jlniohins).
If the infant is over thirty-six weeks, the milk should, after fortj-eig
hours, 1m; increased and strcuirthencd to —
Prkscrii'Tion 33.
» ^■''' 2.00
f ■«'"• 6.M
rri»loi«]s lUQ
24 riR'alj?, each 10 c.c. (4 drachms).
PREMATURE IKFANT8.
SOI
.The iDfantj however, under all circumstances, must be watched critically,
any or all of the percentages of the elements or amounts of the ibod
or decreased acerjnling to the individual indit^atioiii?.
When the iufiint Is biro at the thirty -eighth or thiity-ninth week its
evelopraent is usually m nmr that of the infant at term that the incubator
If ill not be neetled, and ttie food can \ye given in alj<nit the proportions
rhieh woukl h** adapted to the early days of the infant at term (Prescription
_3, page 181).
WEIGHING. — A knowledge of the weight of the infant is exceedingly
i|^K)rtant in the nuihaj anient of itg feeding, and changi^ in the decree of
vitaHty take )>l:ir. >o rapidly that the daily mcroase or deen^ase in its
reight becx>me9 the principal index by which we are guided in changing the
The handlings however, which is necessary to obtain the daily weight is
l^ften a serious obstacle to the maintenance of its vitality. We should,
erefore, endeavor to obtain the weight without reducing the vitality. The
for doing this I shall di^scril^e later.
CLEANSING AND CLOTHING. — A premature infant should not
bathtiJ beyond what is nett'ssary for simple cleanliness.
It should not l)e dresded^ but sliould be wrapped in absorbent cotton.
The cotton stHin cleanses it thor^mghly, and, if ehange<l twice daih% or
tener if necessary, supplies the place of Ixjth ckjthes and bath. As a rule,
no oil or ointment shoukl be applied to its skin.
INOUBATOBS. — I have already told you, when speaking of milk-
aboratories, that it is better not to spare expense in obtaining the very best
for preserving life which comes within our jxiwer. If y«iu appreciate
1 great principle, which lies at the P3ot of all successful methods of pre-
t^ing the lives of premature iniants, you will understand that even the
lUest details which I have s|ioken of, and whieh 1 shall again mention
at length, ai'e not to he coosiilcrtxl trivial or l»eneatli your earnest and
weful attention. The prematuix* infant*s life is m difficult to pR^erve
&t we should make use of every device which our ingenuity can suggest*
''rom the very mt»meut it enters tlie world its viability Is likely to \ye
jniught to an end, and every minute is of important*!' in our endeavors
combat this tendency. We should, thereibre, be re^y to protect it at
'once from the advei'se iufluenct^ which surn)und it. We should have
decided views of how to trt^at this early ijeritxl of life, and alst» have
the means whieh we think should be best employed ready to be supplied
at once.
In the treatment of prc^mature infants only one of the principal methods
of maintaining their viability usually receives much attention. It is c<Hn-
monly supjHKsed tliat if the atmosphen:' whieh suri'ounds the infant is kept
at a suflieiently high temjK'ratui'e all that is requisite has been done for its
luafety. This until very recently has l>een accomplished by placing the
infant in a room where the temi^erature is as high as the nurse in charge
trvi
loro ;
302 PEDIATRIOB.
of it IS able to endure. This procedure is neoessarily a very imoomfortatle
one for the nurse, and at times renders it ahnoet impoaaible for her to osr
her mind intelligently. It also requires a much more fieqaent change uf
nurses than would be the ciise if the atmosphere of the nursery were oookr.
In addition to this means of preventing undue loss of heat^ the infimt b
wTappal in cotton-wool and placed in a basket lined "with hot-water bottk
or it is plai'cil at once in an apparatus which is called an incubator. TIkx
incubators have been used for many years in diffezent parts of the vorid.
notiibly in Paris. They are of diiferent forms, which I need not de^lr
here, as there is nothing es])ecially important to reoommend abont then
when we comi)are them with the latest form of incubator, which I shaD
pn^ntly describe to you (Fig. 80, page 306). The purpose of them all k
the same, — namely, to keep the infant warm. Some of tfaem are made of
tin, with double walls, so that hot water can be continually kept in them,
and thus sufficient warmth be applied to the infimt. Others are made<ii
w(^k1, and kept warm by means of hot-water bottles introduced into dm
from below. None of tliem combines in the best way the many requisitis
necessary to preserve the premature infant's life.
The name incubator has Ixx^n applied to these various devices for keep-
ing up the animal heat of the infant. It is a misnomer^ for incabadoo
means hatching, and, in the precise sense of the word, the premature iniiat
is already hatched and has been incubated. What we aooomplish bv ik
ap|)aratns is analogous to what is done to keep up the n^nimal heat and
})rt»serve the lives of young chickens after they are hatched, and the name
hroodrr would Ixj more applicable to machines devised for preserving tb
liv(?s of premature infants than the term incubator. The woid incubator is
however, so g^'nerdlly used to represent an apparatus intended to prcBerre
the ])remature infant's liie until it has attained the age of two hundred and
eighty days, that it will, in all probability, for the present be retained. The
true meaning, however, of what I am endeavoring to explain to yoais so
much iH'tter expressed by the word brooder^ meaning warmings and not
hatehinir, that I shall use it in s]K'aking of the latest apparatiiB whkii lias
been invent<Ml for the piiri>ose of human brooding.
Bef(>re speaking of the tn>iitment of pri'mature infants 'whcro evoy^
tail eaii Ih* earrie<l out in the most approved manner, I shall mention a frw
eases wliieli ilhistnite the ditien'ut [Hnnts to which I have jiufc nfand.
For instance, where it is ini|>ossible to obtain an incubator at onosfcrpR^
serving the premature inlimt's animal heat, it must be treated in tfaemr
whieli I have ah'eady referred to, by plachig it in a room where tibe
turt*. has Ixi-n raiseil to :]2.2° C. (90° F.).
I have hove n pictun* (Case 100. Fiir. 77, pfte:o 303) representing an infhnt prematiiR
at llio >«'vrnth month, and now lourlivii wrrks nld.
It ij- ill this ]m>k('t. t-nvrloju'd in f<ittt»n-w««.)l, and covered with blankefca. You «e
tliat thi* thoniiomL'tL-r is krpt in the ba:*ket bolide it, and the nune luw oontiniiallT ft)
watch it.
PREMATUBE INPAJfTS.
SOS
It wa« under the care of Br* Hantf of West Newton, witb wh« m I saw it in consul-
Btion. It wjis placed in the incubator wben it was fuyr weeks old. It was taken out of
Le incubator wht-n it wa^j twelve weeks old. At this time it had gained very little in
Flo.
Infant rfrenuitiire at twentf'eighth week. Birth-weight, 1200 nTnunmee. Pni^'nl agv. fourteen weeka.
ated In basket heated by bat-water bottlo. Temfiemuire of air In basket shuwn by thernxometer In*
dtioed between side or the basket and Uiu blankt^L The Infant was zemoved from the Lncubat'jr when
J twelT© weeks old.
|ht, was efnaciat<*d, puny, and feeble* Its abdomen was much distended^ and its skin
tied, dn% and yellowish in color.
SOTB is a picture (Fig, 78) of this infant taken when it was fourteen weeks old,
blcli shows the senile expression of the face so chiiracterietic of preraaturv infants at
lirtb, and later when they are nut thrivitig.
Fia 78.
-4
Inf;uit premalure at twenty-eight weeksL I'resent nice, fourtwti wwka.
Here is another picture (Fig. 79) of this infant, with its day none and its night nvas^
its basket, and the soal«s on which it was weighe<l daily.
304
PEDIATBIC8.
Tliii picture U inBtructive in making you appreciate bow small thi« intuit vii,iil,
well Bhown bj ccim paring the size of \U head with that of the nuraet' heada.
Fto.
hitmt litvuxnitin' Hi ivtvut>t-'i^ht ire«lca, Prewut use, ftNirteeo week&
The next iiifftiit (Cixse 107) which I fhall ^peak af was on© which was pn huuik-t'
'bom at about the thirty-third wc-i'k. It wa^ treated in a basket warmed with heaters, vd
in a nxnu whert^ the temperaturt^ was kept tnm\ 21*. 44* C* (86* F.) to 32/22^ C, (30* fj"
It was ei4rt:*fully nursed by a night riui>i« and u day nur^j.
It woiijjh^^d 24lK) g^nimnio* (iibuut 5 pounds 3 ouiilhss). It wna under the aiw<'f Br
Edward Keynuld.-, with whom I saw it in amjiultation. Its food was canc(\illy regulided
at th'' Milk-LidHirutorVt iind the tirst prescription which was written for it, and wh^
provixi to he adapted t^i its dige^^tiun during the fir&t week or ten day«, was this oxt» (?li>
aeription 84) :
PBEftCRlPTION 84.
U Flit .....,.., T.W
f^^ugnr ... 8,00
Frotcidfl . 1,00
Lime water , 5.^)^
The mixture to be heated for twenty rniuutes at (i».3b" V. (15^° F ),
From my hiter oxpenenee with these cases, I .4muhl bt'ii^in with the peit^'nta^ of I
teidB 0.5CI, as I have h1 nearly dH.")cril>*^d in this pre^criptien (Prescription SO, p, 3410)- lol
early days of thif? infant *& life oxygt*n hud to he adniinistercd to it for two or thr^^ mia
every huur. It wiit^ fed evcrj' ht>ur, and received six drr^ps of brnndv w^ilh eueh f«
At my first exiimination, which wii>i made when it was six hours old, u dt^tinrl can
murmur was heard tit the bii.*eof the sternum, and there wer«? a few fine mokt nkl<* tJir
out both luni;«. The murnmr and the rftlee disappeared in the course of a week, and]
infant, after lodng 135 gramme's (uhout 4) ounces) in the first three days, Im^^u to i
email gairi» in weighty and when it wai* Acveu weeks old it weighed 2730 j^piimme$ (alj
6 poundrt 11 ouncci*), wuk plump, had a healthy colnr^ and seemed very well. It 1
perapire when it was Beveri w^ecks old.
This case received the very cU^^L-st att* ntion, and was treated w^itb all tb^ dntaiU t»
safety which were possible to he attained without the uee of un incubatcirT but n
consider that it^ weight, 2490 grammes (about & pounds 3 ouncea), and tta aire
PREMATURE ENPAiffTS.
305
three weeksi were «uch aa to tnake the preservation of !t« life a much more Bimple matter
than that of the infant (Caee 106) whose picture 1 have jut^t shuwii you, and whose light
weight pointed towardj* no undeveloped and premature a cnnditiun that any omission in re-
gard to Uie closest detail of treatment would have heen likely to prove fataL
This infant had prvgree^ed so far in its general condition and development that at the
age of eight weeks it woa taken out of the cotton in which up t4J that time it bad been
wrapped and was dreesed. At thi^ time it was taking 56 c.c. (!} ounces) at each meal, and
was fed once in two hours.
The next case (Case 1D8) is that of an infant which was four weeks premature, and
which was, for a premature infant^ tolerably vigorous at birth. It was under the care of
Dr, Samuel Breck, with whom 1 suw it in consultation. It was not placed in an incubator.
Unfortunately, its nurse had no idea of the importance of pmtecting it from external influ-
ence*. It was fed on a carefully prepared food from the Milk-Laboratory, and began to
gain in weight, and in every way showed no evidence of \U vitality being interfered with j
but the nurse was possessed with the idea that it needed plenty of cold fresh air. The
window in the infant's room w^as left open one night wben the weather was quite cooL
Tht» following day it did not take its ffjod well, was somewhat cyanotic, and was found to
have lost almost 240 grammes (J pound). It waa then placed, as it should have l>een tn
the beginning, in a warm room, treated %vith the utmo«t care, and not handled mucb. None
of these measured, however, were suffieient to prevent a still further lessening of it** vitality'.
It never rallied frrjm the first blow which was struck at its vitality, and lost its life practi*
cally thrt»ugh the ignorjince of the nurse who was in charge of it.
A post-mortem examination showed nothing abnormal, except tliat the mesenteric
glands were somewhat enlarged.
The next case {Ca*;e 109) was that of an infant bom at about the twenty-fifth week of
intra-uterine life. Its weight was 1080 grammes (about 2\ pc^unda). There are a number
of intept'iiting points to be recorded in this case.
It was not stnuig enough to suck, and had to be fed with a spoon. Its mother's milk^
the amtlynis (Analysis 55) of which I have here to show you, at once caused such disturb-
ance that modified milk from the Laboratory had to be substituted.
Fat ......
ANALYSIS 66.
. , . . . 1.29
Sugar
Proteids , , . .
4,10
6.83
Ash ......
. . . . , 0.26
Total solids » . .
, 12.28
Water
S7.72
100.00
This is the prescription for the modiflefl milk which it digested well ;
Pbkscriftion B5.
Modified Milk.
B Fat ^ 1 00
Sugar . 3.00
Proteids 0,76
The infant's tempemtupe in the rectum was 36.7** C. (98*^ F.). It iecmcd to be doing
fairly well, but did not gain in weight, and on the fifth day of its life was unable to swal-
low. It was then fed by gavage.
It was treated with great care so fur as keeping it warm was concerned, but an incu-
bator could not be obtained for it, and it died when it wa» seven days old.
It is interesting in this cAse to notice that the meconium came as is usual in the infknt
lit term, and began to change its color on the third day, and that by the fifth day the fiecal
movmnento were yellow and well digested.
20
306
PEDIATRICS.
These purticulars wore pven to me Vjr Dr. Wood*, who wm in diarge of the c«ie. Id
death was evidently Out* to the InweHng nf it» rttAlity consequent upon it« age And li4!k of
eufficicnt d^veloprai'tit to withstand the mtiueDces atirroundiDg U in estim^uteriiie life.
I now wish you to examiue tlik incubator (Fig. 80), which was denr^
by Dr, Worcester, of Waltham, Maseacbusetts. It is far superior in its
mcH^hani.sm iind in its general utility to the other incubators which I haw
alreiuly referred to, except that ot* Tamier, which it closely resemblesL
It is practii^aliy a wotxlen l>ox, 76 cm. (2 J feet) long, 45.5 cm* (1 J fa
wide, and 70 etn, (2 J feet) high. This box, as you see, has a glass IM^
which ciiii be raised when necessjirvj but which m intendcxi to be kept clci^
aud to be used as a window tlmmgh which to observe the infaDt^ Two or
Flo. 80,
To left at Incubfttor Ih the oxygtiii tiartk. To left *if jincubalor nn the floor k the l&mp. At
end of liK'nhfltor ia an iintiriuiiiuU!!.
three holes at the end and at tii(^ bottom of the liox allow the entrants
air. A hole at the top and end of the btix^ fitteil witli an anemometer,!
serves as an exit for the air. The continuous motion of the anemometer
shows that the ventilation is being earrird nn pro]3erIy. At the bottom of ,
the lx)x is a metal! ie bHiiiler, A pipe fnim this Ixiiler h bn>ught through tlicj
end of the 1k>x, turns upward for a few inches, and then turns hack aodi
enters the box, where it connects again with the boiler. Outside of the eni \
PREMATURE INFANTS,
307
of the box there is a pipe by means of which the Ix^iler can be filled with
water. A stoi)-cock allows the water to run off from the boiler when it is
De<-fssary to empty it, or to regiilate tlie heat of the water by allowing the
cold water to flow out and warm w^ater to replace it. A lamp of any kind
plai'e<l under tlie arm of the pipe whieh c*3meH from tixe boiler keeps up and
regulates tlie warmth of the water in the boiler. I would here call attention
* to the fii(*t that when the source of heat is outside of the incubator there is a
i danger that the free flame may set tire to the nurse's dress.
Above the boiler is a shelf, on w^hich the infant's l^ed is placed, sufficient
i space being left between the ends of the bed and the box for a free eircnla-
tion of the e<jutained air.
A thermometer is attached to the water apparatus of the btuler, and
indicates the heat of the water.
A thermometer lh attac*hed to the lid of the box» and is intended to show
the temperature of the air in the box.
I have here a picture (Fig. 80) of an infant (Case 110, page 306) in
this iucubatfjr, prematurely born at about the thirtjeth week of iutra-
uterine liib.
I
The lid t>f the incubator is open, representing a time when the infant is to be fed. On
the left of the incubntor purt of tbe oxygen tank is shown. On a table bei^ide the incubator
ftre the metisiiring glftssee^ a glass tube with a cotton «; topper containing the infant's food^
which WHS prepared at the Milk-Laboratory, a pitcher of warm water to keep the ftxxJ warm,
amd the teaspoon with which the infant wa^ fed. In the bed beside the infant you will see
that there is another Lhemnimeter, which it was found necessary to use, us the thermometer
attached to the iid wa* subject U) such variation a in temperature thnmgh the gla^t*, accord-
ing to the variations of the temperature in tbe room, that it did not indicate exactly the
temperature of the air by which the infant was surrounded. In the treatment of this
infant in the incubator much difficulty arose in keeping the ventilation perfect, and at
times the air for hours had to be forced through the lur-box by fanning the air through tl^e
holes of entrance.
This infant waa taken care of in an unusually exact waj^ and with such intelligence
on the part of the nurses and parents that the detJiils of its life in the incubator become
of extrPTne value in our study of the treatment of this class of cases. I ahuU therefore
describe the details of its existence in the incubator from tbe time when it waa horn until
it was sutflciently developed to be safely taken care of in the ordinary way.
The infant and its mother were under the ciire of Dr. George Haven and Dr, W. L.
Riehardaon, with whom I saw it in consultation in the early hours of its life and by T^hom
it was placed in my charge. At birth its naik were fairly developed. Its face was not
especially wrinkled, but its body and limbs did not show mui^h evidence of subcutAneous
fat The lanugo was not present. Its weight was 2040 grammes (about 4} pounds). On
comparing this weight with the weights given in this table (Table 2, page 40) of the
relation of weight to vitality, you will see that it is representative of that of an infant
at term of very low vitality. The heart and lungs were normal. No cardiac souffle was
heard over the area of the foramen ovale. The cry was rather feeble. The infant was very
aomnolent.
I think jou will be able to understand the details of thla case most cleftrty if I arrange
them for you in the form of a table (Table 82),
The table records the details of the infant's life in the incubator during
a period of sixty-four days. The record will, I think, be of great use to
308 PEDIATRIOB.
any one who has charge of a premature infant in an incubator, as it illus-
trates exactly what emergencies are likely to arise and how they can be met
The infant, as is seen by referring to the oolumn of remarksy came
very near dying a numl)er of times, and unquestionably would have died
had it not been carefully managed, as, for example, by the administradon
of oxygen, by prompt changes in its food, by the r^ulation of the temper-
ature of the incubator, and by the constant attention of a day nurse and a
night nurse.
I have now in a general way told you the nudn &ctB which are known
about premature infants, and the results of my experienoe with this class of
cases. The last case (Case 110) which I have described as being treated in
Dr. Worcester's incubator was tlie one from which I learned how very in-
ad(M|uate are our usual methods of. treating premature infants. In the
direction of this case I received so much information as to the medianical
management of the many diiliculties which were continually presenting them-
selves in the daily care of the ap{)aratus from Mr. J. P. Putnam, that it
was at once impressed upon me that a domicile in which an infant might
have to live for several months should be devised and r^ulated as to its
ventilation and general practical usefulness even more carefully than the
houses in which adults live. This meant that such apparatus needed the
skilled attention of an ex{>ert in building and in ventilation. I therefore
lAncvil in Mr. Putiiam's hands the construction of what I prefer to call a
brooder. I am also indebted for many valuable suggestions as to the con-
struction and use of the bnx)der to Mr. G. E. Gordon, who has had con-
si(l(»nihlo exjKTience in jirt^serving the lives of premature calves.
Before insjxx'tin^ the bnxKler more closely I should like you to examine
this table (Table 8^^), in which I have condensed what I have alreadv told
you concerning the reij[uin»ments needed to preserve the lives of prematoie
infants.
TABLE 88.
Indications for conferring ihe Viability of Premature InfemiB,
I. Thfn> sbould U* a reefptaole which shaU guard the infant ftt>m the deleierioui
infliif?ncoj5 of extra-iit<Tine lif»».
II. Thi IV should he an appiiratus that can ho ohtained quickly and traiuported npidlT,
and whk'h thert^lnrt- should ht- kfpt at some central and convenient atatlon.
HI. Tiic place where the briKHier is kept should he ftee from the influence of any
disease.
IV. The hroodor should he bo constructed as to make it possible for it to be abidlatelj
cleansed and <li.sinfeeted each time after it has hecn used, hence it should be mmde of roeCiL
v. Th(f hroodor should, as soon as the infant is placed in it, be under the observBtioo
of tniined nurses nii^ht and day.
VI. The food for the infant should he regulated with the greatest pieeieioii with the
closest attention to minute details, and, if ]>oHsihle, at a milk-laboratory.
These are the principal nilt^ whieli should be attended to ^vdiere the
physicians of aiiv conunuinty wish to ])rovide the best means fbr-pRserviiiff
the lives of the prematiiix; infants in that commuiiity. The expense of nwh
PREMATURE IXFANTS.
300
ineaiis, while too great for any one mdi\adiial, is comparatively insignifi-
cant for a niunber. The brooder at present must necessarily be an expen-
sive mac'hioe, but if provision should be made for it m cvjmbmation with
such scientific facilities fur infant fewling jis I have ah'cady reconimendetl,
I believe that any commimity wonid find it of infinite benefit. I am also
sure that there would result saving of Hie for the people, and saving of
time and expense for the physicians, combined with the greatest satisfactioo
to both p<:H3[)le and physicians. Such a combination, in cities of a milk-
laboratory or in the countr>" of a Babcock milk-tester with a brooder kept
in one central station, I hope to see e^^tablished everywhere. One such
statii>n for dLstricts which might be ijicluded in a radius of ten or even of
twenty miles would be amply sufficient to accxjmplish very favorable results.
BROODEK. — You will now, I hojie, appreciate that it Is often quite
nec*'8sary tci provide not merely a ivoeptacle but an actual habibxtion for
premature infants during a pe-
ril kI of luonths. Such a habi- Fio. 81
tation^ which I preJcr to call a
brooder in order to I'cpresent it
by the name which explains it
rightly, I have hei*e to show
you (Fig. 81).
This apparatus has been
mafle to fulfil thec<inditioDs of
a house for tlie prematui-e in-
fant, and it practically meets
the induct ions t^allctl for in this
table (Table 83, p. 308). After
being used, it am be completely
disinfected and clcanse<l. It is
kept at the Milk-LalM)ratory,
whence it can Ije obtained at a
moment's notice. For pur-
poses of disinfection, and that
it may not abst>rb micro-cjr-
ganbms or dirt of any kind, which in wooden rcijeptacles invariably cause
a dtH-idcd odur, it Is made cntire'ly of mctah
The bn>c>der is snppirt*^!, as you see, on three wheels, preferably made
of light steel, two behind and one guiding wheel in fn^nt. A handle is used
to push it to different pjirts of the n»om, or, if nect^sary, to an adjnining
room, s(i that the mt^thcr can sec her infant if she is too sick to leave her
Ix'd. Tlie top of the brooder is about 91 cm. (3 feet) from the floor, so
that the nni'se dix*9 not have to stoop unnecessarily, but at the same time
can, when sitting down, see into it from above. It is 76 cm. (2| feet) wide
and 91 cm. (3 feet) long. The Ixxly is made of copper ; the walls are
double, and insidated on the outside, to prevent radiation. The water used
Brooder for premature lufiintP, A, m^es for welghlnir in-
faot ; B, giam lid of IneuL^tor ; C ftesh-air box, conliiln-
ing il(X'k-\irork and fan ; D, Um|^ for bcAtlng water-Jacket ;
£, chimney; F, nAnm flue fmin hentlng-fluefl ; O, retnm
ftesh-ftlr flue; H, entrance for freeli air; /, (xmnecTtkni for
orygen tank ; J, mUiug-valve ; K^ ventilAUug exit ; L,
anemometer.
310 PEDIATBIGB.
for heating circulates on all sides, and the infimt is thus wanned by direct
radiation. The top of the brooder is covered in the middle by a thick plate-
glass lid, which can be raised sufficiently to allow the hands and arms of tbe
nurse to be freely used in the brooder, and is by a simple contrivance kept
from falling down while the infant is being fed or touched. A chain i»e-
vents the lid fmm falling backward. On the under side of the glass lid is
a fine wire sliding screen, which comes directly over the infant's head and
lK*tween it and the glass. This is simply a precaution against the possibk
breakage of the glaj^ lid and consequent injury to the infant.
This plated box (C), which you see attached to the upper front end of
the brooder contains some strong clock-work with a fan attachment TIus
oval o(x?ning in tlie clock-box admits the air to the brooder. Below the
opening for the fresh air is a window, through which the fim and clock-woik
can be watched.
Just below the air-opening and above the clock-work is a fine open wire
shelf*, on which is spread a thin l^yer of cotton-wool. The air^ which b^
means of the fan is drawn into the box, is sifted through the cotton and
carried down the air-shafl (H) directly into the brooder. In this air-shaft
(//) you see there is a small st(){)-cock (/). This is the point of attachment
for the tulx; from the oxygen tank, to be used when oxygen is needed to be
mixed with the entcTing air-supply.
In this air-shafl, also, is attached a valve, which is so regulated by a
register handle that the air can be utilized either above or below the boiler,
according as it is needed and as I shall explain later.
The bottom of the brcK:>der constitutes an air-chamber^ and in this is a
boiler wliicli, with its heating or combustion direct and return flues, warms
the interior of the ap])aratus.
Above the boiler is placed the platform of a scale. The balance poorer
of this scale is on the top of the back end of the brooder. The platform of
the scales acts as the supi)ort for a metal pan 61 cm. (2 feet) long and 30.5
cm. (1 ioot) wide, on which the infant is placed. This pan should be made
of sheet iron, enamellcnl on both sides with white porcelain enamel, and
should have handles at either end to facilitate its removal from the brooder.
From the ends of this pan is hung by wires, which can be easily attadied
or detached, a light frame made of four steel rods crossed. On this fiame
is tied with taiK^s a i)iece of strong cotton cloth. This cloth is the infant's
bcil, on which it is placed wrapped in clean absorbent cotton. This cotiaa
cloth is alx)ut 2.5 cm. (1 inch) above the bottom of the pan. The infimfs
head is turned to the back end of the brooder.
At the front end, opposite the foot of the infant's bed, is the exit (0) &r
the vitiated air. This exit passes through tlie end of the brooder and
enters a ventilating pipe which has at its top an anemometer (X). Hie
bottom of the shall is outside the brooder, and has a dosed cone-ehi^
end, which is enclosed in a metal l)ox in such a way that a lamp (2)) can be
placed under it. The heat from this lamp answers two porpoeea. One ii^
PREMATURB INFANTS.
311
by keeping the ventilating shaft hot, to aid the ventilation, and the other is
tij heat the water in the boikn A register-valve (/) attached to the pipe
can shut off the heat if nec^^ssary frcim the b<:>iler, and allow it to go
directly up the double pipe (E^ K% whereby it8 entire power will be used
in promoting ventilation, or tlje valve may be set m m to dirwt the flame
partially into the boiler, thus placing its temperature c<jmpletely under eon-
tn>l. In this way the heat fj-om the lamp (which is enclosietl in the Ijox) is
without danger eutirely utili/.ed for heating and ventilatiuu,
I have now s?hown you the brooder and it^ general features, I ?hall
still finther ex]jhiin to you its mec^hanism by means of tlus sectional dia-
gram (Diagram (5)*
Diagram 6,
\ at brfXMler, L, lid of frwh-Rtr box, open ; 4, entrnncse of tnth air ; C, cotton, resting cm wire
tfMlf Abow clock-work : F, cltx:k-work and fan ; S, vaire rggnlatlng hot and cold fVesh air ; 0, pi fie for
<xvygeo Attachment; C F„ cloaning-flue ; Door, door to lamp-box ^ W, wire irmvae to protect agaliiit
» of lid.
The smoke-flue of the himp, marked ** Heating Fhie/' passes through
the centre of the boiler, marked ** Water'' in the diagram, as far a*^ to the
cleaning-flue, marked C F. Thence it returns and enters the uj aright
pipe marked "Heating Flue Exit/' The horizontal retiirn-flue is not
ehown in the diagram, beeaiLse it is behind the horizontal arm sho\¥n. The
little gate-valve Bhown directly aV^ive the lamp regulates al>solute!y the
amount of heat whieh is allowtxl to pa>?< through the lx>iler, and the tem-
perature of the warm water therein may be tested by a ehemist's ther-
mometer, inserted at any openhig which may be provided for it as directed
when the bnxjder is built.
The fresh-air flues are c?onstrneted, as shown, one above and one below
the boiler. One flue comes in contact with the up|>er or hottest part of the
boiler, and presents a very large surface of contact therewith by being flat-
tened so as to cover completely the upper side of the boiler. The other
flue touches the bottom of the boiler only in one line, or not at all, so that
312 PEDIATRI03.
the air passing through it is practically unaffected by the boiler heat Br
this arrangi'nient the tem{)erature of the fresh air can be regulated at irill
by the attendant by simply raising or lowering the valve S.
In virtue of the large amount of heating surface of the heating flneii
this api)unitus, it is found that a very small flame suffices to keep up the
desired tem^K'niturey and it results from this that no injurious product? of
combustion contaminate tlie air of the room. A veiy small alcohol lamp
can be uschI, while with a less scientific arrangement this fiiel might be
found too exj)ensive.
It is prol)able that an electric current will be found most suitable to
supply the heat in place of the lamp, as avcU as to drive the ian, and this
can be very easily act^omplished with a small battery.
By packing the water-jacket with asbestos, external radiation is pie-
vental.
The heating of the brooder varies as to time and d^ree according to
the atmosphere of the rcnim where it has been standing. If, however, die
ti»miK»rature of the rcwni is 21.1° C. (70° F.), and the temperature of the
water which is intrcKlnccKl into the boiler is about 40.5° C. (106° F.), it
will be found that ai^T the co<iI air in the brooder has been displaced the
temj)erature of the air in the bnxxler will in about fifteen minutes rise to
35° C. (95° F.). The tenii)erature will remain at this point for about hilf
an hour. As is<M)n as the teniiK^rature begins to fall the alcohol lamp should
be lighted, and as srM)ii as the temperature of the water in the boiler rua
alx)ve 35° (\ (95° F.) the lamp should be extinguished. By careful regu-
lation of the lamp and n^gulating the fresh air by means of the repstet-
valve?!, nil iiitellij^t'iit niu-so can kwp the temperature of the broods at
whatever degree the physician orders. The thermometer should, in order to
sliow accurately the teinix?rature of the air which the infant is breathing, be
beside it (ui its IkxI, as when attached to the lid it is influenced by chfuigs
of teiiipcnitnre in the room.
If any diiliculty arises fn)ni tlie temiKjrature not responding quickly
enough to the ref»;ister- valves and lamp, it is well to draw off a little hot
water and rej)hice it by some aM water if it is desired to lower the tem-
peratiin*, while to raise the temjK^ratiire the withdrawn water is to be lephioed
by liot water.
NuKSPis. — The brooder is not intended to obviate the neoessitr of
skillwl iiiirsing. On tlie contrary, a nurse should be in constant attend-
ance nijrht and day. She should have all the details of the infant's care
and the m(K?hanisin of the brooder exi)lained to her minutely, lor an oner-
gency may arise at any time, and always requires to be dealt with
imme<l lately.
The brooder supplies the menns for exact treatment, but intelligmt
minds and trained gentle hands are indisi)ensable. The nurse should fre-
quently obsc^rve the infant through the glass lid, and should be certain that
the anemometer is in constant motion.
PREMATURE INFANTS.
313
FiQ. 82.
Apparatus connected with the Brooder. — A stcthoftco}Te like
one {Fig. 85, p. 323) is the best adapted for exfuniBing the infant in
tthe Imxder. It i.^ii he bent in any direction, and the small calibre of its
Icup i.s lx>it adapted to the infant's size.
A piec^ of dark eloth should be kept over the glas8 lid, to preclude the
light, while the sun should Ix^ allowwl to shine frwly into tlie ixjom.
The metlujd of feeding the infant in the bnxider is important. It fre-
[quently hapjx'us that tlie premature infimt is too weak not only to suck the
ibreast, but also to be fe<l fn>m the bottle. In sneh cases it is customary to
\ a spoon or a metlieine-dropj>er. These, however, are verj* unsatisfactory
aentB. The food is liable to be spilled, the spoon or dropper has to
ll>e fre<|uently filled^ and much time is taken to eoniplete the feeding. The
I lid of the brooder^ also, should not be kept open for a longer time than is
j unavoidable.
I have lately madt* use of a device snggested by Dr. Breck, who first
brought it to my notirx^ when I was seeing a premature
i infant with him in consultation where there was much diffi-
I culty in getting the infant to swallow, and where it would
I not suck.
It is simply tliis glass cylinder (Fig. H2), 12 em. (4f
inches) long tmd 2.4 em, (1 inch) in diameter. The cylinder
is graduatcil to 2 e.c. (J drachm), and liolds 36 c.c, (9
drachms). It is shaped at one end so as to have a small
rubber nipple titttxl to it. The large end is covered by a
rubber eot. The rubber cot, which has no holes, acts as an
air- reservoir, and by simply intrrjclueing the small [lerfi-
L rated nipple into the mouth and gently pressing the ruhlxT
loot the food is slowly forced down the infant's throat,
without choking it and without the infant having to sock
or apparently to use any etlbrt. To fill the tul>e the rid>-
ber nipple and cot are removed, a rubber stoppi'r like this
(Fig. 82) plugs the small end of the cylinder, and the
required amount of food is poured in at ttie large end.
This metlMxl of fkding is esi>eeially desirable for a
weak prematuiT infant in a bi^ooder, because it entails no
loss of strength im the part of the infant, and can lie
easily manage*! by the riglit hand f»f the nui-sf^ while her
I left hand supports the infant's htrnd. This methixl is
far preferable to that of gtivage^ which is not S4j easily
managed by the nurse and causes more exhaustion to the
infant
The tjuestion is often asked whether premature infants,
ev€*n if tlieir livc^ are saved, can he ns well developed
physically and mentally as are those born at term. In my experience, there
to be no question that when once we have succeeded in making tlie
,li
^1
FtKHlef fof prcmjir
tuie lofADtii (reduced
cme-hAl/).
PEDIATRICS,
infant gain steadily in weight and assume the api^earance of an infant « I
t<*rm its subsequent condition diii'ers in no respeti: from that of infanta \xKki
at term,
I have liere to show you a picture of the infant (Case 110, Ik307(|
which was treated in I >r. Won^ester's incubator.
Inf&nt jiretiintiir*' al thi rtv vvL^ckf*. EUrth'WC'ig'ht, 20IfJ prammc-s. Treated in iin.'uljator £irt>'4
PreNDt age, oiae inuiulis, Pr^tient ivetgUt, MiO grammes.
Tliie picture wiu* taken when the infant was nine months old, and it wetgiifid aft
time 8400 gmuiuies (17 J poundt*}. As it* birth-weig:bt was 2040 gramme (About
pjunda)! you see thul it has <juadmpled its weigjht. It was fed entirely on modified
from the Laboratory during the firj^tyear, and is now a fine l^rge boy» walkici|^ And
al two years of age. It is perfectly beuUliy and well developed both phjaically imd
taUy.
Hift fiiateri who wa* premature at the twenty-eighth week, U now eight jean old.
la well developed and «tmng, and ii unUHually bright and intelligent for her age. Sbeii|ii
hcif decidedly in advance mentally of the other children of her age at her school.
JP
I have here the ret-ord of an infant prematurely bom at about
thirtieth week, and weighing 2850 grammes (ulKiut 5 pounds 15 ounce^lT
which was the first pi'enmture infant tliat happened to be treated in this
brooder (Fig. 81, page 309).
^P PBEMATUBE INTAlTrS. 315
I ThU infknt (Cttie 111) was bom at ton minutes pAst three on FebniAiyl6. Itwaa
[placed in the brooder at 9 r.u, of the same day, the temperature of the brooder being
te4.4«»C. (94*F.).
I On the following day, February 17, the infant was given by the nunae 4 c.c, (1
Edrachm) of diluted cow's milk every hour for three feedings ^ which he vomited almost im-
nnediately after taking. The intervals of feeding were then increased to two hours, t^it
Ithe milk was not retained. The nurse then ^ave him 2 c,c. (J drachm) every thn^o hours
Muring the night, which he retained for a number of feedings, but then vomited bile
land mucus, together with ihe undigeiited fotd which hiwi been given him*
I February 18 the infant was found to have l<>8t 420 gmtumefl (14 ounces) in weight, to
■lie very weak, and to be unable to retain the milk diluted with wattr. The meci>niuni came
nway on thie day, and there was a uric acid ^tatn on the napkins. The Infant was very
Btestlesft. Its respiratiom. were irregular, and its feet and hands were cold. The tempero-
raire of the brooder, which up to this time had been kept at 84.4*' C. (94*' F.), was lowered to
|S8.8** C, (98** F.), as the infant had begun to |)erspjre. A substitute food was ordtrn.'d from
rthe Milk -Laboratory on this day, the prescription for which was a^ follows (Prescription M) :
I FftsacRiPTtoK 86.
I B Fat 1.00
I Sugar * . . 8.00
I Proteids 0.60
I To be heated for thirty minutes at 75*> C. (Itj?"* F.).
I Lime water 6.00
I 24 tubes, each containing 4 c.c. (1 drachm).
I This food was given to the infant every hour.
I On the following day, the 19th, the record was that the food had been retained, that
I the infant had feemed so hungry that the amount had to be increased to 10 c.c. (2}
idnichmfi), and that it was found advisable to feed it every two hours rather than every
lhour» There was no vomiting. There were two movements of the bowels, which still
I showed evidences of undigested milk and some meconium. The infantas weight on this
I day was found to be the same as on the previous day, 2300 grammes (5 pounds 1 ounce).
I On the following day, February' 20, the infant wuis found to have giuned 30 grammes
I (1 ounce). It wu-< takiog its fixid regularly every two hours, aUerntiting with the njother*s
[ milk, which had come in conKiderable quantity. There were still evidences of uric acid in
I the urine. The temperature of the brooder was kept at 81,6*" C. (89'* F.).
I On the following day^ February 21, the weight was as on the previous day, 2280
I grammes (6 pounds 2 ounces )« The color of the freeal discharges was yellowish brown,
I There was only one discluu^ in the twtenty-four hours, obtained by the use of a supposi-
I tory. The temperature of the brooder waa kept at B&> C. (86* F,).
I On the following day, February 22, it was found that the infant had lost 60 graramea
I (2 ounces). The substitute food was th<-*n given every two hours, alternating with the
I breast-milk. On that day there were three yellow well-digested movements. The tern-
I perature of the brooder was kept at 29.4^ C. (85® F.). The infant seemed stronger, was
I very quiet, and slept except when it awoke to receive its food.
I On the following day, February 28, there is no record of the infant's weight, but it
I was evidently in a very precarious condition and seemed exhausted. It did not take its
I nourishment readily^ It had five small fgeeal discharges in the twenty-four hours, which,
I however, were yellow and f«irly digested.
I On the following day, February 24, the breast-milk wu omitted, and 4 c.c. (1 drachm)
I of modified milk were given every two haurs, the percentage of the sugar being raised from
8 to 3.6. There were four small faecal movements during the day ; the first one was green,
the last three were yellow and decidedly better digested. The temperature of the brooder
was kept at 29.4* 0. (85** F.)- During the day the infant gained 60 grammes (2 ounces)
in weight. It was so weak on the*e two days that it would have been dangerous to
I take it out of the brooder to weigh it, so that the continual record of the weight which
316 PEDIATRICS.
ciiuld 1)0 obtained by the iiculi*-b(*d of the brooder was of the utmost vmlue in reeolAtiu
the changes in the IVkxI netH-wary to save the infant's life.
On the folUiwini; day, February 25, the infant's weight was found to be 2260 gnnmn
(5 p<.»und8 8 ounces), an increai^ of 30 grammes (1 ounce). The percentages in the muci.
fled milk were then changed tu the following (Prescription 87) :
PRESC'RIPTIOlf 87.
B Fat 1.50
Sugar 4.00
Pn»t«ids 0.75
One dn>p of brandy was given with each feeding. There was one fncal disdiir^e,
which was yellow and well digested. On this day 4 c.c. (1 drachm) of food were giveo to
the infant ever>' two hours until ite feeding at 10.80 P.M. After this it seemed to honen
that at midnight 30 c.c. (» drachms) were given, at 8 a.m. 40 c.c, (10 dimchms) wen? girat.
and at o.30 a.m. 80 grammes (1 ounce) were given. The weight was now found t? be
242U grammeti (5 pounds 6 ounces), an increase of 60 gnunxnes (2 ounces) in the tw^ctr-
four hours. The amount of food which the infant had taken in the previous twentv-f(«T
hours was found to have been 375 grammes (12} ounces). The fiecal discharetf hvk
yellow and wtrll digested. Brandy was continued to be given. The temperature of tbe
briMKliT was kept at 29.4° C. (85° F.). At times a little breast-milk was given to the inf.nt
in order to satisfy the mother, but it evidently did not agree with it.
On Februarj- 27 the weight was found to be 2450 grammes (6 pounds 6 ounces). The
prescription for the modified milk was then changed as follows (Prescription 88^ •
Prescription 88.
B Fat 2.00
«"^"^ O.00
Pn>teids i^ -e
U. lO
30 gnimmes (1 ounce) of this were given to the infant every two hours during the
day, and ov<Ty two and one-half hours during the night. One yellow well-diee«ted firdl
disthart^e wa«* obtained by means of a suppository. The temperature of the brooder w»*
tli.'ii r.-duocd t<. -27.7° C. (82° F.).
Till' followinir day, February 28, the weight was found to be 2480 grammes (5puuii&
7 «»uno«>). Thi* bmndy was still continued, and there was one yellow well-diirested firal
diM'harg*'. Thr. bn^ist-milk had bi»en entirely omitted, and 460 grammes (15 ounces (£
nwtditird milk had Ihm-h taki-n in the twenty-four hours.
On th<- following day, March 1, it weighed 2510 grammes (6 pounds 8 ounces) The
am«mnt <.t' ni.KlilMMl milk uivm was 495 grammes (16J ounces) in the twenty-four htMiB,
and om. drop of bmndy wa> given with each feeding. There was grcAt improvement in
the infant's appj-arance, and it was nuioh stn>nger.
On tin- following day, March 2, there had been no increase or loss in weieht ITie
temp<T.itun. <.f the bnx.d.rwas kept at 27.2° C. (81° P.). 610 grammes (17OTnceB)rf
the m<»dilied milk win* taken in the twenty-four hours. There was one fiBcal t
well digested and y<'llo\v.
On the following <lay, March 3, the weight was found to have increased to 3600
grammes (o pounds II rnnu-es). Tin* prrc-entjiges of the modified milk »4»<^ •!. i. a
to the following (Prcsoription 3(») : ^^ ^^"^ "^"^
Prescrii»tiox 89.
B Fat
Sugar ! . !
Prott'ids ^^
1.00
Therc were two well-digestr-d fa-cal discharges on this day. The tamwMn.*n r *iui
incubator wa-. n-dured to 25° C. (77° F.). (il5 grammes (20J ounces) of the^m^SS^^^
were giv«?n in the twenty-four hours. mwnnsanuis
PREMATURE INFANTS. 317
The following day, March 4, the infant was found to have lost 60 grammes (2 ounces),
and the temperature of the brooder was therefore raised to 26.6^ C. (80^ F.). 680 grammes
(21 ounces) of modified milk were taken in the twenty-four hours, and there was no espe-
cial change in the infant's condition.
On the following day, March 6, 80 grammes (1 ounce) in weight were found to have
been gained, and the infant was looking better and decidedly gaining in strength. It was
evident that the proper temperature for this especial infant at this age and at this period of
its development was 26.6<> C. (80«> F.).
After this time the infant continued to develop normally, and on being taken out of
the brooder in April was thriving in every way.
It is now five months old, and weighs 7110 grammes (14 pounds and 18 ounces).
DIVISION VT.
GENERAL PRINCIPLES OF EXAMINATION AND
TREATMENT.
LECTURE XJLII,
METHOD OF EXAMINING A SICK CHILD. — DRUGS.
Before beginning in detail the actual study of the various classes of
disease which I sliall later prest^nt to you for examinatioii, I should like to
have you understand a iew of the general principles a knowledge of whick
I consider of imjM>rtanw in dealing with sick children.
When a physician is called to see a sick child, he must, if pofifible,
ascertain In'tore entering the nursery what is the temperament of the child
with whom he will have to deal, and by the aid of this information regu-
late the niaiHier in which he approaches it.
An infant in the early months of life too young to fear a stranger.*
child of (|iii('t phlegmatic temiK'rament, or one that is too sick to objwt to
Ining handl(Ml, din Ix.* examined as so(m as it is seen, with the r^jularlK
and precision wlii<h on(» would emi)loy with the adult.
It is an cntinly (lillerent task, however, when one is called upon to ex-
amine childi'cn who are nervous, excitable, or timid, or who are spcaW
and vicious. In dealing with the first and more difficult class of these cases
nnich (Iclilx'ration in the way in which you approach the child is needed.
and nnich diplomacy in speaking to it is indicated. In the second, the
spoiled and vi<ions <Iass, you will not gain time by delaying the exami-
nation, and the sooner you have made it with firmness and per^isteoce
the less trying it will Ix' for the child and for the mother. As a rule, the
more the child cries and resists ne(Kllessly, the less likely is it to have any
disease of serions import.
You will find that it is wise at first to make the child think that
you are not takhig any notices of it, and that you are not even aware of
its pn^sence. It is well to notice its toys, and to appear to take great
interest in them and also in the pictures in the nursery. The child vwr
soon will l)ecome accustonuHl to your presence, and will begin to take the
318
GENERAL PRINCIPLES OP EXAMINATION AND TREATMENT.
319
name interest in yon that yon seem to take in it8 toys. A ner\'ouB, timid
khild will often (mm this point of the examination allow you to examine
pt withnnt fnrtlier troyl>k\
I The pbysit'ian, however, mtist always be gentle both in his voice and in
fMs touch, and on the slighte^^t app^^'araiiec of timidity, or manifestation of a
Idesire to avoid him, he must at once stop the special pa it of the examiuution
livbich he is making, and devote hims^^lf again to tlie eliild's toys.
I All these pi-eliniinaries and minute details, which seemingly delay
■the examination, in faet expeflite it, since when onee the timid child is
Ithoroiighly frightened, the rest of the examinatiun 1>eeomes very unsatisfac-
[tory, fur it is almost cruel in cases of this kind tu attempt to Ibrce an
lexamination, which in the case of the vieious child can be done usually with-
lout tliis fec^Hug of cruelty and ^^ithont hurting the fk'liugs of the mother.
I You should ae(|uire the faculty of examining the child when it is crying
land excitt*d with the same precision as when it is quiescent, though [perhaps
I by a somewhat different methtxl. The traintH:! hand and ear can detect an
labdominal ur pleuritic etrnsion or a soUdilit^l lung almost as well when tlie
Ichild is screaming as when it is perfectly diMjile.
I This is an aetH>mp!L<liment which should l>e mastered at once by every
rpractitioner who expects to liave ehiklren under his care. In fact^ if this
Iwere more universally nnderstttod, we slioukl hear less of the impossibility of
I determining what m the matter with a child on account f»f its being fractious,
I As the physical examination of a chikl is somewhat moi\^ difficult than
Ithat of the adult, and i-etjuires to be made moi*e quickly, you should make
luse of everj' means at your command which will tend to thrt>w light on the
[final n*sult.
I HISTORY. — A complete hLstijry of tlie case is very valuable, and
iBhonld l)e obtained fn>m the mother and the nurse, preferably before seeing
[the clnld, for in this way the physician can obviate asking many questions
I in its presence, a pHx^dure whifJi frequently fatigues it and reudei-s it more
[difficult to examine* It is well to aUow the mother and the nurse to
Itell you in their own language what they know about the (4iild and its
I sickness. Aft<T they have finished, you can easily systematize the history
■ of the case by any qut^stions wliicli you may wish to ask. Although the
■history given by the mother and the nui-se is usually im{>erfect and discon-
|liectE*d, yet it is very likely to sup|ily wrtain imjxirtant [Miints which you in
Ij^our questifms might easily overhmk* The mother and the nurse are so
Icsonstantly with the child that they notice all the slight shades of ditteiTnce
[in its c<mditicm from hour to hour, a knowktlgi^ of which is of gn^at imixir-
[tanee in obtaining a corre<'t appreciation of the gt^neral condition of the
[ child, whatever the disc^ase may \x\
[ Having now systematizcxi in his own mind tlie history of the case, the
' physician on enttTing the niirser)* should pnM-etxl with Iiis inspection of the
child. I an* sup^wsing that the child is in one of the two classes which I
[have mentioned as being especially nec*essary to manage with diplomacy.
320 PEDIATRIOB.
TEMPERATURE. — Of course it is so important to asoertun what the
temperature of tlic child is tlmt, if possible, the temperature should be takn
before the child lias beirome frightened or fractious. The place for taking
the temi>craturc iu these cases is usually in the axilla. ^ You will find tint
the most successful method of obtaining the temperature under these ci^
cumstana^ is to explain to the mother and nurse exactly what you wi^ to
Iiavc (lone. You should direct them to take the thermometer and shovit
to the child as though it were a toy, to put it tuider the child's arm, and to
play witli tlic child until you tell them to remove the thermometer. A rectal
temperature is always desirable when it can be obtained, as it is more end
INSPECTION. — One of the most valuable means of making a diag-
nosis of disease in children is the careful inspection of the child befim
attempting to {x^rcuss or to auscult it. In fact, where children are iiritabk
and restless the insixKJtion becomes of the utmost importance, and an crc
wliich has been trained to understand the different aspects of disease in
children readily makes the diagnosis in many cases without further aasist-
ance. A rule to be remembered, and one which you will find of grat
pra(;tic^l value, is, if |K)ssible, to have the child entirelj' undressed, so tint
you can see the wliole surface of its skin in front and behind. Not only
will you thus Ix^ able to recognize the symptoms attributable to a waj^
irritation of tlie skin, where otherwise you might be led to consider *>MHn «
representing a more general and constitutional disturbance, but yoa will
also find the skin to Ix? a valuable index by which you «i^n judge of dfi-
ea.ses of the other organs. The cyanosis which so frequentlj lepreseds
some disturbanct* in the lieart or lung, the quick respirations of either a
thoracic or an alKloniinal ty|)e, a sunken or a distended abdomen, and tix
|)ositiou of the child, all point towards symptoms belonging to spedalde-
eas<^s. By means of all these symptoms, which we can see at a glanoe, tif
diagnosis of the six'cial disease can usually be made without mudi vi
fnnn other sources.
RESPIRATION.— p:ither when the thermometer is under the chitfg
arm or when you are lx*ginning your regular inspection you can oaoilb'
deteriuin(^ the rate and rhythm of the respiration. Having determined tta
tem]KM*atun^ and respiration, if you have seen all that is neoeaaaiy about the
child when it is quiescent, you can proceed with the remaining part of ywir
examination.
PALPATION. — Palpation is a very valuable means of diagnoeticidiif
disease iu children, whether it l)e of the abdomen or of the thorax. It »
w(>ll to Ix'gin with an attem])t to take the pulse. Sometimes tJiiii can be
readily a(xx)nipli.shed. At other times it is impossible ; and^ as a rule, I
rely less on the rai)idity of the i)ulse in the crhild than on ihe IniorDiadoo
which is received from the temixirature and respiration. It takes so littk to
increa.se the rate of the pulse in a young child that if we were to jodgein
every ca.se by it we should often be misled in our diagnosis. What we
wish esixK^ially to learn is whether there is a slow pulae or whedier it inftv-
GENERAL PRINCIPLES OF EXAMINATION AND TREATMENT,
321
I mits. This we can usually ascertain by keeping our finger for even only
two or three seconds on the chile's ratlial artery. When we have once
obtaintHl a iiiir idi^a uf the rate and rhythm of the pulse we can proceed
with tlie remainder of our examination by jialpation,
A ytHHi^ rhikVs thora<_nc walls are so tliin, and vibration is so pro-
nount'i^l ill them^ tliat often we can detect what process is going on in the
long by nirrcly putting our hand on the chest, and we tmn feel in a chronic
bronchitis what will prove on auscultation to Ix^ coarse sonoroiLs rides. We
\ can uho sometimes feel a plenritie or a ijericanlial friction-nib, and ti'e-
quently a n>ugheiiiug of one of the valves of the heart. It is not altogether
imp»ssiljle in t^ertain cases to distiuguisli the diHerent^* pn^sental U* the hand
'■ betw<x*n a pleuritic eflFiision and a solidified lung. The examination of the
aMutuen, even when the child is crying, can l>c act^omplishwl with ctmsider-
able prti^ision. Waiting until the child stf>ps crying for a setMjnd and
relaxt^ its alxlrmiinal avails, you can, by firm but gentle pressure, m depivss
the ablominal walls jls to obtain a fair knowletlge of wJiether you have an
abdiiminal tumor to deal with. Yon can also readily detect by palpation
fluid ill the al>dt>minal cavity.
A rt^'tal examination is often important in infants and young ehildit-n.
It cad readily Ix* done without hurting tlie child, aud the finger is able to
reach luuili further piX)|X)rtJuuately into the child's |>elvis than iuto that of
the adult, and very much more can be learned by this method than in adult
cases. Au invagination or an apj>pndi(ntis can Ix* diagnosticated by the
i combiuwl exaniiuation through the rectum and by external pressure where
external paljjation alone has failed to give evidence of disease.
In the infant the head should be carefidly exaniint^l in regard to the
fontancllt^- Mcasuremeuts sliould Ix* taken of the bciKl and of the thorax.
At this stagi* of the examination yon will have determined alm^»st always
what disease is afii'i'ting the child, but you should, of e<Hirse, make use of
every known methfMl tbr verifyiug yonr diagnosis. Yon shnnld. therefore,
endeavor to jicrcuss and anstndt the child, but in a S4jmewluit difierent way
from that which you would natumlly employ with the adnlt. The louder
the child (*rit*s, the easier Is it to obtain evideuce through vocal fremitus
w^iat tlie disturbantx' is in the chest.
PBECUS8IOM* — Even when the child h cr>'ing and resisting, pereiis-
sitin may be of the greatest importance. Light j>ercu&sion, as a rule, is
pre feral >le to the deejxT and heavier |>ercussion which is often so valuable in
the adult. The chest-walls, as I have said, are so resf>naut that deep pxT-
cussion rather masks the process which is directly imdcr the finger by bring-
ing out sounds from all parts of the chest. Direct jx^rcussiou with the
finger T have always found pretlTable to using any instrinncnt, ai^ lu this
way both pal}>ation and peraission may be combined, Palfmtory fx^rcns-
gion in ray hands has always pnn^ed exweilingly valuable for diagnostic
purposes. A lew light tajis over the normal Ixiuudaries of the heart and
lung, which I have described to you in a previous lecture (Lecture IV.,
i ^
322 PEDIATRIOB.
|)ages 121, 122, 124), will give you much information, even though you are
unable to effect a more extended percussion of the chest. If the chiU
is crying, you should watch until it takes its breath. Just as it draw:? 'm
its breath it necessarily Htoi)s crying, and at that minute you can get i
perfectly clear result I'rom your percussion.
You should be careful not to make your physical examination too pP)-
tracted. Rapidity of motion, botli in palpation and in percussion, i? veiy
im])ortant, and you should learn to examine a young child with much
greater rapidity than is usual or necessary in the case of an adult Yoo
will in this way obtain much more information than if you wearied the ehiU
by continual ottbrk^ to make sure that you had not made a mistake in the
cvidcnc^e wlii(*h you have acquired up to this point of the examination.
The sounds which can be elicited from a young child's chest are fo
varied that it is more difficult to differentiate them than in the adult K
therefore, you allow yourself to hesitate and to doubt^ you will not arrive
at iis correct a result in your examination as when you have trained your
mind to gras]) at once the salient points in the special phjrsical examination,
and to dc])en(l somewhat more on tlie first idea which you form, thtm woaU
be wise in the <*asi.» of an adult.
AUSCULTATION. — I am accustomed next to auscolt the chikL A
word may, ]KTha])s, not be deemed unnecessary in r^ard to the form of
stethoscoix" which I am in the habit of using in examining iniants and
youn^ children. It is, 1 think, unwise to accustom yourselves to the use
of one form of stcthoscoix*, as you will often have to examine children at
times when you have not your stethoscope with you, and yet when it nuiv
Ix* of the greatest ini]K)rtan(Y> that a definite diagnosis of tih^ case should be
made. I have noticed that children are much more sensitive to the fteling
of the stethosco|Xi than an^ adults. In many cases they shrink fix)m it »
thoujrh it hurt them, even when they have not been frightened by the pit^
vious ]>art of the examination with palpation and percussion. It is, tl^
ibre, oxttH^dingly im])ortant to make the examination as pleasant to the cfaiU
as possible. I have found that a rubber cup applied to the end of the
stethoseoiK' serves this purjK>se well. The feeling of the soft rubber is
pleit«^ant to the chihl, and it wnvcys the sound with almost as moct
elearmss as does the hard rublnT end of the stethoscope. This rubber cup
can l)e applied to any stethoscoix', such as this one (Fig. 84), which, however,
d(xs not convey the sound <iiiite so clearly as does this other stethoscope
(Fig. 8")), which is of such snmll calibre that it can easily be introduced
lx'twe<*n the ribs of even a youn^ child, and which differentiates the soumls
much more clearly than is done by any other stethoscope which I have seen.
In my opinion, it is often of great aid in the proper appreciation of the
sounds which are heard with the stethosiX)|)C in infants and in young chil-
dren, c»s|Kvially when they are cryinj^, to use a stethoscope which does not
«)nvey the sound so clearly and intensely as do others. We ^^m often in
this way diflerentiate a soft wirdiat^ murmur which if a more delicate in-
OEKERAL PRINCIPLES OF EXAMINATION AND TREATMENT.
323
strument were used would be entirely obscured by the loud j^unds coming
from the trachea and bronchi of a crjang or sc^reaming child. We can,
ako, often distiuguirth the fine rakis of a brontOio-pneumoma in contra-
distinrtiou to the loud coan-^e rales which tend to «jbi?curc the other .rounds
in the chest. For a routine examination, however^ and for rapidit)^ in its
completion in cases where we sec that a prolonged auscultation will prove
to be impossible, the smaller stethoscope (Fig. 85) is ix^t miapted for our
purpose,
Fio. 84.
Fio. 86.
Stethoscope,
EXAMINATION OF THE THBOAT.— We have now examined the
child in every way except one, which in an exceedingly im[K»rtant uue, the
omission of which might be productive of erroi*i=; in diagnosis. This is the
examination of the throat I have left the examination of the throat to a
time when we have pmctically finished with the gi:'neral examination of the
child, Vjocause, as a rule, it i:^ the procedure of all others wiiieh irritates it,
and after we have once attempte<l t<j examine the throat we shall st4dom be
foi^ven by the child at that special visit. Some children wHll allow you to
look into their throats without being at all disturbed. As a rule, however,
it frightens them, and we should use the most gentle and rapid methods for
accomplishing oar purpose. We must not expect to be able to sit down in
324
PEDIATRICS.
front of the child and examine its throat for some mioutes, as is |
witli adults. We uniKt atlopt some definite method by whicli we am oooiiol
the ehild and catoli a gliinpst* *if tlie mouthy tongue, and phanmx. Tin
more i|iiirkly we do thi^, tlie Ws it frightens the child, und it ii* im[M>i1inl
that we Bhould not make extensive prepiimtions, which it will niitiee id
which will indicate wliat we an* going to do. The mothers are often mmi
<listurlxd by s«:ving the child iii*ttt frightenetl with the idea that it is g^«ifl|
to have a spoon put in it^ mouth, and tlien, while screaming and cnin
forofd to tlie window and eoni(>L*lkxl to open its mouth. It is far betlff
under all cirt^umstauees to tell the motlirr and the nui'se what to do, and not
to go near the child ouiil they ai-e cutin-ly prepartxl to control it^^ limJ*
and an' holding it in a jwisitiun in which it is practically heJplesa. U
frightens the child nuu-h lc<s to liave it sit in the nurse's lap with \U &«
to ttie window than to examine it on it^ ha(*k. I can illustrate besl iht
l>mper methcKl of examining a child's throat where w^e expect to meet imh
n^istance, by picking out a really vicious child, and one which has b^oj
made viciotis by l>eing spoikd, for in thi^se aim*^ we meet w^th the gnateft
difficulty^ and they arc ca-ic^s whei'c diplomacy, peTsuajBion, and delay are of
no avail. I liajipen t4> have here to-day a cliild of thiB kind (Case 112).
Vaak 112,
CImk'al examltijititm oi throat
She is eight yeani old and well developed, and shp will he dotermmed to rcwa^ %
efforts to examine lier throat- My dinKrlkms for exftniiiiing the thnnit tif such a chili )
us t'tAioVfA :
I do not let hor st^e wbui 1 arn going to exftTtiine the ihront with, nor do I go near L
until she is ready tu Im; examinf^L The mirse h inttmeted to lejid the child to ft wind*?
place u dmir in front of the window, and Hit down in It. with her fact* to the window. Si
then lifts the child into her hip, lu^ding iU baek upripht against her chest, and Md«^
by claaping her arms around itfi amis. By cla*ping the child's ankles between h«r l
1
GENEHAL PRIKCIPLES OF EXAMLNATION A^'D TREATMENT.
325
let knett, the imrse can Al»olutely coDtrol its movements. She cannot move her amis or
her leg^f nor cau she slip down in the nurse's liipr but ^he is farc«.*<l to sit ypright. All
she <^n do b to move her heiid. When she is oneo in thi^ position I place uiy left hand
I on the top of her head, and thus ctmtrol the movement of the head. She will^ as you see,
> open her mouth, and then, wutching me, quickly shut It up again juet m 1 am about to
put the handle of t!ic «p<Kin in her niuuth- I next carefully place the handle of the spoon
between the child's lipy. If neeesiiury, in cases which are very intractable, ck»sing the no»-
irilfi will make the child open it* mouth to get breath. Thia h usually not necessary, und
all that we have to do ii^ patiently, flnnly, gently^ liiid jjeniititently to watch our opjwir-
tunity, and take advantage of it when it comes, to introduce the handle of the spoon be-
tween the teeth, and gradually put it on the tongue. When the end of the handle of the
sprK»n toucbeft the soft palate the child will gag, and by steady prefigure at this moment on
the base of the tongi»e a perfectly clear view of the throat will be obtained, and in this one
glance you should take in all that is to be seen.
You will thos siK'oess fully actMimplisli an exaniioation in a few seconds
w^hicb the mother hml frart^l woiikl bt^ prfihingttl and harrowing,
I prefer to iLSf' a spoon for exaniiniiig the thrnat, IxH'ause in every house-
hold you have one at your eomniand, aod it obviates the use of the same
instninient in a numlic'r of mouths, whieb is s^tmething tjo Ix' cf>nsideretl in
children, wbefe infection by the* niootb is so conim<in. Of course, for those
who prefer to use the UHual tongue-depressor the danger is reduced to a
minim u in if a t^i-eful disinfeetion of tho instrument is made after it is used ;
but in the ease of infants, who should aln^j he exaniiued in an upright jmisi-
tion, the six>on is dwidedly preferable. This is so because the neck of the
infant is so shi)rt that its chin is in clot^* pntximity to ibi ebc^st, and the
handle of the tonguc-*icpiTsst)r interferes witli the piYij>er down wan I pressure
of the instnmieut. The s|KKm-bandle, on the other hand, is exactly tlie
shape which is best adaptt\l to the infant's month and tongue, and the splou,
being comparatively straight, di*es not encroach ujwui tlie thorax when the
downward jiressnre is niade.
In regard to the examination of tlie thnmt, this part of the ehild may be
affected often, eukI may lie the oidy s^inn-*' of the sympt<»ms wbich yon will
be called ujwui to explain, and yet tbtsc symptoms nuiy not lie what }'ou
would expect to find where the trtjuble is in the throat. Young children
are so apt not to tt>m[)lain of troid>Ie in the throat, and to show meix4y
signs of general constitutional disturl«tnet% that the j*hysician is very likely
I to l>e misiwi and to overltx)k the real st^at of the disease unless he makes it
a rule always to examine the throat at bis first visit.
INSPECTION OF THE MOUTH.— It is well when the |>liysician is
examuiing tlie throat i>f an infant in the first two years of its life, and even
later if there are any symptoms which [loint towards the mouth, to examine
(^n»fully the gums. I uetil scan'cly caution you to wash your hands care-
fully iM'foiv intnalucuig your fingi^rs into tlie mouth. This is in accordance
with the rt)nHuon rules of cleanliness, and also is refjuired in onler Uiat you
sliould avoid the intnxluctifai of patbfigenic organisms into the Infantas
mondi. lu examining the gums you can judge whether tliey are swollen
or reddened, dry, moist, or hotter than normal, and also at times, as I shall
326 PEDIATBIOB.
cxi)laiu to YOU when speaking of diseases of the mouth in childroi (L^ctore
XL., iiage 797), you will in this way be able to decide whether there is a
condition of the gums w^hich indicates the use of the lanoet.
EXAMINATION OF THE EARS. — One of the most important
moans of rightly intcq^rcting the symptoms of restlessness, of evident pain,
of heightened tcm|K'raturo, of undue somnolence, as well as a great many
other symptoms, is the examination of the ears of infants and of yoang
children. A slight irritation in the throat may at times cause a conges-
tion in the vessels of the membrana tympani which may produce all tlie»
synipt«:>ms.
It is, therefore, very important, unless you are sure that the symptoms
do not arise from some condition in the ear, that you should examine the ein
at some time during your visit, choosing that time which seems most fiivm^
able in the esixK'ial case. I consider a thorough knowledge of the posrifale
symptoms which may arise fn)m the ear of the very greatest importance fer
the general prac^titioner to |K)8sess.
DRUGS. — An im])ortant fact to remember in the treatment of infants
and young children is that drugs play a very insignificant part in the actual
cure of their diseases. According to my observation, numb^« of children are
being treatcnl by drugs, and yet often, so iar as I can see, this time-honond
means of satisfying parental prejudices is but prolonging the symptoms of
a disease which, self-limited, has run its course. I do not for a moment
question the direct benefit obtained from quinine in malaria and mercniy in
syiJiilis : it is the pmmiscuous use of drugs in every case of sickness to
which I am c»siKvially oi)jM)scd, for in many cases the child will recover with
e(iual or even gn-ater rapidity without them.
Instan<t\s probably arise in the practice of every phjrsician where lie
fc('h that the drugs which have been given have either directly harmed the
child or, by disturbing its digestitm and thus interfering with its nutrition,
have indircH'tly producxxl more serious symptoms than those presoited br
the original disease. The givatest caution should be employed where drags
arc useil with young children, and there should be a thorough onderstandii^
of their action during the various i>ericKls of developmenL The well-known
siLsceptibility of cliildrcu to the action of opium and its alkaloids shonU
make us careful to begin with minimum doses when it is necessary to use
this drug. In like manner, although it is traditional tiiat children have a
gn'at tolerance for belladonna and arsenic, we must allow that an overdose
of th(j former, altliough not usually fatal, may certainly produce moet
ahirniing symptoms, while the administration of the latter as I have seen
it given in the treatment of choi*ea has in a number of cases prodaeed a
multiple neuritis.
The treatm(^nt of diseases by s|)e(*ial drugs because these drugs hare
been given in the past, lxH?ause their administration has apparently done no
harm, or Ixvausc* no n<'w or Wtter remedy has been found, rests upon a Isck
of comprehension of what tn»atment n»ally means.
GENERAL. PRINCIPLES OF EXAMINATION AND TREATMENT.
327
The custom of combining many drugs in one prescription k fallacious,
[ and should be dis^oountenaneed, especially where infants and young c^hildren
are l>eiu^ tn^ated. A single drug given in the smallest dose which will
) accomplish iU purpose, and in the most agreeable form which is C4>mpatible
with the function of digestion, will prtKluce the best results in any given
Iditiease.
The delicate skin of infants and young children Ls peculiarly sensitive to
reflex disturbances caused by drugs in tiic ga^tro-cnteric tract, and thei'e-
ffore we must be careful not to mistake the a|>{>earauces produced by such
reflex irritation for the various legions ctf the skin which may occur in a
specific diseastr. Thus, the similarity of the ettlorescence produced by bella-
I donna to that accompanying scarlet fever is striking. Almost any drug, as
well as certain artich^s of diet, may in some individuals produce forms of
papular erythema, resemMiug very closely some of the dermal lesions of
syphilis. It is therefore w^ise to avoid these possible disturbaoces of nutri-
tion by giving drugs only where they are actually known to be necessary,
and by omitting them as soon as possible.
It has always seemed to me irratiftnal to prescribe syrups aa a men-
stnuim for the administration of drugs to children. Their well-known
tendency t*) fermentation Ls sufficient to stamp them as imfit for the treat-
ment of a j>eriod of life when the undeveloped coudition of the digestive
function indicates the vital importance of protecting this function in every
wav.
Each ciis€' must be treated according to its special patliological lesion or
specific micro-organism. As year by y^ir we are discovering the organisms
which <.mise sj>et*ial diseases, so the trt^Jitincnt of the future will be the
ai-lual destruction and s|^)eedy elimination of these organisms while sup{K>rt-
ing the strength until such elimination has l>eeu accomplished. Where no
known organisms exist, the treatment should be if i)ossible to rt»movc the
cause, and to support the vitality until natural processes have hcakxi the
spwial lesion, pnxluctd either by exposure or by trauma.
In cf*imt»ction with what I have said regarding the unnecessary use of
drugs in early life, the following case is of considerable significance :
An infant five months old was reporied U:> me to h.»ve tuberculAr meningitis. The
kistory of the caue wb« as foUowR :
A healthy bri?a8t-f<Bd ialknt (Ca«© 118), with a healthy mother, had been for two weeks
showing tigna of fretfulnc**, which, as aflerwarda proved, were chjsely connected with irri-
tittioii of the two lower middle ineisow, which were in the pncesa of ixtming through the
^iiTTi. The infant bad bad a slif^ht cold r)r two daySf and on the second day had been more
rf9tle»s than uBUal in the afternoon, and bad screamed a great deal. The attending physi-
cian prescribed a mixture of flfteeo dropb of tincture of opmm in thirty teaepoonfuU of
wnter^ to be given in teospoonflil doses at interval* during the night, if it was found necea-
aary to quU*i the infant During the nit^'ht the infant's bands and feet were reported to be
cold* and by morning it w«* found to be almost unconscious. The physician at this time
madD the diagnoais of luliercular meningitis, and on the foHowing day, when it was seen by
toe witli him, it was found to have contracted pupiU, cool skin, a rectal temperature of 87*
C (98** F,), a fontanelle somewhat depressed, a regular pulne^ 120, and respirations quiet
328 PEDIATRICS.
and not especially slow. It did not notice anythinji^, except when it was roused, atThidi
time it would cry vigorously, as though it were annoyed at being disturbed.
On inquin-, it was found that the nurse during the night had ^ven eight teaspouciu
of the mixture which I have just mentioned. This amount must have contained it ItKt
four dnips of tincture of opium.
A dose of eiulphate of atmpia of 0.0003 (3^ of a grain) waa given at once by the mnitL
Four hours later the pupils became less contracted, but were reacting aluggiahly. An btur
later another dose of sulphate of atropia of the same strength waa given, and the pupil$ tfa^i
dilated, the infant grew brighter, and recovered within twenty-four hours.
After the 8i>iH)nd dose of atropia had been given, an efflorescence, which probably wai
the result of the phyi»iological action of the atnipia on the skin, appeared on the chtftiod
face for a few hours, and the skin then became normal. This efflorescence, it is well to
HH^ord, was at lirst mistaken for that of scarlet fever, so that in the same case an erma«ou
diagm»sis r»f two entirely d liferent diseases was made, and in each case the symptomt nip-
posed t<» represent these diseases were really caused by the drugs which had been given to
the patient.
DIYlSIOlSr VIL
THE BLOOD IN mFANCY AND CHILDHOOD.
LECTURE XIV.
LITERATURE.— NOMENCLATURE— BLOOD-KEY.— METHODS,— CHEM-
ISTRY.^ ORIGIN.— FCETAL BLOOD.— THE NORMAL CONDITIONS
OF THE BLOOD IN EARLY LIFE.
As our knowledge advant^es regaixling the etiology of disease, it Is l)e-
cijming very evident timt we should ticit only din^'t attention to the piithology
of tlie tissues outside of the bhxwl, hut should also investigate the varied
eonditions whieh exist in the bloml itBelf. The blotrtl diwa nut merely absorb
the waste mutter from the tissues and eiirry fresh oxygenattM:! material to
replace it. It plays a far greater part in the economy than this, and is inti-
mately ajnneeted with many dLs*^a^s,
It is not only in the oirpnseular elements t>f the blood that we find
various changes corresponding to certain t'ondititms existing in the indi-
vidual We must in tlie future go still further and rem! what tiae blm>d
serum is waiting to disclose to us.
Although an immexise amount of labor has been expended on examina-
tions of the bl(K>d, both ehemi^ml and mien iseo pie, esj>e«'iaUy in that of
atlults, tlie present state of our knowledge concerning its dimms*»s, and its
conditions as rei>resentative of other diseases, is very ynsatistaetory.
Our knowledge of the blood in early life is still more meagre than at a later
j>eriod. Although in the last few years the literatui-e of the blo<Kl in general
has iM'come very extensiv<% yet that jMTtainuig to infancy is small. We must,
inth^ed, confess that what we definitely know of the diseasi^s of the bhwwl in
the first few years of life is wanting in exa^'tness and veik*d in oljseurity.
It is exceedingly im|M>rtaiit, thert^bre, that the results of individual
investigation in this class of aises should he published as soon as j>o«sible,
for the pur|>ose of rendering mutual aid in unravelling the nivsteries of this
interesting subjec»t. F(»r many years I have met with cixae!^ whir:h have been
difficult to classic l>eyond their evident connection with the bhiiKh
During tiie last two years I have endeavored to formulate more sys-
teniaticallv mv i*linical observations on these eases, and I have ham enal>led
321*
330 PEDIATRICS.
to c*<)ll<i*t some valuable data for cHap^nosis and prognosis. In the aroom-
plishinent of tliis work I have n^ceived much assistance from Dr. William
F. Whitney, who hius witli gn^at patience and labor differentiated the speci-
ni(»ns as they wrre broiiglit to him from the several cases on slides for
niici-oscopie examination. I wish es|KK4ally to direct attention and awari
great merit to Dr. A. H. Wentworth's work. He has labored in this field
ior me imc<'jL«^ingly during the i)ast two years, going to my cases, preparing
the slides, and intimating the red and white* corpuscles and hsBinoglobin. Up
to the present time very little work on infants, corresponding to Dr. Went-
worth's, has lK»en done in this country, and it is therefore especially valuable.
NOMENCLATURE. — The various terms used to designate tlie element
of the 1)1(km1 will s<K)n IxH'ome as familiar to the general practitioner as tho*
now us<h1 in clinical nuxlieine. I think, however, that you may notde«n
it unniH-essary for nu* to explain to you the meaning of some of the woni?
which 1 am al)out to iLse. I have endeavored to do this in the followii^
table (Table S4), and by means of this colored plate, showing the variiME
elements of the bl(M)d (Plate V.).
TABLE 84.
Meaning of ihe Terms u^ed in Dcserijbing the Blood.
Krythkocytes Nnrmul n-d corpueclei* (Plate V., o.)
1. Ilii'maloMiists .... Niu'k»ale<l red oorjmjscles (Plate V., 6.)
of XruinjiFin.
(1 ) Nunnoblujitri . . Siz<' of rn'throcytes, having a small deeply
staiiiiui; iiuch»us ... (Plate V., 6.)
(*2) MoiTJilohla^t-* . . Lari^<* iiuck*att*d rod corpuBclos, having a
lar^c, ofti'Fi fraj;inented, niicU'Us, staining
fnintly (Plate V., 6tf,)
(3) MicroMasts . . . Small nucleated red corpuscles.
2. ll:i'inatnl>la>t^ .... B1(kk1 plates, 8Uppoi»ed by these authors to
of Hay«in and Hizzo- b<^ youn^ n'd blood-corpuscles.
Z«.To.
3. Mirn)cyt<'s Abnormally small erv'throcytes (Plate V., 7^.)
4. Ma(To('yt«'s Abnormally larjje erythrocytes.
nr MrLralnryti'S.
0. l*<»ikil(Kyt<s Abnormally-sliap^d erythrocytes (Plate V., "«.)
<)lii::ofyth:i'mia .... K<*ductinn in number of erythrocytes.
HuMuoly.-is I)<'?*tni(!tioFi of erytbn>cytes.
lIu-rjioLjlobin Colorini^ matter of the blood.
()liLCo('hr<»m:i!iMia . . . Ivrduction of ha'mc»globin.
lI:iMiinirinl»iii:i*niia . . . Pn'-i-niM- of ha.Mnoglrjbin in the serum.
lI:iMnn(^l(ibimiria . . . Pn^.^onec of h:emoLclobin in the urine.
Leicocytks White e.)rpuscb'.s.
1. Lyniphn<'yt«'."5 Round niMnonucloiir (^ell.** about the size of
• •r>inall niononuclrar. r-rythroeytf.-^, with faintly staining proto-
(Vnuni^ (unrip«-) t-b'- plasm. Tli<^ nuebms stains deeply, and
mcnt.« of I.^.i^kow.) 111!.- n«*arly thi* whole cell (Plate V., 1.)
2. Lari^^c monnnurl.'ar . . P\illy dnublc thr diameter of erythrocyte*,
(Mature (rip»') <'le- with oval or round faintly-staining nu-
ments of Uskow. ) <'l.-us, tillinijf a relatively small part of the
^*^11 (PkrteV.,1)
^^1^ ^^^^w *
^^^^^^ ^^^"
^^^^^1
^ Aridemtft \^m\m p3eui3o-L0u^ mixa von jAfvscn ^^^^H
«
^^^H
^^1
■,^«
• •
^H
*#•
^1
•*••
^ ■
OHk -'EflTXi
19 3 ■
^H
,^k '"
& ^^^H
i^'«
t^»
9 ,^
^^^^^1
^^^^^1
^^^^^^^ft THE BLOOD IN INFANCY AND CHILDHOOD.
331 ^M
TABLE M—Omiinued.
■
^V 8. Tmmldonftl forms . .
OellB like the above, but bATiug ati indented
^1
^H (Lobulaled or indented
nucltiua . . , - .
(Plate v.,
H
^H forms of Ufikow.)
^H 4. Neutrophiles
Considered by most observers the Lildest
^H
^H or poly nuclear cells
variety of the leucocytes. The nucleus
^H
stains with baBic stains ; the plasma stains
^H
^H ntorphnucleikr. Old
faintly with neutral aniline stains, and the
^H
^H (overwripe) elemenU
granules atain with a combination of both
^H
^M of Uskow)*
bafiic and acid stains, and hence are called
neutrophils. The nucleuj* u really poly-
morphous, though sometimes (apparently)
I
broken
(Plate y.,
■
^H 6, Myelocytcfl
Large, round, or ovoid cells, with one (aeldom
^H or large mononucleiir
two) large faintly-aUining nuclei. The
^H
^K neutrophiles. ^* Mark*
plaania h M]ed with small granules that
^H
^B seUen" of the Ger-
take a neutral ^tain .
(Plate v.,
,9a,) ■
^H mans.
^^M
^H 6. Etidnopbilea . . . * .
Characterized by the presence of large, round,
hitjhly refmctile granules^ which stain with
■
all iieid coloring matters .
(Plate V,:
H
^^1 (a) Polymorph nuclear
(Plate v.,
■
^H {b) Mononuclear , . ,
{Plate V.
,sb.) H
^H LeucfX'Ttoftis .....
An iacrease in the number of leucocytes »
the increase being in the ptjlymorphnti-
clfiar Tieutropbiles,
■
^H Microcytosis . ...
An increase in tbp number of raicrocytes.
^H
^^m Monochromatopbilic
Taking uuly ime »tain.
^H
^H FolychrotimU^pbilic . .
Taking more than one Jitftin.
^H
^H Bajsopbilii^ ......
Stained by ha^ie stains.
^H
^H Acidophilic
Stained by acid stains.
^H
^H or Eoi^nopbillc.
^H
^H Neutrophilic .....
Stained by neutral stains.
^H
^H Amphophilic
Stained by both basic and acid stain*.
^H
^m ErythrublaaU
A term used by &ome authors to describe
certain very early stages in the develop-
ment of erythroc3rte8 found only in the
bbxHl' forming onran^s.
1
^H Leukoblaata
A similar tenu applied to the early stages in
the development of leucocyte's.
■
^H Mitoieii
A division of nucleus and cell in which the
^H
^H or Karyokineeifi.
division is preceded by certain definite
^H
^H (Indirect cell diylflion.)
1 changes in the nrran|?ement of the mor-
phological constituents of the nucleus and
celL
1
^H Amitosis ...
A simple division of nucleus und cell, not
J
^H (Direct cell diTiMoii.)
accompanied by previous alteration in the
constituents of either.
■
^H BLOOD-TCEY. — ^I should like voii to examine these colored pictures ^|
^m (Plttti' v., faidn^ pa^*
330), which repre.S4:*nt all the prim
I'ipal normal ^H
^1 and abnormal (>onditions of the bhxKJ in early lite. Thev are, in fact, a ^H
^m key which Dr. Went worth has so arranged that, by first becuming familiar ^H
332 PEDIATRIOB.
with the i)ictiircs in the plate, and then calculating the percentages fnni
your microscopic blood-slides, you will be able to read and understand the
special cai>ie wliich you are studying. Thus, knowing the special combiia-
tion of the blood-elemcnte which constitute a certain disease, and swing
that combination under your microscope, you can easily make the diagnosis
of the disease.
This methoil is, of course, more satisfactory than showing the blood-
field of any single case ; for what we see is of no particular value until a
histol(>gi(*ul (x>mputation of the relative percentages of the different element?
(*om]x>sing the blood has determined the especial combination which repre-
sents the ])articular disease.
I shall now brie Ay describe to you the general methods by which blond-
counts are made. For the special technique I must refer you to tbe
admirable laboratory courses that are given in another department of th
S(*h<M)l.
The iustnmient usid for estimating the number of red and white oor-
puhi<'Ies is called the Thoma-Zeiss. It consists of two parts, a glass count-
ing-slide and a mixing-pipette. By pricking the lobule of a carefiillj
waslieil c>ar a single drop of blood is made to exude. The first drop of
bliMKl that comes having been wi|)ed away and a second having taken ite
plue(>, the end of the mixing-pi])ette is brought in contact with it and a pcff-
tion is sueked up in the eapillar}' tube, the amount taken being shown on a
scale. The end of the pi|)ette is tlicn immersed in a diluting fluid, and
tlie bliKKl, with either one hundred or two hundred times its volume of
the diluent, is snckixl into the bulb to which the capillary tube enlaiges.
After this the pi|H'tte is shaken for at least two minutes to insure Ac
even distril)ution of tlie corpuscles. For counting the erythnicytes the bcsl
diluting solution is that known as Toison's, the formula for which is,
Frrscriptiok 40.
U Siilpliutr of ^<»diuiii S.000
Chlorido of soiliiiin 1.000
^^lyccrin 30.000
M^'thyl vii.li-t 0.025
I)i>tiIl«.Ml water lOO.OOO
Ilavinjx blown (uit the first few droiis from the pipette, in order to be
snn» of getting a (IrDj) that rejin'sents a fair average, the next is put in the
small depression that is made ior it in the oounting-slide. Around this
I'entral well is an overflow moat, IxumdKl by a slightly raised glass plate.
Tlic wlu»le is S4» constriict^Kl that, when the central well is evenly fidl of
fluid and s<'aled over by laying on the cover-glass, its depth is exicdj
on(»-tcnth of a niillinietrt*. On the flcK)r of this well a square millimetie
has In-en ruled ofl* into four hundred small squares. The drop of blood,
Just largi» enougli to fill this well, but not to overflow the moat^ shut in by
its eover-ghu^s, is laid aside for two or thn»e minutes, so that the globnks
THE BLOOD IN INFANCY AND CHILDHOOD*
333
I may all fall to the l)ottom. Then, under tlie mieixificope, tht> mimi^er of
retl and white corpuscles Ijing in a definite numlx^r of the .small squares
<ran readily be ermntal, and, na eaeh square is jusi one four-thousandth of a
cubic inillimetre, a very simple multiplieatiou will give us the number of
|corpii^4es in a cubic millimeti'e of the undiluted blood. All blood exami-
nations ui'e rejK>rtitl in terms of cubic millimetres. In my cases, one
huudriHl and sixty small scjuares were c<juntal in each of four suocesaive
I drops of blood, and the avera^ made up from these.
Although, owing to the blue color given them by the Toison's solu-
tion, the leiicmytes can Ije counted at the same time as the erythrocytes,
yet it is often more convenient Ui use a solution that, by rendering the
red eella invisible and emphasizing the nuclei of the whites, will render
the task of CNiunting the relatively small projKjrtion of white cells easier.
For my counts a three-teuths of one \K*r cent, solution of acetic acid was
used, the blood diluted one hundred times, and twenty thousand squares
counted.
The haemoglobin percentage is generally determined by means of the
Fleischl hjem<jglol>inometer. A fine piece of glass tubing set at right
angles in a handle is used as the measure for the blotxl, which is then
dis'^dvcd out in dLstillfxl water held in a glass-lx^ttomctl tvlh The colonxl
wmtcr is civmparcd !jy artificial light with a graduated red gla^ prism, and
when the exact equivalent is found an index on the instrument shows the
perwntage of hsemnglobin.
The tliirtl step in the process is the making of tlie dried cover-glass
preparations. This is the one that c^n be most readily done by the general
practitioner, and the one that will give him the most information. Tlie
CL»ver-g lasses must first l>e can iiilly eleanseil with acid and akH>hol. One
of the clean cover-glasses is taken in the forceps and gently touched fi>r a
moment to a fresh dnij^ i*f 1>1o(k1 as it n-sts ujxm the car ; the second glass
is then droppxl n|>on the fii"st. Jf l>oth wen* |MTfectly clean, the bhK>d will
be seen immediately to spread itself out lietween the two as a deliaite film.
The gla^st^ art* at once separak^tl by a sliding motion, and allowctl to dry
in tlie air. When dry, if protivted fri>m dust and moisture, they cjui be
kejit indefinitely. The next stcj> in the pnici^ss is to harden them. Tliis
may be done by soaking them in benxine for ten minutes, or in equal i>a!*ts
of ether and absolute alcohol tor half an hour; or they may Iw hrat<d,
preferably by leaving tlicm for two huurs on a metal |>late kept just hot
enough to vaporijse a drop of water, but for rough clinical work holding
tiiem in the fingers for a couple of minutes over the flame of an alcohol
lamp is sufficient.
The last step in the process is the staining. To accomplish this a great
variety of stains have I)eeu ust^, each liringing out some one peculiarity of
eell-structun» with greater distinctnt^ss than the others. The eelh shown in
the ailored plate (Plate V., facing page 330) w^ere stained with the Ehrlich
triple stain, which is made as follows :
1
334 PEDIATRICS.
Prescription 41.
li Sutimitr'<I wat»'rv solution of <»ninpt* G 12o c.c.
Sutunit«-<i waU-ry dilution of acid fuchsine (containinfc 20 per cent.
jiK'ohol) 1:25 c.c.
Tf» this un» mldi'd slowly, whilo coiistiintly shukin^ the mixture, a
Sutunit«'d WHt^.Tv solution of methyl green 125 c.c.
Ahsolutt* nlcohol 75 0.0.
This stains tlir nuclei of the leiUHwytcs a blue or bluish-greeii o.>lor, iof
ncutnjphilic jxraiuilcs a purple, and the eosinophilic granules a itJJbh
tin^e. Tlie ervthnM*yU»s are stainetl a faint yellow. Aoct^rding tn tie
amount <»t' h(»atin^ the cover-glasses have had, they are left in the stainir^
fluid from one to lour niinut<»s, and then washed in plain water and drini
Finally, mounte<l in ce<lar oil or Canada balsam, they are ready for exam-
ination with the oil-iinniei-sion obje<'tive.
Of thes<' various pnK^tKhin^ the I'stimatioD of the haemoglobin pcr-
c<'ntii^' nuist U' done at once. The niixing-pi|)ette, having been filled ami
shaken, (»iui siif'ely 1k' hi\ from twelve to fourteen hours or even lous^r
without any changes taking place in the corpuscles that will interfere with
their U'lng counteil. The cover-glass films can, as I have alreadv told vou.
Ix? kept indefinitely.
CHEMISTRY.— The chemistry of the blood in early life ha*? not vet
Ixvn iidly investigated. It may, however, be of interest to vou to havt- a
general idea of this fluid milium which we are about to studv in health
and in disease as it exists in the adult. In this way you will be bettor piv-
pared to understand the mon' intricjite pathological questions which mmi
Im- dealt with later. This general idea cjui lx»st be acquired by directini:
our attention to the chemistry of the 1)1(mk1.
Tlie chief chemical facts whi(4i an^ known concerning the blood have
l)e<'n so lucidly stated by Foster that I can best assist you by quoting fr(»m
what lie says (Hi the subject. F(»ster states that the average specific eravitv
of human 1)]o(k1 is lOo"), varying fnmi 1045 to 1075 within the limits of
liealtii. The reaction of the blood as it flows from the blood-vessels i-*
found to Im- di-tinctly, though feebly, alkaline. If a drop be placed on
a piece oi* faintly re<l highly glazc^l litmus pajKT and then wiped off, a blue
stain will be left.
The wlioic blood contains a certain (juantity of gases, such as oxvgen,
carl>onic acid, and nitrog(.n, which are held in the blcKxl in a peculiiu'wav.
and which vary in venous and in arterial blo(xl, and so serve cspeeiallv todi?-
tinguisii tiiem from each other. These may U' given off from the blood when
expose<l to an atmosphere, according to the composition of that atmospheiv.
Tiie normal blood consists of corpuscles and plasma. If the corpiisc*h'?
Ix' sup|M)se<l to retain tiie amount of water projK^r to them, blood mav in
general terms, Ik- considenMl as consisting by weight of from one-thiid U)
-omewhat Ic.-s than one-half of corpuscles, the rest being plasma. The
plasma is resolved by the clotting of the Wood into serum and fibrin.
I
■^ THE BLrX>D IN INFANCY AND CHILDHOOD. 335
The 8eriim contains* in UX> parts, —
Pniteid Rubetanced about 8 ar 9 pnrti.
Fat*, variou» eitmctives^ and ealxne matterB about J or 2 parts.
Water ....,.., , . , . about 90 parts.
The proteids ai'e para^Ir»buliu and serinii-albumiti in varviii<r propor-
tion8» tliero imng prttbably more than one kind oi* eerum-albiiniin. We
may perlmps say tliat tliey CK)eur in about equal quantities?.
The fats, whii'h an.' smnty, except after a meal or in cei-tiun jmtln>
logical (Mjnditions, consist of* the neutral lats, stearin, palmitin, an<! olein,
with a ctTtaiii quautity of their resjiective alkaline soaps. The e<. implex
fat leinthin oct*nrs only in verj^ nmall quantities. The amount present of
the |)eeuliar a]cr>hol ehok^terin, which has so fatty an apiM^arancf% m also
«maIL Aniotig the extractives pn^sent in stTum maybe put duwu nearly
all tlie nitrogenous and other Bubstances wliirli ibrm the extractives of the
btidy and of tt>od, such as urea, kreatin, sugar, and lactic acid. A very
larjjje numlKiT of tiicse have Ik^cu discovere<l in the UockI under various
circumstanct^s, the cousideration of whici must be left for the present
The mlor **f bkK»d or of !^:'rum is pr*ibably due to tlK* prcs*^nce of vola-
tile ImkIics i\{ the fatty acid series. The taint yellow color of serum is due
to a sfiecial yellow pigment. The most characteristic and important eliemi-
cal leatui*** of the saline c^>ustitutiiiu of the serum is the predominaucr, at
least iu man and in most animals, of s<Klium .salts ov^er thos*' of jHitas,siuni,
In this rcsiXH't the serum (»tfers a markt-d contrast to the corpuscles, IjCSS
marked, but still striking, ai*e the abundance of chliirides and the prwerty of
phospliatcs in the serum as c<:>mpaR^l with the corpusi'les. The salts may,
in fact, l>rieHy \h} dcsc^nl>ed as ronsisting chit fly of sodium ejiloridc, with
gome amount of gwxlium carl)ouate — or, more correctly, Bodium bicarbonate
d jvotassium chloride, with small quantities of soilium sulphate, sodium
Losphate, calcium phospliate, and uiagnesium phrwpliatt^ ( )f cvcu the small
quantities of phosphates found in the ash» part of tlie phospliorus exist? in
the senun itself, not as a jihosphate, but os jihosphorus in s^jme nrgjini<* bmly.
The red coriHiscles contain less water than the serum, the amount of
solid matter Ixnug variously estimated at fn^m 30 to 40 p^-*r cent, or more.
The solids are almost entirt^ly organic matter, the inorganic salts amounting
to less than 1 per cent.
The nxl ctdoring matter which in normal conditions is associated with
this stroma may by appropriate means Ix* isolated, and in the ease of tlie
blo<3d of many animals olitaliied in a crystalline form. It is callc*j hfrmo-
gl(Mn^ and mi\\ hy projier uiethrxls l)e split up iuto a protci<l Ix'longing to
the globulin grfjup, and into a colored pigment, containing iron, callwl
hfjtmojtiii. Haemoglobin is therc^ibiv a very ctinqjlcx lx»dy. It is fiiund to
have remarkable relations to oxygen, and indeed the rtnl corpusc^les by
virtoe of their haemoglobin have a special work in respiration, for they
oxygen from the lungs to the several tissues.
336 PEDIATRICS.
Of the organic matter, again, bv far the laij^ part oonsiRts of hsmo-
globin. In 100 {)art8 of the dried organic matter of the oorpui%:lffi of
human blood about 90 |)arts are hsemoglobin, about 8 portn are proteid sob-
stnncH's, and about 2 {larts sltv. other subfitanoes. Of these other subRtame
one of the most im]K)rtant, forming about a quarter of them and appamitlj
Ixung always present, Ls lecithin. Cholesterin appears also to be noniudlT
pn»sent. The |>rotcid substances which form the stroma of the red cor
pusc^les a])i)ear to belong chiefly to the globulin family. As r^^aids tbe
inorganic constituents, the ooq>uscIes are distinguished by the relative
abundancti of the salts of potassium and of phosphates. This at least is
the case in man. The relative quantities of sodium and potassium in tbe
coq>uscl(»s and serum resj)ectivcly appear, however, to vary in diflbent
animals ; in some the sodium salts are in excess, even in the corpuscles.
The j>rotcid matrix of the white corpuscles is composed of myosin, or
an allied Ixxly, paraglobulin, and {lossibly other proteids. The nudd con-
tain nuclein. The white coqnisiJes are found to contain, in addition to pro-
teid material, Icc^'thin and other fats, glycogen, extractives, and inorganic
salts, there Ix'ing in the ash, as in that of the red oorpnscles, a preponder-
ance of |)otassium salts and of phosphates.
The main facts of interest, then, in the chemical composition of the
blcMKl aiv as follows. The red corpuscles consist chiefly of haemoglobin.
The organic^ solids of the serum consist partly of serum-albumin and ptrtly
of ])araglobulin. The serum or plasma contrasts in man, at least, with the
corpuscles, inasmuch as the former contains chiefly chlorides and sodiam
salts, while the latter are richer in phosphates and potassium salts. The
extractives of the 1)I(kk1 arc remarkable rather for their number and varia-
bility than for tlieir abundance, the most constant and important being
|>erhaps un»a, krc^atin, sugar, and lactic acid.
ORIGIN. — According to Ziegler, the regeneration of the colorless blood-
corpuscles tak(^ phicc principally in the lymphadenoid tissues of the
lyniph-j^lauds, the spleen, and the intestinal tract The lymph-bulbs con-
tain regions, shari)ly differentiated from tlie surrounding tissue, in whidi
arc always to \ye found stellate* figures which for the most part belong to
fret; cells. These n'^rions arc called by Flemming ''germ-centres." In
addition to this, a division of leuc^ytes takes place in the lymph-channpk
of tlic lynipli-glands and other tissutis, and there can be little doubt thtt
lcu(»ocytcs also divide while circulating in the blood or wandering amoi^
the* tissuc-cletls.
Tliis division may lx» either by mitosis, which gives oella with pecu-
liarly lobat<' or crown-like nuclei, or by amitosis, in which case the nodens
api>ears bn)ken into fragments.
The mitotic division is tliat which leads to the formation of vigoroDB
cells. To what extent the amitotic division — ^that is, the breaking dcrini of
the nucleus — is also followtxl by cell division is diiScult to determine but it
is probably true that this represents the result of a process of
THE BLOOD IN INFANCY AND CHILDHOOD.
337
I
I
and that the change from mononuclear to poly nuclear cells should therefore
be ltx>ked upon as a degeneration. Fi'apently under pathologitiil eonditions
there fK-eiirs an inereai*c» in leuc^xyte-forniation.
Sinn^ in lenaeniia tlie spleen^ the lytoph-^landi?, or the Inme-marr^iw
show a hyj»ertmpliic eojidition mth increased eell-prfKJnetion, it may bo
sup(M^se<l that they furnish the increase of leucocytch to tlie bliHxL The
rejreiii 'ration of the red l>loud-ix>rpU8eles occurs [irobably by mitotic division
of tln^ hhI nucleated younjj^ forms. In adults this division takes place only
in the lw>ne-nmrr*nv, which k true aW> of mammal?, birds, i^ptiles, and the
tailless amphibiie ; in the tailed amphibifc and in fishes it can occur in
the spleen as well. In the embryo thk process can go on in the entire
vascular system. Later it becomes conei-ntrated in the liver, spleen, and
bone-marrow, and finally hecxmies restrictKl, acconling to oiu* present
knowledge, to the marrow alone. Where thest^ nuclcatnl young forms
originate is still a matter of dispute, some iuvt^stigatrFrs CMiUsidcring that
they are the dirwt cleswndaots of the y ruing fi>rnis i>f emliryonic life and
that they have always held liaMn<igli>bin, others maintaining tliat thev are
developed from pre-existing nucleated forms without Inemoglobin, which in
tlieir turn are said l\v some to nndtipl}' in the v^essels of tlae marrowy and
by others to originate also in the spleen.
Neumann l>elieves that there either oceurs a development of the nucle-
atcnl blood -co r|>usclcs out of the leucocyte's of the Ijloml which after larth
ai*e citnvcyctl througli the arteries to the lM>ne-marni\v, or that they spring
from the tissue elements of the lx)ne*marr<tw.
Fate of the Red Corpuscles. — Alj*iut tlie length of life and the
ultimate fate of the red corpuscles little is known. Osier [if^iots out
that the bile e^jloring matteiN and certain of the uriuary pigments have
their origin in altered hiemoglobiu, which would rnpiire the daily destruo-
tion r»f many rt^l blo<xl-<*orpusi'les. So far as we can sec^ these corjuisclcs
are removc^l without uiidcrgfjing much alteration. Certain evidence?, hciw*
ever, seems to point Uy tlie spleen and liver as orgims in which they
are broken up, and in which they are iKThaps ustd again in making the new
ajqMLS4'les.
FOBTAJL BLOOD. — In acconlauc^? with tlie fact that the younger the
individual tlie more unformed, or rather unriix* and iuulevclo|KKl, art^ the
elements of tlie hlof*d, certain stagt»s of the *^>rpu.s4^'ular development iK'iiig
trausmitttHl dire^jtly troni the tietal ninditions, it will l)e wise to s(w;ak tii>?t
of the character of the blood in intra-uterine life. Taking these conditions
as a starting-piiiut and using the adult blriod f<>r com|jarison, we can obtain
a fairly comprtthcnsivc understanding of the variniis conditions which are
known to be pres£»nt in tlie blood of infants and children.
Ac<>ording to Schcrcnziss, the sp'^-itic gravity of the ftetal bl<KKl at the
m*)ment of birth is somcwliat lower tlian tliat of the adult's. That of the
senim is markedly lower. The red corpuscles are poor in hsBmoglobin and
rich in stroma. Compared with the adult, the haemoglobin is a^ 76.8 to 100-
22
338 PEDIATRICS.
Tho amount of Hbrinogen is relatively small, and aa compared \nxh the
niotlior's l)kKxl Ls iw 2 to 7.
K(vtal 1)1(mk1 is not well (|ualified for the method of quantitative analysis
by nieiiii.s of washing with salt solution, because many of the elements
which an* l<M)S(»ly hold in the retl corpuscles, especially the haemt^Iobin,
are easily washcil out.
The iietal l>kMMl is somewhat richer in sodium and considerably poorer
in iK)tassium than is adult blcMnl. The amount of chlorine not combined
with sodium and iK)ta.s.sium is much less than in adult blood. The sex and
woij^ht of the child at the moment of birth do not appear to have anv
influence' uimiu the (juantitative comi)osition of the blood.
Simc authors have thought that they found a lessened tendency to cca^
ulation in th<* bl(MKl of the ncw-boni. Kruger found that this tendeDor
existed in tlio sens<» that the iHiagulation occurred slowly. He thought that
this was due to the diminished tendency of the leucocytes to undergo retro-
gnide changes. Ho also found more iron in the blood at birth than after a
la|>se of fourteen days.
ERVTinM)C\TF>*. — Normally, the red corpuscles in the fcetal blood are
nuclcatttl, at least in the early months ; they are of the normoblast type
(Plate \\, 0, facing |){ig<» lUM)). After the seventh month they duninilh
rapidly in numlxT, and give place to the normal red corpuscle. There
is sinne ditleivncc* of opinion Jis to the frequency of the occurrence of the
normnhljb^ts in the last few months of intra-uteriue life, but the best
obs(»rvei-s si'cm to agrix* that tluy an' rather infrequent.
Lkl'ixk'VTRs. — Fischl, in a ivi)ort of four cases, found up to the end
of the seventh month very f<»w (H)sinophiles, after this a large number, and
then a dimiiuition towanls the end of full term ; and the oljservations of
Weiss iv^nv witli this. He found little variation in form and in size. There
is a l(»w |KM'ccntagt» of lym])ho(ytcs up to the seventh month, the majoritr
of the c()rpus<*l(.s consisting of the largt^ mononuclear cells (Plate V. 21
After the seventh month, an inei-ease of the former and a diminution of the
lattiT occur as full t<'rni is approachwl. The transitional variety (Plate V.,
2(i) predominates at birth, and later gives place to the polynudear (Plate
v., '^ and 4, facing pap' XM)).
( Jundohin found tliat in the 1)1(kh1 of premature infants the lymphocytes
(Plat(^ v., I) were lx»th relatively and abs^ilutely increased, and that itW
therefoiv a younger bloo<l. He found als4) tliat the same changes occur in
the leucoeytes (»f the prcniatuiv infant's l)lood as in that of the infant at
full term, only that thciv is a mon' rapid diminution up to the thiid or
fourth (hiy, and that the l(»ucocytes ivmain Ih'Iow the average a lonser timCr
from ten days to three ww»ks, than they do in the blo^ at fiill term.
When the development of the infant was slow, its blood was conespondimrlr
sl(»w in development, its red eoq)us<-les wei-e diminished, its haemoglol^
was diminished, there was an increase? of leueoeytes, and in this way a con-
dition of anaemia with leuc?(xyt<Ksis was productxl.
THE BLOCJD IN INFANCY AND CHILDHOOD.
339
^m Just as I liave explained to you that to understand intelligently the
Hdlsea^^l et>nditioni4 of early life you miii^t first actjuire a knowledge of the
B normal development of tlie iijfaut and i^luld dnring the diflei'ent p<:Ti«xls of
■ their existeuct% m I wish to impresi» upon yon the im|M>rtance oi' kuo\\ing
Hivbat exlste normally in the bknid of early life l>efore you eau apprt*t»iute
the ahnormal etmditii>08. I shall therefoi'e first deserilx* what is foimd in
I the nurmal infant's and ehild*8 blood, etjmiwiring it with the adult*s hluod,
and tlien [joint out the variations canned by disease.
NORMAL BLOOD AT BIRTH.— Amount,— Weleker states that tlie
total aniuunt of blotnl at birth is ooe-nineteenth of tlie body-wt-ight* His
opinii^u is based on the examination of a piorly deveIope<l infant, in which
the umbilieal cortl was ligatured immediately at birth.
8c*hneekinp: plaet»s the amount at one-filfe*ntli <if the bwh -weight, from
an examination of ^ve full-term infants, without expressing the bhuid
from the plaeenta, and w^ith immediate ligature of the cord. When the
cord was ttt^tl later, and tlie so-ealled ** rest^rve*' blood was expressed from
the placenta, the pereentage ro^e to one-ninth. In adults the relation of
[the blcMxl to the body-weight is stated to lie one-thirteenth. All authors
[agree that there is a tem[>orary gain in the amount of the blood when the
I cord is tieil late.
Reaction* — The reaction of the blortd at birth is always alkaline.
CoLOli. — The coh>r is found to be darker in the eapillaries during the
[first few^ days tlian at any other time.
Specific Gravit^\^ — At birth the sp<?cific gravity of the blood is about
fl065, and this does not vary lor the first few weeks. From this time up to
[the M^eond yc*ar then^ is a ec»nstant diminution, detTeasing in Ixiys to as low
[as 1048 and In girls to 1050. It then gracloally rises, till at the end of tbe
|£rst year it has reached the normal average of 1050 to 1058. The spetnfie
I gravity seems to be nnintlneneed by the nundxT of n\\ or white corpuscles,
[iiMxl, rest, exercise, or other nni^^'S, but depends directly upon tbe amount
lof haemoglobin. As a whole, the specific gravity is, apart from physio-
[logieal variations, very amstant in the same individual, and remains for
^^-eeks and months the same. Hock and S<:'lilesing*^r place the greatest
twenty-fc»ur-bour variati^m at n,0(M}25. Let me here n'mind you that the
■ appearance of the chikrs skin is unt an index to the specific gravity of tbe
bl(KMl i»r to the amount of the hsemoglubin. Cliiklren often appear anaemic
I withcnit any eH[>ecial alteration in either of these eruditions.
I Specific Gravity of tJie Blood-Serum. — Hock and Schlesinger's
results are the most reliable. They estiniate<l the S|K'cific gravity liy a
inethod of Hammersi'hlag's which has not yet Ix^en published. They
pbimd in young children tliat the physiological variations were much greater
than in adults, and were often Ixtwecn 1026 an*l 1031. Adults, on the
other hand, aecordmg to Hammcrschlag, showeil very little variation, jM?r-
haps from 1029 to 1031. Older children n\si'mble adults. The dtxJuctions
H&om these investigations seem to be, that any marked change in the sjieeific
340 PEDIATRICS.
gravity eitlicr of the blood or of the serum, aside from the action of drags
on the haemoglobin, denotes a marked change in the whole organism and in
the fiHu-tions of the various organs.
H.KM()<JU)UIN. — The haemoglobin is found to be leas firmly bound tn
the red corpiisclo in the iniaut at term than it is in adults. It is, however,
])rr>iM>i*ti()nately gn*ator at birth than in adult life. The hienioglobm, like
the s|Hi'ifi<* gnivity, which, as 1 have told you, seems to be dependent upoo
it, r(>a4'h(^ its maximum at birth. Starting at 100 or 104, it falls rapidly t»
its minimum in the first thnv weeks of life. (Hock, Schlesinger, Widowitz,
iSchnialtz, and Ilammorsc'hlag.) The lowest percentage that you will find
vari(»s from 50 to OG.S jwr cent. Fn)m two weeks to six months it remaios
about the same, and then rises slowly.
Ekythuoc^vtks (Plate V., 5, fiicing page 330). — So far we have bea
studying the bhnjd as a whole. I shall now direct your attention to ite
more minute o<>mi)osition. Here, under the microscope, is a specimen show-
intr till' normal I'ed cnirpuseles, as seen through a Leitz oil-inmiersion ^
and an iM'ular No. »*i.
All autiutrs n^wo that there is a large number of these erythrocytes it
biitli, and also that an incn^sc* occurs in the first twenty-four hours. As
regiinls the actual numlxT in a cubic millimetre of blood there is mndi
diversity of opinion. Fn>m the second day the erj'throcjtes b^in nor-
mally to diminish, and fall eventually, according to Lupine, Grerard, and
Si'lilmimcT, to r),(KH),0(K). Tlu^e autliors found the loss of bodv-wcight
duriiijr the first twenty-four hours to l)e accompanied by an increase of the
red eorpusol(»s. Lepine attributed the variations to changes in the blotd-
plasma, and not to a new formation or to a degeneration of the corpusdos
Ilayem always found a larger number at the moment of birth than in
th(» mother's 1)1(mk1, and givt^s as an average 5,350,000. He states that
tyin<»: the <'onl inilueneed the numlx?r, the average being perhaps balfi
million lii<rlKT when the e(»rd was tied late. This effect is temporarv, how-
ever, as is shown by Sehiif's exix^riments. When the infant's weight ir«
lf)west, Ilayem found that the w)unt reatrhed its maximum. From this time
a sl(»w but constant diminution took place, and in the second week itwis
found in Ix* alwait half a million l(«s than at birth. He thought that the
iner(\ise was due not alone to the loss of fluid, but also to the inervflsfd
formation, IxH'ause in maximal counts he found the corpusoles smalkf,
and ('onsi(lere<l them, therefore, youngcT.
Stierlin examine<l (»l(ler children, and found the erythrocytes to be vht
similar to those* found in adults. There appeared to be more red ooiposdes
in each cubic millimetre of the bhMxl of boys than in that of girlsy about
350,0()() more.
Schiff seems to have done the most thorough work on the estimation of
the erythnH-ytes. lie c}il(;ulat<il the* total bhxxl quantily as well as he ntf
able, and l)as<>(l his results on this. He found the highest oount on tliefiist
day of life, and a diminution in the next few days, with hoorly
THE BI/>OD IN rXFANCY AND CHILDHOOD,
341
Lbut etii'ii suceeediiig day tlie eoont was lower. This shows the value of
fciDdueting exjxTimentH on the bitwxl at the same houi* of the day. The
f inerea.se i\i\er birth is only set^miiig, according to Schitf, and is due t4j a loss
of fluid antl consct|iient aincentration of tlie blood, because atler the lirst
feeding the coonfcs an" biwer* He agrees with Lupine, except that he thinks
the changes in the blood are not due to gain or loss in weight, but to the
fluid taken into tlie system, and he sliowed that in a fasting infant, atier
several hinii*s, ther*? was an increa^st* in the n\l c^>rpuscles. ychifl* places the
j average at birth at 5,800,000, and is unable to observe any influence of sex
at this age.
Leucocytes. — The white corpuscles are mort* numerous at biilh than
I in adults or in young children. As I have already stated regarding the
I red CL»rpus€les, the counts of the W'hite ccjrpuscles vary according to tlie
' exanjincr ; so that our knowledge of the exact figures which should repre-
sent these counts is by no nieaiLS st'ttled,
Schitf found the highest counts, in the first twenty-four hours following
the first feeding, t^i be from 2(>,000 to 3r>,iKK) in a cubitr millimetre. He
never found the ni[>id diminution noted hy Hayem at the end of a physio-
logical loss of weight, nr>r did he find so low a <x>unt as 4000 to 6000 at
this time. He calletl attention to the daily variation in fMiusotpientx^ of
. digi^tiim, which is (if the utmost importauc*^ to Ixi'ar in rnind when ex-
ItHiining pathological blood. He estimated that from the twelfth to the
eight*'enth day the average figures were from 12,000 to 13,000, and for older
children 10,000.
I lay em found that in the first few days of life there were three or four
times more lou*'<xytes than in adult blixKl, and his estimated average was
IS^TOO. His average of 5000 for adult bhwKl is mther hiw. He found that
this average of 18,000 jK^mlsted until the physiologi(*al loss of weiglit had
I ended, when it was rapidly reduced to fmm 14,(XX) t<j 12,0tX). At the time
when the iufaiit begins to gain in weight the ctjuut rises to from 19,0fJ0 to
23,000, aud tlici^e i-emains constant tor a ivw days. The daily variations
in the early days of life are more marked than in adults*
Gundobin, in an examinatitm uf infants from ten days to a year old,
found an average of 12,J>00, tlie variations tx-ing fnjm 10,000 to 14,<JO0.
The adult variation he estimates to lye from 7(X)0 to 10,000.
Boochut and Dubrlsiiy found tlie average of a number of counte in
chihli-en from tvvu to fitttn^n years of age to l*e 6700.
Denis examined the blcxrtl of artificially fed and breast-fed infants. He
foimd the dimiiuition of tlie leuci>cyt4»s occurring on the fourth day, and that
it toiik j»hux^ more rapidly in the breast-fed than in the artificially fwh He
observed that the c«>nnts in infants were higher than in adults, and that
an increase of the white corpuscles occurred in poorly nourislied infants.
He n.'fers to the influence of food on the c^junts, and states that soon after
feeding an increase in the leucotytt's was observed.
I Anna Bayer, a pupil of Denis, estimates the leucocyte of new-born
:U2 PEDIATRICS.
infants and yonn^; (*hilclrcn as between 16,000 and 23,000. In later child-
IkhmI, up to tlu* sixth yi*ur, she placed them at from 9000 to 10,000.
The i^use of the leiicocj-tosis of the new-bom, aooording to Gundobin,
is a prt-iloniinanw of the " over-ripe" elements (neutrophiles, Plate V., %
tlH*s<* (vUs iorniing fn>m tiO to 80 per oent. of the total increase. He
thinks this is due to a diminished activity of the retrograde mctamorphusi
I'Voni tho second day tlie process is more rapid, and irom the seventh dr
in the tenth day the wliite corpustJcs have reached their normal condirii*,
wliich is found to be due to an abs4)Iute and relative increase of lympho-
i*ytt»s, — tliat is, the bhnKl Uxx^mes younger.
Gundobin opix^ses L6pine*s theory that the leucoc^rtoBis of the new-faon
iniant is due to a concvntration of the blood, and also Schiff's theon* tfait
then' is an in(*n>as<Hl flow of lymph from the tissues into the blood wha
the rhihl is hungry.
A fair average of the leucocytes in the blood of in&nts fit>m six months
to a year old is trom 10,(KH) to 12,000. After the first two or three weeks,
an<l up to six months, it is found to be from 12,000 to 14,000. Combining
th(*s<^ ol)ser\'ations a< well as we can, 1 find the average figures regarding
the nunilxT of the erythnM*ytes and leucocj'tes at difierent ages to be » I
have repn^sentetl in tliis tal)le (Table 85). These figures assume a loes of
weight for forty-eight hours and then a gradual gain.
TAIJLE 85. (R. C. Cabot.)
Norma f Anrntjr Number <[f Bhnnl-<\irjmMle8 at Different Ages in Oases ufhere ihertwu^
Ijus.s t,f Weitjhf in the First Forty-Eipht Hours,
A»rc. Kr>throc-yt«. LeucocTttt
At l.irtli 5,900,000 21,000
(26,000 to 86,000
after flnt feeding.)
p:nd f)f 1st <luy 7-8,800,000 24,000
" *Al j^tMierally increaaed. 80,000
" 4tb " 0.(K)0,000 20,000
7th *' TijimOOO 15,000
H>tli day 10-14,000
rjtli to isth (lay 12,000
1-tycar 10,000
«jth year aii<l iipwanl" 7,fi00
Aft<*r a meal :](),( MM.) leucocytes is never an abnormal count id m&nts
unih'r two yeai-s.
Nucleated Red Corpuscles (Plate V., 6, facing page 330). — ^Neomaim
and Kollikor found hu-ge numlnTs of nueWtinl red corpuscleB at birth (err-
tlirobhists of Ehrlich, the " CN'lhihs rouges" of the French). Hayem, Lofft,
L(M)s, Fisciil, and other authors did not find these numerous erythiobliste,
and say that they art* found in lai^e nunilx'rs in fcetal life onlj. The few
which an» found are usually of the normohlast tyjK?. After six months tlwr
an* rarely or never found normally. They are considered to be the iwolt
of delayed function. Pathologically, their presence may be of oonndaabk
THE BLOOD IN INPANCV AND CHILDHOOD.
343
i
I
importance. Ehrlich divided them into three kinds, dej^endinj^ on their
size and oa the staining property of the nucleus : (1) the normoblast, which
is the size of a normal red corpuscle, and has a small, dceplv-staincxl
nucleus ; (2) the glgiuitobkuit or mrgaioblaiit, which is very much lai-ger,
|KTha|)s thret^ or four times, tlxan the red corpu8i'le, and has a largc% pale,
or fnignieutcd niicleiii^ ; and (3) the mieroblmt or jHukiMjidnt^ which is a
very rare form, and cc)rrcs}K>nds to the inicnxyte in sizc» The normohla*t
is the ty|K* ct)iumiiuly t5»und,
LEUCOCYTES. — Five varieties of w^hite corpn^^cles are found nor*
mully in lioman hhiod, and they have been elai?s%ified in various ways.
Ehrlich's class! tieation is as Ibllows ;
h Small Mononuclear, or Lyinphoc3rfces (Plate V., 1, facing |>age
330). — These are small, round iu sha|>c, alMiut the size of a refl corpuscle,
mid contain a large round nucleus, which usually takes an intense stain
with all basic stains. The protoplasm is a narrow band encircling the
nucleus, aud at times is so narn>w as not to be visible. It sometiint^ stains
faintly with eosin, and sometimes d<»as not stain at all. These lymphix^ytes
often vary mocii in size, and at times are so large as to be indistinguishable
from the large monomicleai* variety.
2. Large Mononuclear (Plate V., 2, facing page 330). — These cells are
considerably larger than the lymphocytes, ^d'ten two or thro*^ times. They
have a lai^ oval or ovoid nucleus, which stains faiutly, and a large amount
of almc^st cijlorles.s protoplasoi surrounding the nucleus and giving the cell
ver^* much the appearance of a va<'uolc. The protoplasm stains very taintly
with eosin.
3. Transitional Forms {Plate V.» *2'/, facing pagr:^ 330). — Among the
large mononuclear cells there is Ibuud at timt^ a transitional variety. 8imi-
laj' in other resfK'cts to the large mononuclc^ar n*rpiiseles, they dit!er in tliat
the nucleus is umlcrgoing transition. This is shown by a mort* or less dt*ep
indcutatiun, which givt^ to the nucleus a saddle-hag or horseshoe shat>e.
4. Polynuclear, or more j>iv)ix*rly Polymorphnuclear, Neutrophilea
(Plate v., 3, facing page 330). — These o>rpu.seles are somewhat smaller than
tlic large mononuclear, mom namd iu shnjM% and with a jxMi'uliar (>olymor-
plious deeply-retaining nucleus. At times the nuclei i-esemhlc the letters S,
V, Z, E. When stainerl the nucleus often appears segniented ; hence the
name ** |>oIyuuch^u' " The pmtoplasm is aridopliilir ; that is, it iias an
athnity tor acid ?^tains, and is tilled more or less ci>m|jletcly with fine granules,
which are not very refractive and are stained by neutral stains ; hence the
name *^ neutro|jlii!e/' These wir|msck\s are more ct>ntractile than the other
varieties, antl are the oui»s most ri*t*<piently found iu pus, as they have the
faculty of pa**sing easily thr^mgh the walls of the vessels by means of
tlieir mobility.
The last thrt^^ nanxr^l varieties aiv generally tY»nsidere<l tn be the same
e^irpuscle undergoing metainorpliosis, during which pri:»eess the ppit^iplasm
becomes ojm*|ue and is ehangtHJ from basi>|)hilie ti> acidophiUc, The
34t PEDIATRICS.
opacity is due to the fine neutrophilic granules which have appeared in the
{)n>tophi8ni. This change is sup|x>sed to occur in the blood, and, according
to Ehrlich, is due to some nutrient material present there. PosBiblv the
(*orpuseIes are better nourished in the blood tlian in the organs which are
8up|)osed to pnxluw them.
The transitional conditions arc supposed by Uskow to be either a
degenerative or a rij)ening pnxxss, of which the lymphocytes represent the
" young" or " unriix; cell," the large mononuclear the ** ripe" cell, and
the i)olynucl«ir cells or neutrophiles the "old" or "over-ripe" cells.
6. Myelocytes, or large Mononuclear Neutrophiles (Plate V., 8a,
facing pag(» lltlO). — These are large round or ovoid neutrophilic cells which
pn>l)al)ly originate in the lx)ne-niarn>w. They contain one, very seldom two,
lai'ge round or slightly bent nuclei, which stain blue. The body of the cell,
which forms a ring around the nucleus, is crowded with a quantity of fine
neutrophilic granules. Myelocytes are rare in normal blood, but are much
increased in some of the pathological states. (Klein.)
6. Polynuclear Eosinophiles {Pkte V., 4, fiicing page 330).— These
cells are giuierally alK)Ut the size of neutrophiles, and have a nucleus, stain-
ing deeply, whic^h is similar to that of the neutrophile in shape and in its
apparent segmentation. The protoplasm is acidophilic, and is more or kas
completely fillwl with coarse generally round or ovoid highly refractive grah
ules, which have an affinity for acid stains. The origin, significance, and
comjx)sition of tht^se cells have caused more discussion and researdi than
thost* of any of the other varieties. Ehrlich states that the granules are no!
albuminoid, and concludes that their tYmiiwsition is of a complex nature,
Weiss maintains that they arc^ albuminoid, and bases his assertion on the
H'sults of micro-chemical cxjKTiments performed by himself and others.
Ehrlich thought at one time that the only place of origin for these cells was
the lH)nc-marrow, and that their (M^currence in the blood in laige numbns
significil chr(Mii(^ changes in the blood-making organs. Since then it has
b<»cn satisfact<n'ily demonstrated that they iK-cur — pathologically, at any rate
— in various sccrcti(»ns. NeusscT found them in large numbers in the blood
in c<*rtain skin atlln'tions. Aa*ortling to Canon, who verified this, the number
was less dcjKMidcnt upon the disease itself than upon the amount of surfkce
involved. They arc fnH|ucnt in the blood and bronchial secretion in asthma;
also in the prostatic sc<Tction under certain circumstances, and in the urine
of septic nephritis. The numl)er is normally very variable in the blood of
infants and children, so that they have not the significance that they mar
have in the I)1o(k1 of adults. Weiss considers their increase as oocuiring
entirely indc|H'ndently of the other leucocvtes, and for this reason their
comparative jx^rccntage has a (h)ubtful value.
7. Mononuclear Eosinophiles (IMate V., 86, facing page 330). — ^Veiy
similar to the myelocytes an: the so-call(»d eosinophilic myelooTtes. They
differ from them in having in the cell pmtoplasm eosinophilic gnuules in
placci of neutrophilic grauuk»s.
THE BLOOD IN INFANCY AND CHILDHOOD,
345
I
8» Broken Cells. — In addition to the above-mentioned varieties, we
find in some conditions of the blotxi |K>lynuclear eella that have lost their
regular <Mitllne aiul api>ear as though biin^t, with their gi-anules scattered
outride the rell-lxKly. Their ti^uae and signifieance are still matters of
dispute,
Gkanules.^ — By reitson of their affioity for certain staining reagents^
Ehrlieh waja enabled to differentiate seven varieties of granule^? oc^*urring in
tbe ct?lk of the blcKxl, five of which occur in the human bhxid. The
staining fluids mv divided into acid, basic, and neutral stains. The latter
are obtained by combining a basic with an acid stain in certain pniiioi-titinH.
This affinity for certain staining agents or groups of staining agents
Ehrlieh terms their elective potter ; the degree of intensity with which they
stain he terms their Hnctoriai^ power. He cfnisiders that but one kind of
granule ever oe*-'urs in the same t^^ll, and then (tuly in the j>rotoplasni. He
attributed the former of tliese phenomena to a specific secretory funeti^»n of
the protoplasm, aud hcuce the term sjwt^ific granulations which he applitnl
to tJieee granules. These granides ditier in their reactiun to staining fiuids,
in Slice, in shape, and in solubility* They are usually more or less round.
Their size is alx>ut the same in each variety, but is marktxlly diflerent in
different varieties, the tM)sinopliiles luring the largest.
The lym}>h-glands do not prmiuee any cells containing granides, and
Ehrlit^h lx*lievi*8 that each variety must have its own peculiar protoplasm.
He l«x>ks upon the granules as the prtfrfhiet of cell a<^ivit\% whieli is s^mie-
tjmc*s a function of n'serve juutcrial, and at other times is a pnx'cas of elimi-
natiun. He found tlieir composition to be c5omplex.
Ehrlieh rla-^^ifie*! thcsc^ five varieties of granules that are found in the
white wlls in human bloml as fSiUuws :
1. a. Granulee. — Eo^inopkiftc. — Stained by all acid stains. They are
neither fat nor albimdn. (This lias since bi*t"o denied l>y Weiss.) These
granuk's are coarse, round, and higiily refractive. The leuoxytes contain-
ing them are prt^sent normally in the bltxxl in small nu miners.
2. ^ Granules. — Thc^se ai*e fine round granules stained by acid and basic
stains (amphophilic), aud occur in thi' metlullary cavity of human Ixmcw, and
in many of tlic leucocvtes of rabliits and guinea-pigs.
3. r Granules* — This variet)" Is ba-sophilic, aud represents; the German
*' mastzellen-kornung/' Thin^are mrxlcTatcly cH»arse, njund, and not very
refractive. They are snid by F^hrlicli not to otx-ur mirnially in tlie blood.
Other authors, however, have fimnd them in small numbers. They are
found in l)one-niarrow nnd (*<iun(M'tivr tissue* They also oe*^^* pathologi-
cally in the bloiKl of leuaemia in varying numljers, aud occupy more or less
of the protoplasm of the large mononuclear cells* They are thought by
most investigators to be pathognomonic of leucaemia when found in large
mimlxTs.
4* ^ Granulee. — These are basophilic, and are found in the mono*
nuclear elements of humau bloixL The ditlerence between this variety and
346 PEDIATRICS.
the '* mast7A>Ileii*' gmnulcs, both of which are basophilic, has not vet been
de^^cTilxJd by Elirlich.
5. e Oranules. — Xcutmphileii. — These granules are stained by neotn!
stains, are very fine, are not refractive, and usually fill the protoplasm mnt
or less t^)mi)letely of the iK>lynuclear leuooc^'tes with the exception of the
e<»sino|)hik^. The nature of tliese granules is not known. This affinity 6;
staining reagents is more tlian superficial, as a chemical reaction is supposed
to (Kvur. Weiss doubts wliether the granules in the cells are the resalt(^
a s|KH>iti(* (vll function. The living cell is a very complex substance, vidi
varictl pro|K;rti(^, morphological and chemical, and the granules nutT be
fornie<l in a nuniIx.T of ways and from chemically difieient substuioeg to
serve various pur|)oses.
Percentages of Various LeucocyteB in Normal Blood. — Estimates
have IxH^n made by many observers of the percentages of the diflferent ko-
(^M'vtc^ in normal bliMid. It is sufficient to note that the blood of iD&ote
diHers from that of adults in that the blood of the latter contains fixMn 6(i
t4> 75 ]XT cent, of neutrophiles, the remaining 40 to 25 per cent beiif
made uj) of mon<muelear cells, of which about 28 per cent, are lymplw-
cyt<'S ; whiles in the iniant the mononuclear cells, which include the lympbc^
eytes an<l the hirgi* mononuclear iicUs, form the majority of the cells, periiip6
two-thirds or thre<M{uarters, and in very young infants the percentage is ertii
higher. The following table (Table 86) illustrates what I have just said:
TABLE 86.
Adults. In&nta.
SniuU iniinnnucl<Mir 24 to 80 per cent. 60 to 70 per cent
Lur;^«' innnniiuclt'ur 3 to 6 ** 0 to 14 •*
Nrutn»i>hil«.\^ 60 to 75 ** 28 to 40 "
En.>innpliil(vs 1 to 2 " } to 10 "
Ginulobin finds very little ehange from the above figuics until the
iH^iiinino; of tlu? third year, when the blood resembles more that of adults,
the neiitr()j)liiles and niononuelear elements being present in about cqnal
I)ro|MH'tioiis. In cliihli-en of eight or ten years he found very little diflief-
eiice from the l)ln(Kl of adults.
Ills e<inclusi<nis are that infants' bl<Kxl is (1) richer in white coriNisdes;
(2) richer in young f(»rni elements, the absolute and relative counts of the
lympli(K'yt4^ Iwing tlinn' times as large as in the blood of adults, while the
*' over-riiH.'" elements, or neutrophiles, are half as many; (3) in infiuitsthe
white eorpnselc^ remain relatively longer in the "unripe" and in adults in
the ** over-ri|K*'' stage.
ExiKTiments have also Iknmi made to determine the constancy of the
absolute niimlKT of white eorpiiseles and their relative percentages in health?
infants under ditferent conditions. It is found that the longer the interval
iM'twecMi the fw^lings the m(»re marked is the inerease in the white corpuscles
during digcnstitm. After two or thnt^ hours' fasting there is not much
THE BLOOD LN INFA^NCY AND CHILDHOOD,
:347
chaoge in the blood ; after five hours' interval there h always a leucDeytosis
averagmg from two to four tbousatid. The caiii^e is tc» be found in an abso-
lute aud relative inerease of neutn>phile^, the number i4' which corresixDnds
to the increase. Morphologieall}^, therefore, the bhiod i.s older.
The time of day, variatiou^i in tem}K*mture, and physical exertion seem
to have no effect iiiK>n the number oi' the white eorjjutii'les. Mot*t anthoi's
place tlie normal |>ereentage of eosinophiles betwec^n 2 and 10 |xt cent. It
is safe to say that they may Ix* somewhat inereasc^l, even c<iiisidenihly, in
infants* blood without having the same signiiieance as in adults' blood.
It may l>e of value to speak of certain scjurees of error in computing
perccmtagt^s w^hieh Weiss mentitmed^ — namely, that it is nut enough to
oount the varieties of corpuBcles of eat-h kind» and thus estimate the |)er-
oentage of each, beeause yoo an* then dealing wath t^mpamtive and not
ahs*jlute figures. It will n^adily ha seen tliat if a leueocyt*tais is prt^sent,
and one variety of corpuscle is increased, it must make the (jthers apjK^ar
relatively diminished, w^hereas they may Im* absolutely normal or even in-
creaj^d. The folh>wing table o£ Weiss show^s this plainly :
TABLE 87.
Counts. Bosinophilea.
1 800
2 31)0
3 600
4 .... . . fiOO
Totiil Lt'ii(»oeytei.
UllKM)
34-
20 J KM)
1.5+
40,tXlO
1.5 +
10,000
6+
I
This table shows how little reliance can be placed on a c<imparative e*)unt
in a given case^ for tlie percentages show a marke<1 variatii>n withe »ut Ixnng
any index as to w^hether an actual change in tiie nnml>er of e^isinophiles
has occ*uri-ed or not. In tlie tirst e<jnut they are normal ; in the setond
they are at»solutely normal and relatively dimiuished ; in the third they are
ibeolntely increasetl and relatively diminisheil ; and in the fourth they are
Ebstjlutely and rt^latively increased. This explains ti) some extent the
contradictory percentages which have been reix^rtt^l. In onler, therefore,
to estimate an absolute inerease of any variety a |Missibly (x>neuri'ent leueocy-
ttrnk must l>e taken into acoonnt. Anotlier s^>uree of error men tiunecl by
the same author lies in the staining fluid. Where acid and alkaline solu-
tions are combined for stain in *jr purposes, it is possible, accidentally, fnr the
alkaline solution to Ix* so strong that not only do the eoar^ grannies stain,
but also the fine neutnij>hiles. Bith have a red ndor, and a jiers^m cle|H»nd-
ing on the cokir alone might mistake the neutrophiles for eosinophiles. The
size and refraction of the grannk^ shonld thei^efore be obscTvixl in every
case.
»
^f THE BLfMJB IX INPAKCY A^'D CHILDHOOD, 349
You %vill notice the liigb relative percentage of the lymphocytes, which
you ^vould expect in the early days of life. The percentage of polynuclear
cells \va.s extraordinary on February <i, es|)e<'ially when wimpared with tlie
<Hiiu3t thi\?i» day?i later. For an infant, tliis was a very marked neutixi-
pbilic leucocv^osis, for which no cauae could be ascertained,
THE NB'W-BORN.— Gundobin thinks that it is pmiier to s[)eak of
tlie new-born iniant'B blo<)d a.s pathological. He considers tliat tlie nior-
pl in logical changes which occnr in tlie bbicHl during the lii*st iew day 8 of
life are not accountc^l for by the oixlinarv [ihysiological conditir>ns ; that the
variati<m.s in the weight of the new-lmrn and the cjmiiititati%T and qualita-
tive changes in tlie form-elements of the blood eorresjioiid, 8<3 far as tJiey
are caused by the same processes ; that the proljable cause of the raor[>ho-
logiad and the chcniiral differences between the ne\v-lM»rn iidant*s blood and
that of the nursing inlant Ls to hr^ found in the deviation fnimi a normal
tissue metamorphosis occurring in the new-born ; finally, that the organism
of the new-born infant sliows very little ]>ower of resistantt* to jiathologieal
pro4iesse.s, and that tlie exajuiuatiou of the blinid after Ehrlich's metli<xi
shows better the length of the tM*rit»d of development usually designated by
the term ** uew-l>orn^' than any other means.
I have herc^ auotlier infant (Case 114), fimileen months old, to show you.
It is apptmMitl y perfectly healthy, hut a physical examintttiori shows that it» growth has
beeD rttiiriliti, mnd thnt it really only repro«<^nts thf devt'lopnieiit of an infant alw3Ut seven
months old^ go far as its weight, te^th, and funeti*>ns are ooneerned. The hlof>d examina-
tion presents eharActemtie« which corre^spcmd U* the «tage of it* development rather than
to its age. Its blood therefore can be considered abnonnal, hut i I lustra live of an early
ftiige of development.
BLOOD EXAMINATION 2, (Whitney ond Wentworth.)
Infant J4 mimthH. Dfrvefffpmeni eorr€»pon(iA to 7 rrmnihji.
Erythrocytes . , . . 4,928,760
Htemoglubin , 45 pi-r cent.
Leucocytes 2i\,i)Qi}
Small mononuctear . ............. 66 per cent.
Large '' . 17 **
Polynuclear .,,..... .......... 16 **
Eoeinophile* 1 **
With a few exceptions, Jiiieh m mfilaria, leiicsemia, chlorosis, ansDmia
progres.siva ])c*riiieio*^a, and auaemia iiitaiitiini [jseudu-leuka^mita voo Jakseh,
it is hardly wise at preneiit t<^ attempt to classify changes in the ele-
metitj? of the 1>I(mh:I, aeci^ordinfr tn tlieir orijiin, int*> primary and scxxjndary
dif^eases* I t^liall therefbri' merely exjilaia to you exaetly what was found in
my examinations of the blood in various diseases, wnth the hope that this
%vork may aid you in understaiidinjr tlie far more extensive investigations
whieh are lx*ing made in Eumpe,
There are certain ehange.H in tlie blood which oeatr under varying eondi-
tioiis, both physiological and pathologiml. They are quite commonly met,
350 PEDIATRICS.
and are fouiul in many different diseaficSy whether the diseases are prinuir
in the 1)1(hkI itself or are merely reprei^nted seoondarily by the changes io
the I)1(kk1. TIk^' general changes may be divided into two broad classes,
(1) leiKHK'yt(»sis and (2) oligocythaemia, and I think that you will better
understand what I shall say concerning the blood in each disease if I fint
desiTilM' tlu^se general classes, M'ith, so far as is possible^ the especial diseases
whi(*li JK'long to them.
LEUCOC YTOSIS. — The best definition of leuoocytosis that I can gir?
you is one that has Ix^en formulated by Dr. Richard C. Cabot. He^vs
that *' lcuc(K'yt4)sis is the pn*siMi(*c in the blood of an increased number of
white <vlls of the same varieties morphologically as those in normal blooi
a plurality, and generally an ovcr\vhelming plurality, being polynuelear."
Pliysiologicidly, we find a Ieucxx*ytosis afler the ingestion of any proteidfool
It is at its heiglit alnnit two hours afler a meal, when the total number of
leuco(y tt*s may Ik? as great as fn)m 13,000 to 30,000, according to the age
of the child. Pathologically, a leuoocj'tosis follows a considerable number
of dist^ases, and seems in a general way to dei)end upon the amount of local
reaction to which the disease? gives rise. We find a pronounced leuoocrtoeig
in most levers and in most s(?ptic processes. Von Limbeck, in his article od
inflammatory leuc(K?ytosis, says that a leucocytosis not only aooompanies
an exudation, but " corresiK)nds in degree to the number of cells in the
exudation ; that is, whether it is serous or purulent." Of the pvogenie
bacteria he sjiys that the staphylococcus seemed most productive of leuoo-
cytosis, csiKHMally the pyogenes aureus. It is not known why this should
lx» s<). In these t-ju^s tlic incrtu^ is almost wholly composed of the polr-
nuclcar iieutrophilcs, which may make up from 90 to 98 per cent, of the
entire Icu(*(M*ytc c<mnt.
Although 1 sliall have occasion, in showing you cases in the wards, tD
sj)cak in <lctail of many of the diseases tliat give rise to a leucocgrtods,
I will now l)ricrty enumerate them. Pneumonia shows generally a leuro-
cytosis, an<l esjxK'ially if tlie case is to have a favorable termination. In
pncuuKmia the large increase in the number of leucocytes seems to follow
closely tlic course ni the pathological process, and the "blood crisis" is
foinid t«) anticipate the *'' tcmiK'rature crisis" by some hours. Pericaiditis
and cndcM-anlitis, advanced plithisis, pleuritis, erj'sipclas, acute rheumatism,
purulent meningitis, j)haryngitis, diphtheria, septicsemia, osteo-myelitis
scarlet fever, variola, sonu* profound anaemias, whether primary or second-
ary, leucjemia, lieinorrhagcs malignant new groi?vi:hs, abscess of any kind,
including a]){M>ndicitis, and many skin diseases, are among the otheis that
sliow lcuc<K*ytosis. The dis<^'ases in which the leucocytes are approximatiely
normal are malaria, tulx*rcular meningitis, tubercular and serous peritonitis,
influenza, measles, typhoid fever, and pulmonary phthisis unlos there is
a sccon<lary infection by other Inicteria. Comparing these two lists, you
will s(H.^ that tlieiv are some cases in which the leucocyte count may be of
gi*eat im|K)rtance to the physician in making a difierential diagnosis. Bf
THE BLOOD IN INFAXCY AND CHO.BH0OD.
361
Bte aid we may in mme vases differentiate scarlet fever from measlcg, a puru-
Bent from a tubeniular meningitis, and a beginning pneumonia fmm a tnl>er-
Ecnlar meningitis or typhoid iever. Lastly, we may by tlie leiiefxyte coiitit
llilone l>e n\i]v to dtN^'ide Ix^twa-n .^ei^sh antl tualaria in a patient wiio.se unly
bymptonii^ are malaise and returning chills.
I Leuc-KMIA. — The di^ase Liilled leuc^mia isuinetinu^ iieeurs in infancy
bmd ehihlhood. lvh?ljts, voo JaLsi-h, and Siinger de?>erilx' c<jngeoital eases.
■On the whole, it is a i-are disease in infiiney, and when it occurs it i«
probably always a mixed form, A pure myelogenous form of leuca?mia
is very rare. Tfie etioh^gy of the diseai5e is obsc^ure* C-ases have Ix^n
re|)orti'd which followed wngeniUd syphilis and rhaehitis. It is thought
|by R)me to l:>e an infeetious disease, but the evidence Ls iusuflieient. Von
[Lindxx'k thinks that it is a disease* of the lymphatic system. Others say
jtliat £my anaemia or llodgkin's disease may pn egress to leuciemia under
loertain cireumstanees, a^ may also aneemia infantum pstnido-leuka^mim. A
IliumbcT of east^ are apparently primary. This is one of the few dist^ai?es
Iwhich t-au 1m:' diagnostiraUxl defmitely from the bhxMl-examinution alone.
I Speakiug of the htematology of leuciemia, we find tliat it ix^curs in two
Idistinet varir tif^s, acf'ording as the Iym|>h-glands or the spkru aii<l Imiuc-
Imarrow have Ix^en most affected. I will Ix^giu with a short description uf
■the latter, the splcno-myelogenous. The first and i>erha[»s the most striking
ithiug that you will u^iticv in examining the bhx>d is the great iiicn^ase in
Ithi' leucocytes. Von Jaksch ivfMirts a ease in an eiglitecn-muutlis in taut
Iwhem the figures were 1 tu 18, and another in which the astonishing ratio
lof 1 to 2M was found. But a leucwvtosis alone, even a pn)found one, doc^s
Inot make a leucamiia ; it is the €»sj)et?ia! kind of hnictx'yte that yun nuist
lde|Hwl u[w»n, tfie so-cal!etl myelocyti^s, or " markzellen'' (*f Elirlieli (Plate
■v., 8a, facing page 330). Thc«*<:^ cells, which are said ne%a^r to Ik* ibund in
inormal bhj<id, art' present in this dist^ast' in varying projxirtions n|i to 20 jwr
Ic^nt. nf the entire leucocyte count, or evi'u higher. Associat4Hl with tlicse
Khere may be the eosinophilic markzellen (Plate V., 8//, tiicing page 330),
I which Ritnler and others have held to be tHjually diagnostic ; alsii the duarf
letjsiuophilcs (l^late V., 4//, facing page 330), which ditler only in size from the
■ordinary jKjlynuclear eosinopldlic cells. These three varieties of elements
■are found in givat uunilxrs in the marrow of the long bones, and tlientt' arc
leuppf^scil to get into the 1>1(mkL Of the forms of leucotwt*^ with wlricli
lyou are familiar in normal \Ai»A you may fiud the ixdynuck'ar CHisiuuphik-ti
pncreased. Their variation was tliought at one time to lie of diagnostic
Rmportani>e, but it is now conpidonxl to lie of no value. Tlie {>oly nuclear
iiaeutropliiles are normal, or fret|Ucntly art:* relatively diminished and varj^
■in size more than usual. The lymplitxvtes in pui'e spleno-niyelogenous
HeuGsemia are always diminished. Karvokincsis is marked in the leutxMvtes.
iThe erythrocytes you will find rt^luc«:d, hut never so much so as in the
■ primary or even the secondar}^ anaDmias. The percentage of ha&moglobin
Ideereaaes proportionately witli the numlier of red globules or jslightly u
362
PEDIATRICS*
advance of it. La^^tly, micWtecl red cells appear, mostly noniM»bbt
thuugh mepilt>ljla8t« are not very rare iu cliildren*
Turniiij^ iu»\v to the ?^ee(>nd or lymphatic variety, the bIcHid-picmit ii
very dirterent, though (juite ns distiuctive. In thii? the leucocytes areiMff^
80 greatly increased, aiul neldom exceed the proportion of 1 to 15. Tbei^H
niksLs iV8ts ii|MHi tilt" womUo^ful rt^lative inci\?ase of the lymphocytes. TThP
as ynu kn(»w, shuiild nuike 25 to iH) p^^r wnt. of the eutiiv leiinwytiHT^tinl
HeiHmlinj: to the n^v uf the child ; Init iu thi^ form of leucaemia 90 pcroas
and r*ver hfis In-i^u re}>ort<Hl, even in atlult*. Relativ^e to these, all die'itlw
leiifwytes aiv diniinishid. The 8pc?eial eelk, which 1 have told ym m
found in varying piYipirtions in tlie Bplenoniyeloj^nous form, ajr nir;
pc*rha|»s tlit'ir rK^tisinnid pn^niee may bc^ exjjlained by a slight iDVolvTUkut
of the iMJue-marrow, even in tlie jiurt^t tymphatie forifi.
Cask 115. (DainnTi und ("heever.)
Wuren Mufieum, llanttrd rtiivui^Uy. Lymrihritlp leupwmia. Boy. 8yemis old.
This case (Ciwe 115)^ the hbton^ and picture of which 1 have brau^ht tnnu the wJ
Mugeum to show you, is tbttt of a hoy vii^ht y^ar^ M, n^purted by Dr. H, F. Dfmiaii.
hftd ahowri yymptfims of enkrt^ed i'orvit!iil f^hinds for n yimr, but bii^ gencfnU he
been ftiirly go<:>d. He nevt^r had fiiiy pum \n the ^ lurid s^ and was well enouifh to i
eohooL An exiiminatioii of thu bUxwl showed thut the relation of the 1eucocyt4»
eryihrncytei* vari^ d from 1 to 50 to I to 10.
Two months prtniouf to tbi- time wbi'n this picture was tnken, the tumor bad i
rapidlvt and you see it is of coneidt»nihh^ *JSie^ involving the entire left ^ije of tii«
The boy compkined at thi^ time of headache, which probably was CHus(*d bv prcpromi
the recurrent vessel** of the neck. The uoifis of inipactcHl ^'IniRbs bad begun eiideiilii U
preAS upon the trachea, and nn cxi*rtton the re^pimtion was slii^litlv interfered with
piilpfttion the tumor was found to coni^ijit of many bdmle^, wbk'b Wftn> to some eit^-nt i
ble, and appeared to be made up ^►f an en billed chain of lymphatic glands. It
THE BLOOD IN INFANCY AND CHILDaOOD.
353
fW>m nejir the middle line of the Deck in front, back upon the edge of the trapezius on the
left Hid^, nnd above from the lobe of the ear and angle and body of the lower jiiw down to
and benuttth the clavicle. The left shoulder was depressetl by it. A number of en lulled
cut4iueoua veinfi ran over it in VfUiou^ directions. As the tumor ishowed no signs of soften*
ing, but was steadily enLarging^ it wati deemed best to attempt it^ reinovaL The operation
wa* performed by Professsor D. W. Cheever An incision wais mndti^ from ju*t h>eh»w the
ear t<» near tbe cricoid cartilage^ through the skin and platysma, and disck>8ed a lobulated,
hard^ glandular masa, lying mainly beneath, and partly behind, the stenjo-mastoid muscl^.
Contrary to expectationT it was found very adherent in all directions, and tht; lobule^i were
bound together by strong tibr«jU8 tissue. Couiiiderable time and care were r»xjuisjt** to
divide the adhesions, which were too strong t** yield to anything but the edge of th« knife.
It WHS found neoes.sary to divide the sterni>-iiia*toicJ, and to dissect aside the externul jugu-
lar, which mn^ somewhat dii^placedj over and lhr<mgh the tumor. The lower edge of the
tumor extt*jided l>Hjieath the clavicle, into and below the i^ubcliivian triangle. The base lay
lover the sheath of the cariitid, which was necessarily exposed for about two incbes. Con-
I tinuous dissection was required, even to the last adhesion, for they could nowhere be made
to yield
The boy recovered in a few weeks, a large part of the wound healing by first intentloiL
The tumor was found to consist of a lobulated amss of hypertnipliied lymphatic glands,
Annly hound together by investing flbroui ttesue.
Tw^t years after the operation the child wa« alive and fairly well| although the glands
on both sidea of the nt?ek w^erc again found to be considerably enlarged, as wero abo those
in the Hxillie. The turther history of the case is unknown, and the report i^ in many ways
I unsati^fiictory, but tbe facts as stated are all that I could ascertain about it. There is no
I doubt in my mind that it was a case of leucaemia*
f
T]w sc<Y»inl general rlass, which I have referred to as liable to occur in
many tliseitses, i^ r>ligoeytliietiiiii.
OIJQOCTTH^MIA. — The atiiemias are of commou otxrurrence in
infancy and eliildhtMxJ. Our ordinarj* methods of examination are evi-
dently inyuffirieiit to discover tlie causes of tlie amemia. It seeim< as if in
Hie future we miist dirtrt our attention to cttiier methods of invoi^tigation,
and especially to the exatuiimtiou of the lil(xid*serutn. It may be of
interest to refer briefly to Mara^Iiano*s recjent thc<»ry rt^nnling the bl(K>d-
serum ami its a4'tiou on the txirpust^les. Mani|^liani»'s n^'arches ujiou the
bkxKl-plasma have tended to show the various relations existing between
die organs and the bloo4i» Pnjuoyuee*! l<K'al pathological chtrnges in-
fluence the tM^mjxtsition of the bltxMl-scrtim, su that in et>nsetjuenee of
tJiis the eorpusc*k^ later are destroyed. The length of time required to
prtfdud^ this result dc[x>nds ujM*n their re^iistance. Tht-^e oljei«*rvatioii8
tlirow light on a nnml^er of clinical result^*, and on the de|»enden<^ of
the anieniias ujx)n severe pathological disturbances* Iklaragliano found that
the erythrocytes, when pathological ttmditious were present in the serum,
were rapidly destroyed, wh(Tt*ius in healthy senim they remained almost
intact. He examined the blorwl mtuiu in N'ariiKis discas^^s, as, for iiistan<x% the
essential anaemias of all grades, earcinonia, satunH-ni»i-. -pleufi-myelogeuous
and lymphatic leuctemia, puq»uni, cirrhosis of tiic hvcr, nephritis, pneu-
fia, typhoid tever^ erj'sipela^, anil tuberculosin. In all thet^' diseases the
m has a destructive effect ou the eorpiiselee as et>mpared with normal
m, but with quantitative differences de[)endiug on two factors; (1) the
2a
354 PEDIATRICS.
vuliiorahility of the reel oorpusc^les, and (2) the destructive power of the
seriiin. If both of these factor?* work together, the effect produced i> «-
tivnie. lie is very cautious alx)ut explaining the cause, but deuie:* aiv
definite relation l)etwwn the amount of albumin and the destructive in.wif
of th(» serum, and rather inclines to the belief that the quantity of salt- it
the siTum 1ms some influence. While the erythrocytes are being de^t^«)y^;d.
however, the bhwHl-making organs are luidergoing an increased functionil
activity, and pnKlucing erythnxytes to supply the loss. Maragliauo con-
cludes that diUcrent iH)nditions of the serum produce in the red coq>ii?tWj
all the ai>iH'arances of necn^biosis, and can even destroy them. This giv«
an anatomical, ])hysiological, and |)athological basis for our belief in inde-
jMMidcnt diseases of the 1)I(kk1. This theory concerning the blood-serum i?
at least i)lausil)le, and until it has lx?en proved incorrect it may Ix* aoeept«l
Perhaps this nccrobiotic ix)wer of the senim, which depends on some pre-
vious disease, varies in dilfeivnt diswises and in different individuals. Evtji
ii' it is j)rescnt in suflicient amount to cause anaemia in a given case, it may
not do so l)(H*aus<' of the resistance of the blood-cori>uscles to its influemv.
The variation in these two factors — namely, the resistance of the red corpur
cks and the destructive iM)wer of the serum — will account for the variation
in the degree of anaemia pnwluced in diiferent individuals having the sany-
dis<.»asc.
We know that in distillrxl water the coloring matter of the red oorpii-
cles is extracted irom the stroma, but when a certain percentage of sodium
chloride is added to the water the integrity of the red corpuscles is pre-
served. That the erythrocyt<»s are not normally destroyeil by the serum in
which tli(\v float seems to dei>end upon the presence of a sufficient quaDtity
of salts in the s(»rum. A serum in which there is just enough saline mattff
to j>rcserve the nxl corpuscles has Ixx^n calleil by Hamburger '* iaotoDic.*'
But JH an isotonic scrum would easily lose its protective properties, owing n»
its dilution after each meal, we gt^nerally find a higher salt percentage than
i> ucccssnry to pres(»rvc the md corpuscles, — a condition designated bvthe
term '* li\ pcrisotonic."
From cxpcrinicnts upon animals it has l^een proved tliat the senim pi>r
scsscs powerful ^•<'rnii<'i(lal projM'rties, which are easily destroyed bv raising
tho l)loo(l to a tcmjK'nitun' of o.">^ C. (l'U° F.) for a short time or bvex-
j)osinir it to li<;lit. Still more sin<rular is the fact- that not on Iv does the
mi-\intr of th(» scrum of one animal with the blood of another of a diffen?nl
sjM'cics destroy its pTmi<i(ljd jxmer, but also that the aclded serum acts a?
a solvent lor the red eorjjusch^s and renders the white corpuscles inactive.
There is consideraMe rc^ason to believe that immunity from a given diseai*'
dejK'uds uj)on tlic character of the serum ; and Klemperer is now carmn?
on some interesting exiK'riments with a view to producing immunity br
serum inoeuhuion.
In regard to what are usually looked upon as primary anaemias, we can
speak of such diseases as chlorosis, pernicious aniemia, and ani»>tr|ia infantum
THE Bt-OOD IN INFANCY AND CHILDHOOD.
356
I pseudo-leu kae mica (vou Jakscli). By far the greater number of aufemias in
[early life are, however, of secondary origin. Hemorrhage, the aeute iufee-
Itious diseases, syphiHs, rhacliitis, new growths, intestinal aflk'tionsi, and dis-
leasea of the respiratory system^ skin, and honeys, are the onliuary caus^t-^ of
^ndary aii£emia« The degree of the aua^mia dejwnds u|k»u the iniiividiinli
[upon the severity and length of the disease, and upon other causes whicli
as yet imlvnowu. The secondary ariiemia.^ may be either of a mild
lor of a severe form, and may be accompanied or not by a greater or le^s
•degree of leucocytoais. The mild forms are usually spoken of as anamia
^ chronica iet^h^ while the severe fiirm;^ may be callcfl aimmkt ehronica f/rapia.
The blood in these cases shows a varj^ing degree of oligocytluemia and oli-
1 gpc^hromaemia, with or without leueocytosis, and» if severe enough, piikiJocy-
tosis, microcyt(»sis, and at times micleattd r4xl eorpiLscIes, Tlie latter are the
[more frequent the younger the child, and generally m-cur during the hi^t
iyear. They are never very numerous in these caiscs, and are» as a rule, of
] the normoblast tyj)e.
Primary Anaemias. — Poor as the classification of the anaemias into
aary and sec^oudary may be, it will, I think, keep the subject more
rly before your minds if I follow tliis very imperfect division, which for
of simplicity' it has seemed almost neoessary to make. I sliall
berefore sjK^ak at one* of the anannias which are supjxvsed in Ite primary
[and which I have just enumerated, wishing it, however, to be undci'stood
%t I use the wortl primary only provisionally until further light is thrown
an this class of diseasc»s.
Chlorosie,^ — Although it is still a matter of dispute whether chlomsis
shun Id lie chissed as one of the ana^miaSj it will simplify what I Iiave to say
on this subject if I sj)eak of it as such,
Weiss doubts if chlomsis cK-curs in infants and young childix*n, but
lie observations of Henfteh and others tend to show that it does. The
I distinguish hig characteristic of the disi^asic is the very low percentage of
^hffimogltibin rc^Iatively to the nearly normal mimlier of erythrocytes, wliich
[is in marked contrast to that found lo other dist^as*.^^, cs|recially progressive
peniicio!is anaemia, Thei'e is very little or no leutN)cyt<»sis, Oinsidcmlile
variation in tlic size of the er^'throeytcs ownrs, {Kakiktcytes, micrrwyte^, and
[inacroc\*tcs bt4ng often found.
In this (x>nnectifin I \\\\\ i\4vv you to some interesting Av<irk on the
intc*stinal origin of ehlonisis which has been done l>y Dr. Fori^hheimer, of
; Cincinnati, and to his original views and new definition of this disease.
This infant (Case 116), eighteen months old, lia» never h»d the symptomii of any
1 ipecial diAeasci beyond a pallor of the nails, slrin, Upe, and mucous mombraiie of the gumt,
I with low of aj)petite and strength. This ha« lasted for about aix monthg, and drjoi* not
I appear to depend on cUmatt? or habitation, m the infant ha* been during thi« peril >d in a
I number of houses, botlj in the city and at the seashore. An examination of the bl-MKJ
ahofwed that it was a case of chloro«i«, the erythrocyte* being gomewhat reduced and there
ll»eiDg a decided oljgochrc»m»mia.
356 PEDIATRICS. '
BLOOD EXAMINATION 8. (Wentworth.)
Erythnwvtea 4,427,50a
Hijciiiuglobin 85 per cent
(Thi* infant gradually impruved under a coune of treatment which wu hzph
dietotic.)
Tlu> noxt c>a8o (Case 117) which I have to report is that of a female infknt, elercBi^
onc-lmlf months old. The pallor of the lipe, guxuB, skin, and nails in this cue n
extreme, und was accompanied by loss of appetite, but no especial emaciation. TIk bM
examination gave the following result :
BLOOD EXAMINATION 4. (Whitney and Wentworth. )
ErythrocyteM 4,470,000
Hsnmoglobin 80 per cent
LeuetK'ytes 26,000
Small mommuclear 46 per cent
Large ** 21 "
Polynuc'lear 80 "
Eosini>phile8 8 "
The cause of the chIoix)sis was apparently arsenical poisoning from mD-
pa|K'rs. The chlorosis was always extreme during the nine months of tk
year when the infant was in its winter homey and was unafiected bv trat-
ment, either dietetic or medicinal During the three summer months tint
it was away thnn home it decidedly improved, but it immediately gret
M'orse on n^turnin^. The i)a|K'rs throughout the house in its winter hon
were found to Ik' dan^rt^rously arsenical, and on their removal the infiot
rai>i(lly improved, and in a few weeks regained its healthy color, strai^
and apix^tite. If the chlorosis in this case was caused by arsenic, it must
of course lx» classcnl witli the secondary amemias.
Both these casc\s illustrate the fact that extreme pallor does not neces-
sarily indicate a ^reat reiluction in the number of the erythiocytes.
The sy ni])tonis of this disease as met in infants are progiessiye loa cf
ai)iHtite and of strt^nj^tli, and extivme pallor of the skin and of the mncoos
menil)nine, not accompanied, as a rule, by marked emaciation.
Ansemia Progrressiva Pemiciosa. — I shall next speak of a vm
severe form of primary aiucmia, the prognosis of which is so aerioos thit
it is called antrmia perniciowi,
Biernier in 1 868 d(»scril)ed a disease under the above title^ and sud tbt
it deve](>iK»d apparently without any ctaisc and by a gradually inaeftai^
and constiintly progressing aniemia caus(»d death. The pathological and am-
t<)mi<*al changes consisted in a gn>at diminution in the amount of blood in all
the organs, witli marked fatty deg(»nenition of the heart, blood-vesselsy liver,
and kidneys. Capillary hemorrhages were frequently found. Since that
mass of literature has lxH*n accumulating on the subject Varions antboR
have observed erases in infancy and in childhood. Most of the cases, how-
ever, wen.' over a year old, and it Ls certainly not a oonunon diif^HBe of orir
childhood. The description of the disease does not differ materially fiva
THE BLOOD IN INFANCY AND CHFLDHOOD.
367
ithat of adults. Tbere i8 ao apparently s]>aiitaoc>oiiB beginning in most cases.
iKlebs and Frankenliaiiser tliooglit that tliey found wrtain njicnKxxxn in the
Ibloor], but this has not U^en proved. Cai?it^ have been i'et^)!'ded wliieh liave
Ideveloped as a result of efingenital syphilis, and thtTe an- other ease:^ in whieh
mie presen<^'e of siieh intestinal parasites* as the anehylostt>nia dumlcnmlis and
Itlie bothrioeephalus latns have appeared to be followed by it. Cases have
lalso apimrently t"<^llo\ved refK'ated hemorrhages. The majority, however,
liDceurred without fuiv dis^«ovenilile eause.
I The blcKxl in pernieious anaemia h thin and light-eolored, and all the
Ifonned elements are markedly deerease<l. The enormous diminudou of
krythrwytes, whieh is more marked than in any other disease, even in the
Kigbest grade of simple secondary aniemia, the relatively high hfemoglol*in
Iperecntage, due to the large amount of htTmoglobin hi eaeh eorpusele, and
I the presc^nce of megaloblaste in large nuni Iters, are considered to be diag-
Inostie tj{ tliLS disease. Poikilwytosis is usually pronoiuieed. Mieroeytea
land maeroeytes are common. There is generally a diminution in the
"^nuraljer of leucoeyteSy the prevailing type being mononuclear, but at times
we find a distinct leueot^vtosis. It has been pointed out by von Jakseh that
[the degree of leucocytosis is never so great as in anaemia infantum pscudo-
enkfiemica. Eosinophilie cells are, as a nile^ present in uunsual numbers,
lyelocj^tes in small niumbers are not infrequently tound. Cliuieally tlie
lisease does not differ from that of the adult. It is the severest tyj>e of
Ittll tlie anaemias, and all the casejs have pnjved fatal, except those in which
I intestinal parasites w^ere found to be the cause and were removed beibre
[the diseii^^ had become fnlly established.
Tbii* infunt {Cme 118), six months old, is appHPenlJy a ca«e of pernicious annmiftf
I Although the blood exftminatioT) doe& not entirely i*stablish the diagnoeia. It entered the
rlioepital when it wa« five and one-hftlf montba ttld, witli the biatory of having been fed on
I* variety of ptitent foods from the time of iU birth. On physical examination nothing
lAbnormttl was found in the abdomen or thorax, and it wa* not especially atrophic. Ita
I weight was 2841 grammes (6 J pounds). It now weighs* 2915 grammes (Of pounds). Since
Kenterin^ the hcj^pital it hiu^ failed to reispond to treatment of any kind^ whether dietetic or
Imedicinal, and hae become more and more anjtmic. You will notice the extreme pallor
(of the mue«ju§ membrane of the gums and of the entire skin. The following is the report
[of the examination of the blood :
BLOOD EXAMINATION 5. (Whitney and Wentwortk)
IrythTocytee 2,087,500
Hemoglobin 85 per cent
Leucocytes , *.».... 6,5^
Small mononuclear 66 per cent.
Large '' * . • 10 "
Polynuclear , , 86 '*
Eosinophiles , « . . . . . , 5 **
(The infant continued to fall progressively, and died about two months later. The
[temperature and puke were pnicticaUy normal through the whole course of the dtseaM,
S58
PEDIATRICS,
and tjuthtng Kbnorm&l was at any time detected in the thorax or abdomen,
auto^K^y. A ftiw du>ni before death there appeared extensive heoLorrhjiges undiff i^^
of the ttbdumen. )
ThU infant (Case 119), seventeen months old, presents the t^^iciU app«^ranos tif » |
aideais aniemia. On entering the hospital it weighed 6026 grauiiiie» (ia.(Ki peondi),!
has been progressively losing, until thiiF^ morning its weight wmb only 5798 gnumtiss (113
pounds). It h emaciated and has had but little appetite^ but it h«$ evinced a daiD«l»«t
any dirt ilmt it can lay its hands on. A phviitcal examination reveals nothing aboocBii,
«uch fu« thoracic disease^ enlarged spleen^ or enlarged lymph*glaiid;§. The skin hL thrtz^
parent ratlnT waxy appearance (well represented in Plate V., fiK:ing page 330, An
Infantum FseudoLeukajmica von Jaksch} which occurs in ansmiaa of the highest |
Cask 119.
Auiemift perulclcna, Fenmle, 17 moulii& oM,
She is rather apathetict in fact, almost dull, and can be handled and ej
out any apparent dii^comfort- The result of the bUxjd eiuminatjoti is very sign
BLOOD EXAMINATION 6. (Wentworth,)
Erythrocytes 1,022,500
Hiemoglobin . , 17 peroeal
Leucocytes 10,000
The nejctcase (Case 120), an infant nine months oM^ was seen by me in consullalki
with Dr. C. P. Putnam, who has kindly pr^Jvidt^d me with its previous bist*.>rv. Tk i>
fan t was healthy at births and up to the time of its present sickness had never had irr
disease. For several months it had pr<»grcfigively grown pale, and ite appetite had d^ddoi^
lessened. It bad not, however^ lost matfnHllv in weight, but had grown weak phrsifalli'i
and its mental hebetude had been so noticeable that a suspicion had arisen thai it wi* Wf-
ing in cerebral development. On inspection the infant seemed moderately lkt> but t^
muscles were soft, and the skin was of an eitreniely pale and waxen tinge! It wa^ *tv
dently very weak. On phj^siciil examination nothing abnormal was detected tbcjut t^
head, thorax, or abdomen. All the organs seemed to be of natural aixo. Am
of the blood, made by Dr. Dane, resulted as follows t
BLOOD EXAMINATION 7. (Dane.)
Erytbnxjytea 1,671,000
Haemoglobin 22 per centl
Leucocytes , , . . . ig ioq
Small mononuclear , 42 per cenl
Large ** jg
Polynuclear. ...,.., *,,.., 40 4*
Eofsinophilea . , q ,4
THE BLOOD IN INFANCY AND CHILDHOOD.
369
^
You will tiotieo thp great roduction in the number of red corpuscles, the relatively
llarge jjerceutage i>f hatfmoglobin, and the slight inci*a«e of whit** celU, The di1ter«>ntittl
'count gives U8 no s|>edftl in formation in regard to the cause or chanuiter of the disease.
(The child died a few dA3's later without fihowing any other Bymptonis.)
The next case is the fourth id which the- clinical history and the great
oligocythiemia seemed to jxjint towards aineniia perniciosa m the most prob-
able dl'^ejLse, but no elaborate bltMxl examination was made.
A female infant (Case 121) entered my wards at the Children's Hospital on the 16th
Lday of ApHK 8be wa& then nine months old. Nothing ahnurmal wa« detected in the
llungs or hetirtt and thore was no appreciable enlargement of the liver, spleen, or lyniph-
fglands. The pulee varied from 120 to 140, and the temperature from 86.7'' C. (98.0t>«» F,)
■^ 87.8«* C. (lfNJ,04'» F.). The respiration wa-? from 44 to 68. There were hemorrhagic
lipcita on the nnklei< and head for a few day*, but these soon passed away^ and nothing
|»bnormiil was detected except extreme pallor of the skin, progre«iiive loss of appetite,
ciation, and quick respiration. The erjthrticytes wert* reduced to 786,0(X>, and there
marked poikilocj'tosis. There was a Alight amount of albumin in the urine. The
iint grew rapidly worse on April 22, and died in the evening. There was no autopsy.
Ansemia Infantum Pseudo-LeuksBmica (von Jakseh). — I shall now
speak of a form of chronic priman^ ansemia where, in order to make a
diflerential dia|;uosi8, we must c^>nsider the etiologj^ and phv^^ical signs as
well a8 tlie blm>d examination.
I Von Jak^h, in 1889 and 1890, was the first to describe this disease and
give it thLs title. Since then it ha^ lieen the suliject of much investigation
and wntcntion, Vou Jakseh based his diagnosis ou the following ixiints :
that it \vm a disease of infancy, charaeteriztHl by marked oligoi'yth^emia,
oligtK'hroma^mia, cr^nsideralnle jiernianetit leutY)(*yti>sis, marked splenic en-
larg:enicnt, at times enlarge* I lymj»h-ghinds, only moderate or i^light cuhirge-
ment of the liver, and clinically to be ditlercntiattHl from knieiemia by the
dispropjrtiou existing between the size of the liver and the spkM?n. The
moiT favorable pn>gnosis is also an aid in the diaguosis. Alx>ut the same
time Haycm describc^l a similar disease in a cliildj and noted tlu^ pn^ence
of inuncrous nucleated red corpuscles. Von Jaks(*h had noticed them, but
had mistaken them fur Iciicn Mbytes having crytlirtxyti.^ inside of them.
Haycm notctl es()eeially that many of the micleated rtnl i-orimscles were
midei^oing mitosis. This had never been observed before in the circulating
bIcMxk
Lu^^t verified Hayem\s observations. He dcscTilied this as a disease of
early infancy, and emphasizt^d the chronic course, the intense anosmia, and
the large size of the spWn and the liver w ithout enlargement of the lymph-
glauds. He only found a slight lcnc^K\vtosLS, in which the eosiuoi>lules
were quite nnmerijus. He c<jnsiders the largi? nnmlier of nncleat(*d rwi oir-
puscles, many of them showing mitosis, as t*s|M*cia!ly imjK>rtant for diagno-
sis. This t:^)ndition he has not found ho marked in any other diseast* of the
blood. He considers this one of the raiv affc*'ti<uis of infancy, as accyjrding
to his statisticB it was met only once in fifteen hundrtxl eases of anaemia, and
360 PEDIATRICS.
he thinks that it does not occur after two years of age. The effects of «,
temix^nunent, habitation, lioredity, and climate axe not known.
He thinks that rhachitis and syphilis, which at tiineB produce i
with enlargi<l spk>on, do not cause aimmia inftntum peeodo-kobedeL I
I^K>8, Weis8, Sonima, and otlicrs have written a great deal about lim ik^
ease. Some of them (H)nsider it an infectious disease. Most of ibiem ia^
that it has any connection with malaria, syphilis, and llie digestm diripl'
anccs, and only cK'casionally mention its connection ^th rfaatfdiitii.
Asa result of my investigations of a considerable nuinber of i
aiueniia of every grade in young infants, it seems to me tliat -m
arrived at a degree of knowledge which justifies us in making 1 1
nosis, in certain cases, of aufemia infantum p^udo-leuka^niica van Jii
and I shall presently show you some cases; illiit^trative of thte d
We are dealing with a disease of infancy chamctc*rized by a clin:iiiic^
rather ran* (xxjurrenoe, and etiological obficiirity* The cIiDical ^yi
are those of a grave anaemia, with a ''waxen" appearanee of the
The child may he somewhat atrophied, but is often &irly uourifihed* Tbfl I
is always considerable splenic enlargement, with only modeimte or i^l^l
enlargement of the liver. The lymph-glands axe generaUj aoi
enlarged, but never form {jackets. The blood is chaiacteriaed hj :
olig<K;ytluemia and oligochn)niH?mia, together with a lenoocytOBii irli]i&B|
oft<»n considerable. Nucleated red corpuscles of all ^rpea are veiy nvmem^ I
and many of them are found to be undergoing mitosiB in their nndei Vti^
kilocytosis is marked. The polychromatophilic eonditioa of the red cwr-
pusolos, nientiou(\l by Alt and Weiss, may occur. The eoeinophilie cdb
vary in nunilKT, and at times are much increajsed. They aleo vary wm-
siderably in size. Occasionally small numbers of the lai^ mononnckar
neutrophiles and the (K>sinophilic '^ markzellen" of Muller and Bieder Uf
found. (Klein.)
The (^jurs(* of the disease varies. Von Jaksch layB streee on the moif
favorable ]>rognosis as compared with leucsemia. All of my cases law
been fatal without any a])parent complication, and even if the dkwe
remains stationary for a time the risk from intercorrent disease is gpeit
Four ciises which apparently can be classed as representing thia dwmit
have (K^currwl in my ])racti('e. The first case (Case 122) yoa will lemember
seeing in my wanls at the Children's Hospital, and may be described tf
follows :
A boy, throe years of ape ; liad never had any disease, with the ezoeptiim of a qna-
tionaWe niahiriu, inm\ which he liad entirely recovered two years previously. The ftShfr
said that since his secund year he had }iH>ked pale, and that a physicdan waa conaulted iboat
him eight niontlis before he entenKl the hospital. He entered my waxdi on October 4. He
child, as ytju will remember, was of a waxen color, well shown in Plate V. (flwinff pi^
330), and the mucous membrane of the lips and nails was nearly white, with a liridtiiiga
The skin was almr>st tnini^luoent. There was not much emaciation. The aiileen was coa-
sidembly enhirpjed, and could easily be felt about two inches hdow the botder of the lih
The liver was slightly enlarged and could be felt upon palpation. The glands wen enlaigri
THE BLOOD IN INFANCY AND CHILDHOOD.
361
I
to the size of peaa in the neck, axillw, and groins. On percii&don the heart showed no
I ealiu^gemeiit. A loud systolic munTiur wafi heard over all th»? cardiac oriftcas. Tlie action
of the heart was verj rapid, hut re^^ukr. Its impulse was in the fifth int'^rspaee iiisidi^ of
the mam man' line. Auscultation and percussion of the lungs iihowed that thej were nnr<
malj with the exception of &ome sibilant rales. The respirations were SO Uj 44 in a minute.
Case 122,
AiMPTniiiL iafaatnin peeudo-leiikitmlca von J&k^cli. Male, 3 yeaii old. Lower border t>f rtbe, eiilui;gefl
liver, and splet^n outlined in bliy^k.
The temperature at entrance was 38.8« C. (101° P,), and afterwards varied from 89,6" C,
{IQS.SP F.) to alRmt 38.8*» C. (10l« F.). The pulse varied from 125 to 150. Diarrhcea was
present when the child entered the hospital, and at first there were four to kix very offensive
movements daily. For three or four dnjB preceding death the movements were more fre-
quent, hut were not so offensive, und contained mucus. Vomiting occurred at times. The
infant was treated with modified milk^ biistuulh, and stimulaots. An examination of the
blckodf October 18^ resulted as follows ;
BLOOD EXAMINATION 8.
Erj-throcytes 1,295,000
Hiomaglobin .15 |>er cent.
Lcueocytc« 64,600
There were numerous prjikilocytes, microcytes, and megalooytes* A number of the
corpuiicles were pale, and many of tht*m containtMl very little hieraoglobin.
The polymorphous charucter of the bliHid whs wty marked. There were numerous
t mudeattd red fiorpunctfA (Plate V., fi» faoini? page 3i30), chiefly of the normobliiAt type, and
In many of them the nuclei were undergoing subdivision. The mnnopkiles were absolutely
and relatively itierensed. None of the ^* niarkzellen/* characteristic of leucwmin, were
presentt and the leuctx'ytes were largely of the polynuclear variety. The child died October
20, and a partial autopsy was obtained.
A micn»scopic examination &how<xl no evidence of leuciemla in the liver» spleen,
kidneys, or lymph-glands. There were no evidences of syphilb or rhachitisj nor of any
inflammation which could have caused the leueocytosis.
362
PEDIATRIOS,
My st'cond c*aae (Case 123) of lliii^ diseoiBe I happen to have here I
wards to-day to »how you. It is a male iiiikiit, eleven months «>ld.
Tbe previous hbtory of the infant Iiaii not been Mcertained, as the parents h^ni
peiinnl. You see that h« i« p<jorly developed tind somewhat emaeiaied. This skinbii
waxi^ri color, und tht* mueouit membrane of thtj lips and giuns is almtjtg'l colorle
dfjectiona are frequent; they cotitain parliallj digested blood, and have fa oil
* ilur that dbinfectants are constantly required in the n>om. The cervical h
and thcNM) in the groins are sHghtly enlarged. I find nothing abnormai on eiamiiihig liji
Case 12a.
Aiiscmia inrantum pnetidivleakopmleA viin Jnlci^^h. Male, il monihs old. Left lonror bonkr of ijla»
eniifona eartUa^, im*i eutargied ffpleeo marked in black.
<Uf^E 128,
Anemia Inftotum pBeudo-leukfennlca von Jak»ch. Male, 11 tnon 1 1 1 --11, i
ribe, etisiform ULrtllujur^i an*1 enlarged liver raftrkt^l in r»iaiiv.
hrjirt mid lungs. Piilpation of the nbdomen reve4Us a InrE^t^ tumor of firm
begiunmg under the lowtsr bordr-r of the ribs in the left axillarj- line, wid
towards and considembly Mow thn umbilicus. This tumor ii evid«^ntly the splven. a&d
you Kee I have outlined ita edeje in black* On the right i*ide of the abdomen the ^dge<
the liv*^r can l»e felt ju^t below the rib». I have outlined ibis edg^ in black. Ther^ ap
tt> be no tenderness nf the boneis or enlargement of the epiphyses such a^ would a^-cnr I
rhachiti^, and there is no evideiiee of fiyphilw. The following eiainination of the
hm just been made by Dr. Wentworth :
THE BLOOD IN INFANCY AND CHILDHOOD.
363
I
I
^■^ BLOUD EXAMINATION 9. (Wentworth.)
Erythrocytes 1,811,250
Hs^moglobm 20 per eent.
Leucocytes I16,&00
Smiill tuononuclear 46 per cent.
Large " 34 "
Polynuclear 16 »^
Eoamophilea , , . . 4 **
A drop of the blood, you bc«, u watery and of a puli? red oolor, but tht eorpUMslei
tbems4L'lvL>« you will observe on this slide under the microscope are not markedly pale. The
erj'thn>cytes vary much in size and ehapc, poikUoct/Us^ mkroc^fte^^ and macrocyicA nU ht'iag
pre&ent. In fact, the polyfnorphmi» elmnwt'^t of the blotid is very pronouneedt the norino^
bla^t type of the erythrocytes predominating. Mitoses nre very frequent, and &huw all varie-
ties of subdlvit^lun, many of the orythrooyteA huvine: two mielei, others, being in process of
lubdivkiun, «howiri|; three and fttur segments. Many of the nuclei aleo lie eccentric«lly in
the cells. The leucocytes are very variable in this case, but the moDonuclear type prevaiU,
The eofiinophilei; are relatively and absolutely increased, but are somewhat smaller than
usual, and are polynuclear.
(The infant failed rapidly and died. No autop«y wjw obtained.)
My third case in the series is one in whi(*h the blrKxl examination was so
iinsati8fac?torv that there is a possibility' of mv Ix^ing mistaken in my opinion
that it should be plai-ed under the heading uf aniemia infantum pseuJo-
leuk^emiea. It would seem, however, from the hii^torv, and fmni the physical
examination, that it can better be considered a ea.se of this di.sease than of
aecondary antBmia.
A male infant (Case 124), twelve months old, entered the hospital Augusi 15, with
the following history. The mother was healthy, the father was said to be tubercular.
There were three other living children eaid to be heiiltby^ and one child, a boy seven yeai«
old, was said to have died from some di^ea^e of the brain. The infant was healthy at
birth, wntf nur&ed by its mother and throve until it was five months old, when patent foods
of various kinds were given to it, and it was nursed irregularly. It then began to have dl*
g^tive disturbances. On examination it presented so typical a picture of the two cases
(Cafie« 122, 128) which I have just described as representing ana'mia infantum pseudo-
leukiemicu that I have had this colored sketch matle of it. (Plate V., facing page 830.)
You will notice the intense pallor of the entire f^kin, w^hieh ha^* the ^^ waxen" eol<i>T in a
pronounced degree. The transparent ears are very notieeable, and, as you see, I have
mapped out the border of the enlarged Rpleen in black. The inguinal glands were slightly
enlarged, and the liver was scarcely perceptible beneath the margin of the rib*, but the
spleen was enormously enlarged, extending down inl^» the left inguinal region as far as th«
crest of the irmm. There were no other enlarged glandif detected. The abdomen was
rather distended, and the infant was not e^peciidly emaciated. It had had convulsions
from time t.i time since it wiis five months old. There wuis no evidence of rbachitie or
of syphilis. An analysis of the mother'^ milk made on August 25 was as follows :
ANALYSIS 66.
Fat 1 91
Milk-sugar , 6.45
Proteid.<( ...,., 2,66
Mineral matter 0,17
Total solids , 11.19
Water * „ _e8.81
K 100.00
364 PEDIATRICS.
The examination of the blood gave the following reaulta :
BLOOD EXAMINATION 10. (Whitney and Wentworth.)
/. AttgusiS6. II. October 17. III. Novembers. IV. December 19.
I. ErjthixKjytei* 1,585,000
(All of large sixe wid normal red color.)
Hu*iiu>gl«>])in 80 per cent
Li'UCiH'ytcs . . (The estimate was too doubtftil and unaatUfactory to report.)
Small niononuc'leur 61 percenL
Largo «' 28 "
Polynuclear 14 '*
Eosinophiles 2 "
Megaloblasts and normoblasts in moderate numberi.
II. Erj'thrucytes 8,215,000
Ha-nioglobin . . . 46 per cent.
III. Erjthrotytes 8,800,000
HaMnoglobin 45 per cent.
Leucocytes
Small mononuclear 58 *■
Large ** 45 «•
PfJynuclear 8 "
EoHinopliiles 8 '*
IV. Erythrocytes 8,925,000
Ilienioglobin 40 per cent.
(Treatment of various kinds, both medicinal and dietetic, appeared to liave no eftct
upon the patient's general (ronditionf and when last heard ttom it was g^win|f pragresciTelj
weaker and m<>re ana*niic.)
I am fully aware that without the count of the total leucocytee the diaenona is not
proved. There should have been found a decided leucocytosia, which I shall Buamt V>
have been the case, as ull the other characteristics of the disease were present.
The fourth case which I shall speak of as one of anieinia inikntiim
pseudo-leiik{emi«i o(?currcd some years ago in my practioe, andy as no rdi-
ablc examination of the blood was made, I cannot, of oourae, acoept tbe
diagnosis as proved. It was, however, so interesting that it is well to pot
it on record, as it may in the future be valuable in oomparison with ghs
having similar clinical symptoms, especially as an autopsy was obtained.
The infant (Case 125), a male, was first seen and examined by me irhen hmufbar
months (Ad. The parents were healthy, and there was one older child, ^If^ heaJthr.
There was no hii>tor}' r»r hereditary disease in the family. Their home was in a comfoiiaUe
countr}' house, well l)uilt, with ^(kkI drainage, an unpolluted water-aupply, and no anoue
in the papers, curtains, or furniture-coverings. The house was built on a conaideimble ele-
vation, and was not in a malarial district. The infant was healthy at birth, and vdgiicd
8750 grammes (S\ pr>unds) ; it was nursed for a short time, and waa then ftd with TarioiH
artificial foods. It soon began to show digestive disturbance and to gtaw pale. It krt
somewhat in weight, had a gradually lessening appetite, and at timea Tomlted.
On physical examination nothing abnormal was found in the thorax or abdomsD.
There were no enlarged glands. The symptoms were entirely those of ftinctlonal indiee»-
tion, and under a proper regulation of the diet it improved somewhat for a time ^Hl 1
was a gain in weight.
THE BLOOD IN INFANCY ANB CHILDHOOD,
365
Two months later I afj^in saw the infant^ and^ wilh the exc<^ptiQn that the pallor of the
akin bad tnucb incrtn&ed, nothing abnormal was dieooverod. Tht* iiifunt was brought to
the Children's HuBpital to he under my caru when it was eight iiKHiths old. I then found
that it had a much enlarged spleen. The liver aod lymph-glands were not enlarged.
There whs a slight alhuminuria. The erythmcytes were reporU'd io he diminished and the
leucocytes increased. It* weight wa* 6704 grammi^ (14| pounds), A few hemorrhitgic
spots were reported to have been seen on its legs and thomx before entering the hospital|
Imt they were not pn^sent on entmnce. The infant began u^ fail soon after coming to the
hospital, and died a week later, the spleen having decreased in size. On the day of its
death it heeame very restless and cried a great deal, putting iU hands to it* head. Nothing
abnormal was found on examination of the ears. Slight oedema v/as delected at the base
of both lungs u few hours hefore deaths and it flually died rather suddenly. The follow-
ing is the report of tho autopsy made hy Dr, W. F. Whitney :
The body was that of an apparently well-nourished infant^ and externally the only
remarkftbl© feature was the extreme pallor.
The lungs were nornml and rtilrsicted.
The heart was of normal size and i^hape and without any malformation. A micro-
scopic section showed an oceaisional granular fibre. The splet^n wtib tibghtly enlarged, finn,
and somewhat pale, Mierofieopic examination f«ile<J to show any deviation from th*^ normal
structure. The stomach and intestines presented nothing abnoniml. The liver wa» of
normal size, its consistency was flrm^ and its appeamnce wai* marked on section by a pule
whitish colori which wan everywhere present, and had no relation to any jmrt of the
lohules. Microscopic examination showed that the liver-eells were separated by large
epaces, looking at first like dilated capillariesi filled with small cells similar to leucocytes.
The appearance was very similar to that of a foetal Uver of the fifth month. Chemical
tests failed to show the presence of any free iron in the liver-cells. The kidneys and other
Lcsgana presented nothing abnormal
»
Secondary An.'emias. — ^The secTindaiy antemias are so numerous and
arise from so many ditferent cmuses that an exhaustive discussioD of them
wimld hiirdly l>e praetiailjle iu a rliiiic'al leetiin\ You must bear in mind
what I have already said ix^irding them ; first, that almost every antemia
whieh we meet with h tKHxmdary, — that is, that it arises somewhere outride
of the bliMid-making org^aus ; sec^tmd, tliat in almos^t every' diseaiiie of any
organ a secondary anjemia i.s liabh> to arise, and is of a high or a hiw grade
aoeording to the severity of the dL^^ise, The ehanges in the form-ek^ment^
of the blood which are foimd in these stximdarv cxjiiditions are simply the
constant oecnrrenoe of oligocytliiTmia and oligix'hromiemia, the presence or
absence of leueoe>1:osis, and the abseuee ♦d' tlie nther charaeteristies whieh
are supposed to belong to chlorosis, anaemia perniciosilt and aniemia infantum
pseu(h>-lenkfl&mif^i von Jalcsch. Where tlie lenefK'vtosis is grc^t, the anaemia
is usually one of the graver forms, and in these grave ana?miiLs the leueu-
cytes are foimd to vary from 14,0tK> to 54,000. You may remember this
infant {Oa.**e 126, page *^()^\ four uifmtbs old, whieh I examinee! h^'lore you
in the wards of the Infant'^' Hospital six wc*eks ago. It re|)res<*nted at tliat
time what I shall later descril>e to you as a moderate grade of infantile
atrophy. It wil** much emaeiatetl, and the interference with the normal
aetivitv of the intestinal absorbents was sc^riously affecting its nutrition. It
w^as pale, but did not have the ** waxen*' pallor which I have described in
previous cases.
366 PEDIATRICS.
A blood examination at that time gave the foUawing result, which truj
simply that of a mixlerate grade of anaemia :
BLOOD EXAMINATION 11. (Wentwortli
Krythrocytei , . • . . - 3,ULw,::sjj
Hemoglobin . 40 |.it r ctiiL
Leucocjtei . , . • . . * . 11,500
The treatment was by fcKCKl adapted to the dijs^bled conditioD oft
absorbents, — namely, a low i>ereentajje of fat with a rather high perceatae*
of sugar and a mtnlcTately high pcrt<»ntage of proteidts. You see whsU i
marked change has cK^'urred in the appearance of the infant, which \ai
grown fat and is no h mger ana?mic.
Cask 126.
Mal«, 4 months old. Inikntlle atrophy of mediom guide, with moderate
TEBATIONT. — Witli the exception of the case last spoken oCyw
will notice that uji to tlie present time I ha%^e said nothing whatever
the tivatmcnt oi' theR^ clisea^^es oi' tlic bltMid. I liave done tliL* purposely i
order to impress upon you that in infants and young children these <
de|K'ud, so far as I can ascertain, almost entirely upon some interfei
witli the niitrilion. It is very rarely that I give drugs in any form in
diseases. The tresitnient of antemia perniciosa and anjemia iniaiituin pemti^ ,
leuktemica von Jakst*h, either with or without irf»n, arsenic, or other i
is well kn*)vvn to Ix^ inetlk^tuak On the other hand, the
ehloro.'^is and the seeondar>' aneemiaa has, in my exiK^rience, !► ij
usually by complete recovery, Thk ti-eatment has bc^n, iSrst, to
the can.se, whether it Ix^ the inhalation or ingestion of pijisons, sndi
arsenic or impure air and improjwr foml ; second, to adapt the percentagQ
of the food so &b to meet the requirements of the special disease or r€@alte <
that dLsease, in order that the infant's nutrition may be thus i^storedtos
state of e<|uilibrinm, and the cHeets of the dis<:*ase may be eradicated* Fioffi
tliis stand-point you will understand that it would l>e impracticable to mtftr
into the subject of treatment in detail in siieakiug of the blood as a wkfeJ
THJE RLOOD IN INFANCY AND CHILDHOOD.
367
treatment of all these disi^ases of the bl(K)d is merely tliat of the esi^eekl
3se which causes the blcMKl-ehatige^, and, as I have just said, is well
lllustratfxl bv the treat nieiit fvf this ease (Oii^ 126) of aufeniia 8<x-<iiidarv to
infantile atrophy. If ynu thonHighly understand the priueiple whieh under-
Blies the treatment aud 8ul>st^]uent recH>very of this c^Lse, you wull a]>preeiate
Bthe truth of what I have just saitl, and will Ix* prepareil to treat intelli-
B gently all the cu-^es whic*h I have already deseriL>ed to you,
H The more severe tj'pes of secondary aniemia ai'e of great interest and
irn^Mirtance in the study of infants aud of children. As the gnule of the
I anaemia beeonie?^ higher the s|XTiiic gravity of the bloml ljeeomt*s somewhat
lower. In ajtldition to tliis there is more variation in tlie sizi* and shape of
Hie er)"throcytes. There is pcdkilocytosis and micn>eytosis, A few nucleated
erythnx'ytes, geDerally of tlie normobh%*^t type, are fbimd. They are, how-
ever, not very numerous. The same causes give rise to these grave forms
IL8 to the milder forms of ansemia. The terms "s^'philitic aneemia** and
" rhachitic anaemia'* are mLsnomers, as there are no eharatrteristic blood-
changes in these anicniias.
CONGENITAL SYPHILIS, WITH ENLARGED SPLEEN.— 1 will
[now show you a tase oi* eongeuital syphilis whieli has been under my care
ijbr some time, aud in which a numlxi" of careful bltHxl examiiuitioos have
Ibeen made. It represents very well the grave secondary anaemia which at
accompanies syphilis ; Init, as I have already told you, these examina-
ions of the bl<MKl show nothing characteristic of syphilis, but merely an
[ordinary seooudaiT auiemia.
ThU infant (Case 127) h three moDths old, and U being nursed by its mother.
Cask 127.
^llmle, a monUw old. CX^ugeuitiil !>yi»liUij', bruvt^ ^cconclH^3r arm-miii. Lower bolder of rlto, fllUi rib, tmd
enlaiKeti spletti nuirkcHl lu black.
It WM health,? at birth, and remiiined sn until it was three weeks old, when it showed
llBftrkcd H'philitie legions, which have since becomt? very characteristic, I ehall not here
lenter intt? a full descriptioD of tbt^ ca»^^ a^ I shall show it to you again in a few day* io
Icotitiection with Bonie other cases iUustrating my lecture on congenital syphilis* The infant,
368 PEDIATRIGB.
as you see, is fairly well nourished. You will notice the " wmxen" pidlor of the skin.*
charucteristic of the higher gradus of grave anaemiaa. There is a mcMlerate enlAi)gemn:i
the liver, which on palpation U found to he hard and somewhAt tender. The ingmBil
glunds are slightly enlarged. The post-aural gUnds are enlarged. The spleen k nnc
enlarged, uiid extends, us 1 have indicated with the hlack line, frota the fifth rib totbekt
inguinal ri'gion. It has, as you see, a peculiar tongue-shaped outline. It is hard. bulk
not tender. I can detect no other glandular enlatgements. The eTami nation of the Uool
give^ the following n*sults :
BLOOD EXAMINATION 12. (Wentworth.)
Nov. 17. Kov.flL
Krythn»cytes . '. 8,887,000 8,800,000
Hienioglohin 47 per cent. 46pere«L
Leuc<K:ytes 20,000 20,000
There is a consideruhle variation in the size of the erythrocytes, whicdi aie
Then> is ]K>ikil(xrytosis in a moderate degree ; there are also aome micraesTtes
cytes. The mononuclear elements predominate (ahout three-qaarCeEB). The
are not numerous.
RHAOHmO ANiEMIA. — Rhachitis is so oommonly met m cdf
life ufWr the first six months, both alone and in oonneotion witb oAff
(lisseases, thut I tliiiik it will be well to teU you what ia known abont ik
bIcMxl Ix'fbn* s]H>akin^ of tiie 8e|nirate blood examinations which I hsvt hi
made in a iuiiiiIkt of different eases. In this elass of cases there is a ooa-
plete iudeiK^ndeuce of the s^K^eific gravity, as influenced by the couneof tk
diseiis(>, except when it Ls complicated by ansemia. When this oocnis tk
siHH-ilic gnivity falls, and it invariably rises as recovery from the riiachiti?
takc^ phic(>. UnU>8s this disease is accompanied by a secondary amema,
the I)1()(h1 is practicsilly normal. Hix^k and Schlesinger found that if the
secondary anteniia wits nKKlerate in intensity, and diarrhoea and vomitiD;
cK'C'nrnHl, it simply made the anaemia more acute. The nuyority of die
lenixMytes were found to be mononuclear and about the size of the enrthn)-
cytc*s. Tlien; is a nKKlerate i)ermaneut leuoocytosis in most of these cas^
and at times the mononuclear leuooc\'tes seem to be the most numerous fini
RiiAriirrrc An.kmia without Splenic Enlargkhekt. — ^Thisinfim
(Cas^^ 128), a fiMuale, seven mcmths and three weeks old, has just been
brought to the hospital for treatment. The enlarged epiphyses of thewrifts
and ankh^s, the rhachitic n)sary, and the other symptoms which so oom-
monly ocrur in infants fed <m patent foods, indicate that this is a case of
uKMlcratc rhachitis. The infant is pale and poorly nourished. The blood
examination gives the following result :
RLool) KXAMIXATION 18. (Whitney and Wentwotth.)
Krvthr.>cyt«-s 4,492,000 (oocaaionaUy nucleated)
H:im«iirlnbiii 70 per cent.
Lhum .cytes 22,000
SinuU in()n()i)U(;lcur 33 j>er cent.
Lar^f " 32 **
Pulviiudear 86 "
THE BLOOD IN INFANCY AND CHILDHOOD.
369
Rhachitic Anemia with Splexic ENi^RtiEiiKXT. — This case,
Iwhk'li I have under treatmeot in the waitl.s, is a very interesting illua-
Itration of rhat'hitis with a sei'ondary anaemia of high grade, aoct>iiipanied
by enlfirgoment of the s|)leen.
The child is three years ald| and, as you see, is fiiirly well nourished. (Case 129.)
Cask 129.
Malt, it ycara old. Rbaeh Ula, with € n 1
II haB, however, enlarged epiphy^esi a rhachitic rofiat^s the ^uare rhachitic head, and
DarkfHl bowing of the legs. On physical examination I find no indication of enlHrgement
I of the liver or glands. The sploen h very much enlurgi^d, and I have indicated the po«i*
Ition of \u outline and \u iioU^h, im you eee, in black. The blood examination has just been
Lmadef and gives the fnUowing figures :
BLOOD examination 14. (Wentworth.)
Erythrocytes . , . 2,686,250
Hiemoglobin ,.,... 35 per t?ent.
Leucocytes .,..,.,...... 13,000
Poikilocytes and marked pallor of the corpii»t4ee were present.
24
370 PEDIATRICS.
1
LECTURE XVI.
THE BLOOD IN INDIVIDUAL DI8KA8E8.
Ttphoid Fever— Soarlkt Feteb— Mxablbs— Vahiola — ^Difhthx&za — PKrmosu-
Broncho-Pneumonia— Pneumonia and Emptima — Eicptxma — ^Mzliabt Tubu-
CUL08I8— Tubercular Meninoitu— HTDB0CXPHAi.ir8 — Chorxa — Nxphbitb-
Tubercular Peritonitis — Infantile Atbopht — PxBxoariTis— SooEBUTUfr-Io-
TERU8 Neonatorum— Sclerema Neonatokum.
A NUMBER of observations have been made on the blood of chUdnn
whore a condition of fever was presenty and a few regarding the sprafic
gravity of the blood in connection with a heightened temperature.
Widowitz found in five-eighths of the cases examined during fever dot
the haemoglobin was higher than in the post-febrile period. The renuuning
three-eighths of the eases had other complications. Regarding the diminu-
tion in the numlx*r of erythrocytes and the percentage of fasempglobin afler
fever, he explains it either as an actual diminution of hnmoglobin or a
dilution of the blood by absorption of fluid from the tassues.
Sc^hifT^ who has made the most reliable and methodical experiments (»
this subji'ot, differs from Widowitz in some points. He found a diminuDno
of erythnK-ytes during the fever and an increase afterwards, and in loi^-
contiiuu'd fever this was mcKlified somewhat, so that the absolute count w»
lower. Tins he considers due to a diminished production, and so a condi-
tion of anajmia is gradually produced. He considers the diminution of the
erythrmytos in acute fever to be [mrtially due to an increased degcneratioa
of tlie red cx)rpuscles, and also to the increased metabolism, and not to
diminLshcd produetion. He could not perceive any connection betweoi tlie
noriuiil daily variation of the temiwrature and the blood-count. He haxA
that the luemo^lol>in was diniinislicil at the beginning of the fever, together
with the riHl corpuscles, but that later it was even more marked than the
diminution of the rcil corpuscles, i^sjwcially when the fever was long
continued. He notoil ca^»s in which the red corpuscles increased later, bat
the hienio^lol)in reniaint^l diminished, or even sank lower.
Regarding the leuccwytes in fever, Schifl^ considers that thi^ do not
follow th(^ course* of tlie fever, as regards increase and diminution, except it
the Ix'ginniug, when there is an inen.»a'«e. Some other authors consider tint
the k'm?(KTte cf)unt is not affwtinl by the temi)erature alone, but that iriw
fever is accompanied by local suppuration the leuoocytoBis is much more
marked. This agrc^es with the results obtained in adults.
I shall now show you a numlwr of cases in the wards repxesenting dif-
ferent diseases, in each of which a blood examination has been made lately.
TYPHOID FEVER.— Arnheim found a striking diminution in the
THE BLOOD IN INFANCY AND CHILDHOOD. 371
[ amount of hflenioglobin after defervescence had occurred, and in spite of an
1 increase in the number of the eiythroeytes. In this di.seii.se we know that
the leueoeyteia are usually diminished in nnmberj but that there is a prn[x>r-
tionate increase in the lymphocv^es. (Thayer.) This also occurs in malaria.
In the early stages the ernhrocytes are increased, as is also the haemoglobin.
In the later stages a condition of aufeniia may occur, pn>ducing a dirainu-
» tion of the red corpuscles and hj^moghibin.
Here is ii girl, eight years old (Cftae 130), with the clinical aymptoiini of typhoid fever.
[ The eijoniiiation of the blood gives the following ref^ult t
BLOOD EXAMINATION 15. (Wentworth.)
Erythrocytes ., , 4,602,500
Uiemogloblii 50 per cent.
Leucocyte* 7,000
The next case (Cose 131) 16 also one of typhoid fever, in a boy six years old, and the
I result of the blood examination m as follows ;
BLOOD EXAMINATION 16. ("Whitney and Went worth.)
Erythrocytes 5,496,250
Hmmogiobin . . 64 per cent.
Leucocytes ... ..*,..,. 7,000
Small mononuclettr .... 14 per cent.
Large '» .... * 20 ♦•
Polynucleiir 66 •»
As I shall not take you into the contagious wards thiisi morning, I think
it will l>e well, bt^fore pas^in^ on to tlie otJier patients, to ri'mind yan in a
few words of what we should be likely to find on examining the blood of
childi-en with scarlet fever, measles, variola, or diphtheria.
SCABLET PEVER.—WidowiUc divides the cases of scarlet fever
systematically into three grouj)s ; ri, those with a mild course and without
eompliratioiig ; A, thr^^ in which nephritis occurs as a cf>m|)liciition ; and c,
thos^ with a malignant course. All tliree from tlie bcginuing sbow*:^ a
high percentage of haemoglobin, which io uncomplicated cases diminished
with the disease, and rose again later witliout rcui-ljing the former liigh
percentage. In the castes of nephritis there was a rapid fall of the haemo-
globin. The malignant cases showed no constant rc^latinn. As alx>ve men-
liuued, leucMxytosis was generally prt^sent, even in the stage of incubation*
MEASLES. — Amheim found in uncomplicated cases no special
changes in the liiemogk^bin. He found slight variations, hut less than in
scarlet fever, and in convalescence the hsemoglobin often reai^hed the high
percentage found in the efflorescent stage of the disease. Von Limlx^ck^
Pick, and Kicder found no leu(*ocytosis in uncomplicated cases of measles,
and thought this fact of value in the diagnosis fnim scarlet fever.
VARIOLA. — Aruheim found the haemoglobin diminished at the begin-
ning of the disease. After the formation of pustules and during their exsio-
372 PEDIATRICS.
cation, lie found an increase of the hsemoglobiOy with diminution of the
ervthrocytes. Wliere complicating suppuration occurred, both the erythio-
c}^C8 and the hicmoglobin remained for a long time abnormally diminisbed.
Hayem found in " variola confluens" that the erythrocytes were dimin-
ished to two million ; in tlic stage of eruption they were normal, and in the
i?tage of suppuration, in ccmseciuenoe of the concentration of the bh^ thty
wort* incnnusiKi. Two weeks after the iall of the temperature they we»
normal.
It. Pick roi>orts forty-two cases examined by him in which he foanl
no U'ucfK'ytosiSy exc(^])t in the stage of suppuration or in some complicadiiD
like ])iunnnonia. The temperature, the severity of the diseaaey or even a
fatal termination, unless complic*ated as above, produced no leueocytosis.
DIPHTHERIA. — Bouchut and Dubrisay found in severe eeptioemif
forms of diphtheria an increase of leucocytes, increasing and diminishing
with the sevorit}' of the ])nx*ess. The mild cases showed no leuooc^losis,
which fac*t, w^-ording to these authors, has a prognostic value. Von Lim-
beck found always a marked leucocytosis, and it was greatest in the sevenst
easels.
PNEUMONIA. — The leucocytosis is generally very marked^ comin;
on fn)m six to twelve hours before the physical signs of pneomonia
show themselves, and in tlie same way the temperature crisis of the pneo-
monia is sometimes preceded by a crisis in the number of the leuoocrte
of alxjut the same length of time. This, of course, is of value in jwog-
nosis. There have been some cases recorded (generally fatal ones) in which
the leucooyto.si.s did not occur. This may possibly have been dependent apw
the nature of the infection. Von Limbeck's experiments upon dogs seem
to show that Friedlander's bacillus caused a marked leuoocytosis, whems
Fraenkcl's diphxHxxjus caused scarcely any. The leuoocytoais is said to be
higher in children than in adults in pneumonia.
Hero in this noxt ImkI {Csum 182) is an infant eight months old with the chancteriitK
clinical syni})tom8 and ])hy6ical signa of a fibrinous pneumonia, inTolvini^ the whole of tk
loft lower l(il)o of the lung. As the case is one of undoubted pneumonia without oompli-
catiun:«, the blood examination which has just been made is of unuaual intemt :
ULOOD EXAMINATION 17. (Whitney and Wentworth.)
Erythrocytes 4,818,750
Ila'inoglnhin 64 per cent
Leueocytes 40,000
Small mononuclear 61 per cent
Large " .21 "
Polynuclear 27 "
Eosinophiles 1 "
The small percentage of the p<^>lynuclear cells is very unuiual in a oue of thiiKnii
They an* generally much increased, and their small percentage, though paitiallj mooaaa^
for l»y the age of the infant, cannot be entirely explained in this way.
The next case that I have t^.* show you (Case 188) is also one of pim 1
THE BLOOD IN IKFANCY AND CHILDHOOD.
373
monia, in ft boy three and otie-half yeare old. Three exnminBtioni of the blood have been
made in thb case. The first one waa made eighteea houra after the crisis hud occurred,
the second one forty-five hours after the crisis, and the third on© has just been made to-
) day, which is the tenth day since the crisis occurred.
BLOOD EXAMINATION 18. (Whitney and Went worth.)
(A/itr cntta.)
L
XL
HL
isbmm.
4fiboiua.
10 days.
Krythmoytes . . 4,698,760
4,849,166
About the same as before.
Htemoglobin . . 62 per cent.
63 per cent
Not taken.
X^uoocytea . . 24,500
29,Oi>0
17,600
Small mononuclear . . .
. 28 per cent.
21 percent
Large ^* . . .
. 18 *»
11 "
Polynuclear
. 61 »*
68 **
Eoftinophilefi
. 3 »
At the time that the second exfttninatbn waa made the temperature was normal- The
I percentage of polynuclear ct'lls in Ihifi case would be very small if the patient were an adult,
I but for a child of this age they show, as would he expected^ a moderate increase. To-day,
with a normal temperature and with resolution completed, we find, as we should expect, a
' decided lessening of the leucocytosis. Dr. Cabot^s obserrationB have convinced him that
the so-called bbK>d crii^l** occurs in only a certain percentage of cases of pneumonia, and
that a blood lysis is more common.
BRONCHO-PNEUMONIA,— The next case (Case 134) U one of broncho-pncu-
fcfDOma occurrinic in ii rhtithitie child four y^nrs old.
BLOOD EXAMINATION 19. (Whitney and Wentworth.)
Erj^throcytes 4,286,250
Hiemoglobin . 63 per cent.
LeucHx-ytfifl ... 64,000
Small mononuclear . . , . 18 per cent
Large ** . II **
Polynuclear . 71 **
The pTjPUtiionia was marked hy certain rirrumRcribed patches of dulness in both bocks.
It ran th*/ iLsiiiil cou^rse of brt»rich'i^pnt^umoroa, and re^^ulted in complete recovery.
PNEUMONIA AND EMPYEMA.— The next case (Case 135) is that of a boy
thirteen years r4d, who has had a marked film nous pneumonia running its usual course,
and now has an empyema as a complication. He hm been aspirated, and streptococci were
found in the pu«. The result of the blood exajnination h very sigmflcant.
BLOOD
Erythnjcytes ,
EXAMINATION 20.
(Whitney and Went worth.)
, , , 8,513,750
Hiemoglobin , . 48 per cent
Leucocytes 45,000
Small mononuclear ...,.,. 8 per cent
Larpp *' 6 ••
P*)lynucU'ar , 80 *»
Eosinophiles 1 **
On comparinir this case with the two cases of fibrinous pneumonia which I have ju«t
i^own you, you will note how much larger the percentage of polynuclear cells is than
Iwhepe the pnoumnnia was uncomplicated.
EMPYEMA.— This next case (Case 186), a boy twenty months old, is one of
I empyema. The blood examination was made yesterday.
374 PEDIATKIGB.
BLOOD EXAMINATION 21. (Whitney and ^Wentwortli.)
Erythrocytefl 4,898,760
Uiemoglobin 48 per cent
Leucocytes 28,000
Small mononuclear 9 per cent
Large *• 16 "
Polynuclear 74 "
Eufiinophiles 1 *'
(Thii* infant had the radical operation for empyema performed on it, and oltimiteh-
recovered completely.)
Here in this next bed is another case of empyema (Oaae 187), ten yeua old, in iriiu
the blood count was made this morning.
BLOOD EXAMINATION 22. (Whitney and Wentworth.)
Erythrocytes 4,866,000
Haemoglobin 00 per cent
Leucocytes 66,000
Small mononuclear 7 per cent
Large ^* 8 ■<
Polynuclear 86 «•
(This child was operated upon and recovered completely.)
MILIARY TUBEROULOSIS.— Tou wUl rememher the mala i-fc»t tvca^
five montliK old (Case 188) which I examined before you in the waid ymtardajt andlaHiek
there was u question whether it was a case of simple starvation or ona of gHMnI
tuberculosis with some complication. The blood examination resulted aa fldlmvt:
BLOOD EXAMINATION 28. (Whitney and Wentworth.)
Erytlimcytos 6,667,800
Haemoglobin 06 per OMd
Luuc(x;ytes S9,600
The autopsy thi.<4 morning showed a general miliaxy tuberculotia of all tin
an absence of pneumonia.
Miliary tulH'i\'ulosis in adults shows no Icucocytosis, and the inoreaoe of Uie
in thi.s (Misc \< but moderate, and might be due entirely to starvation.
TUBERCULAR MENINGmS.— Here is an interesting oaae of oenbnl&w
(Case 139) in a malo infant. The clinical symptoms and general aspect of the duU iff
thost^ of tuberculur meningitis. The blood examination, however, shows *l»*t fimw con-
plication is in all probability present.
BLOOD EXAMINATION 24. (Whitney and Wentworth.)
Erj-tbrocytes 4,641,S60
Haemoglobin 68 percent
Leucocytes 88,000
Small mononuclear 22 per cent
Largo ** 20 ««
Polynuclear ^ <«
In considering this case I must remind you that the hacilluB of tabetcoloeb h noti
pyogenic organism. As I can find no lesion in any of the organs to acoount fiir tfw
increase in the leucocytes, a large proportion of which are polynuclear wM|||WM|iin^ «i
THE BLOOD IN INFANCY AND CHrLDHOOD. 376
I muft suppose that the original miliary inflammation was followed by a secondary infection
' of Rorae pufi-producing organism.
(The infant piissed lhn>ug^!] Iho various typical stages of tubercular meningitis and
[ died. No autopsy was obtain L*de)
Thu stiitcment thai the leucocytofiie which i« at limes found in tubercular meningitis
^depends on some complication is well illustrated in the case (Case 144)) of the little girl
eleven years old who was shown to you a few days agt> a* a case of tuberLular nieningilis,
The clinical symptoms were very typical from the beginning to the end of the disease, but
blo<id examination, as 1 explained to you at that time^ led me to believe that some
Eiplication was present.
BLOOD EXAMINATION 26 (Wentworth.)
Erythrocytes 5,298J50
H Hemoglobin 68 per cent.
Leucocytes 87,500
The autopsy showed the case to be one of tubercular meningitis, represented by solitary
tubercles in the brtdn witiriout any purulent exudation. There was, however, found in the
abdniiien an appendiciti.-^j which accounted for the leuo«>cytofiis.
HYDROCEPHALUS.— TbiK little girl (Case 141), six years old, is a marked case
of hydrocephalus. The hist'jrj'' of the noticeable enlargement of the head corresponds to
the general Hydrocephalic appearance of the child.
Casi 141.
In the result of the blood examination of this case I cannot explain the high per-
I centage of the polynuclear cells.
BLOOD EXAMINATION 26. (Whitney and Wentworth.)
Erythrocyte'* . . . , 5,675,000
Hiemoglobin 80 per cent
Leucocytes 19,000
Small monoDUcl^ir 4 per cent
Large " , .8 **
Polynuclear ....*....«*..... SS *•
Eosinophiles & **
This next case (Case 142), a boy two years and ten months old, is apparently also one
of hydrocephalus, but of slight degree. The blood examination resulted as follows i
\
376 PEDIATBIOB.
BLOOD EXAMINATION 27. (Whitney and ^V^entworth.)
ErythrxKjytes 4,492,600
Hnniuglobin 72 per cent
Leucocytes 20,600
Small mononuclear 20 per cent
Large ** 20 **
Polynuclear 68 "
Eoifinophiles 2 *'
Th(> cuuso of thirt I(>ucocy toeis ifl not known. The examination of the lungs and the hw
was nei;utive ; tlio head measured twenty-six inches ; there was protnuion of the ern, u
well as mental disturbance. The child remained in the hospital, and showed conDnoed
improvement until complete recovery some months later.
OHORFiA. — I shall now show you a case (Case 148) of chorea of a severe type, b«
without complications. The child, a boy eight yean of age, can scazcely swallow, lod ii
unable to speak, stand, or walk. The choreiform movements are, aa you see, oonout
The result of the bhxxl examination is as follows :
BLOOD EXAMINATION 28. (WentworUi.)
Erj'tbrocytes . 6,222,600
Hemoglobin 60 per cent
Leucocytes 19,000
There has at times been a faint hsemic murmur over the base of the heart, but this te
been very transient and has now passed away.
NEPHUmS.— I have here to show you two cases. (Cases 144^ 146) of lenml disevb
The examinations of blood made in renal disease in children have not been veiy extenfire
or satisfactory, but in general the specific gravity of the blood Is quite low, on aocoontof
the loss of albumin in the blood serum. The specific gravity of the serum is modi dimia-
ished, 1022 to 1028. Khnn, in a series of observations upon the blood in the nephritv
of scarlet f(f'V(T, has found an increase of eosinophiles in fkvorable rases, ^w»5^ an absence cf
them in fatal vioiw.
ACUTK Nkphuitis. — This first case (Case 144), a boy six years old, was one of
ucuto nopliritis. The urine at present, however, only shows an active hypenemia of tb»
kidnt^y. Tiie hlornl examination gives the following results :
BLOOD EXAMINATION 29. (Whitney and Wentworth. )
Erythrocytes 8,481,260
Hii'inoglobin 51 percent
Leuc'tK-ytes , . 82,600
Small mononuclear 8 per cent.
L"rir.- - iQ ,4
PolyiiU(.'lt*ftr 80 %t
Eo.-iiiophilos 2 '•
The yKTcentaije t)f the eosinophiles, you see, is no greater than normal, altfaoogh tbt
case seems to he tending towards recovery.
Chkonic Nephritis. — The other case (Case 146), a girl nine and one-half t«»
old, is one of chronic paR-nchymatous nephritis.
BLOOD EXAMINATION 30. (Whitney and Wen tworth.)
Erythrncytes 4,866,000
Ha-moglobin 80 per cent
Leuot»cyte8 33 qqq
Small mononuclear 86 per cent
Large ♦' 4 f«
Polynuclear . . qq u
THE BLOOD IN INFANCY AND CHILDHOOD. 377
Unfortunately, the perfontage of ooeinophilea in this ca«e was not reoorded. The aixe
I of the leucocyte count is retuarkiible*
TUBBBCULAR PERITONITIS.— I have here two c&^es of tubercular peri*
tonitU, in which tbts tliagnoeis haii been verified by kparotomy. The blood examinationft
were made before the opemlione were performed.
The firHt case (Coac 146) wm one of an infant eighteen montba old| and the blcMid
examination resulted as follows:
BLUUD EXAMINATION 8L CWhitney and Wentworth.)
Erythrocytes , . , , , 4,970,000
Htemoglohin 48 per cent,
Leucooytea . . , 19|0<X>
Small mononuclear .Id per cent.
Large ** ...,..,.*. ,18 '*
PoiyDUcIear* ♦ . . . .... 78 '*
Thi* caeei as well as the fin^t one, followed the rule of an absence of leucocytosis in
tuberculofliSf for at this age the leucocyte count may be as high as 19,000 to 20,000 under
physiological conditions.
The second cai*e (Case 147) U a boy nine years old
BLOOD EXAMINATION 82. (Whitney and Wentworth.)
Erythrocytefi .,.,.,..,.. . 4J92,600
Hitmoglnbin .,.,.,. 56 |>er cent.
Leucocytes , . . . , 7,500
8mall mononuclear .18 per cent.
Large ** . . . . , 81 *'
Polynuclear , . . . . A4 *»
INFANTILE ATROPHy.— The next case (Case 148), eleven monthe old, h one
of infantile utrophy. The extr*.Hiie emaciation of this infant is well seen in Imiking at ita
Case 148.
trilantite utMi'hy. rimnlv, U monthw
back, where there is an almost entire absence of fidip<ise tissue, so that the ^ertebne and the
riba can be studied as though on the dissected skeleton*
378
PEDIATRICS.
The result of the blood eicaminatioD in thie case u m follows :
BLOOD EXAMINATION 33, (W«mtworlh.>
Erythrocytes 4.7S8,i80~
Ha:*inoglobin .,..*,,.., 76 pcvocBL
Leucocytes .......,,.,..,,.,,....., 21,000
ThU cuunt yms made after the infant had been under treatment for aver I
half tnonthtf bo that we Cfttitiot take it as typical of the early dagea of the <
GuflFer found a gradual diminution of erythrocytes aad an
leucocytes in these cases of iufantile* atmphy, which he referred to
acoompauying anit^niia. Parrot found that a diminution of red corpoidl
oonstantly went on until death, and that the increa.se in the leucocytes 1^
responded to the severity of the disea;@e. Schiff made some experimoifa
pmving the aual<5^y between these ca^^es with loss of fluid and
which fluids were* withlield, Iwth causing ooneeutrdtiou of the blood.
PERIOSTITIS.— In order to show you of what great impor
careful examination of the IjIimxI may h- in determining^ the diagnooij
obecure casei^, 1 will report to you the following case (Case 149) ;
Case 149.
Fema](^ iiifani, 15 iiitimhs old, Pedt^titlb of l[M>th It^.
Many of you will i^riicfiibor smng the infant nl th<» Children** H*^piialt where U wn
brought to be treated for n ponsif^tent and painful Bwullini^ oC the right tbi|:h. It in
at that time fifteen months old, ^nd the puhi hail been so severe that it had k«t muck
I THE BLOOD IN INPAAXY AKD CHILDHOOD. 379
sleep. The right thigh w&a swollen to nearly twice the size of the kft one, imd was very
len^e, — in fuct, so much »o that the outline of the hone could not be distinguished. The
suffering of the infjirit wa* §0 great that it was transferred to the Intunti*' Hoj^pital, where
lit came under the surgical can^ of Dr. Lovett. For the purpofle uf diagnosia an incision
r was made on the outer sidt of the right thigh. On reaching the boue^ it wiw* found to be
covered with a layer of grayish, friable tissue, at least a quarter of an inch in thickness*
The aspect of the growth was that of a malignant tumor, and this appi:'amnce was eo
etriking that a i^mall bit was removed and referred to a pathologist for examination. The
rep4>rt ffLini this eianiiuation was that th« growth remiived was not large enough for a posi-
tive diagn'usig, but that it simulated very closely an oeteo-sarcoma. A few days later
another incision wa:;! made in the right tibia, which can be seen in this photograph taken
imDiodiately after the operation.
Another piece of the growth was removed, and on examination was reported by the
pathologist to be probably an osteo^earooma. The infant had been in the hospital for
I about ten days, and the swelling had steadily increased, while its general condition had
become worse. The question of amputation was considered, but at this time a blood count
was made, which &o 5tr<jngly pointed toward the absence of u malignant growth that it was
considered wiser to postpone the operation and wait for l^irther developments.
BLOOD EXAMINATION M. (Whitney.)
Leucocytes.
Small mononuclear 46 per cent
Large *♦ 18 •»
Polynuclear. 86 '*
The significance of this differentiation of the leucocyte* lay in the small percentage of
the jKjlynuclear variety, which should have been found increased if the dlgease of the bone
had been a new growth, such as is pepre*;ented by osteo-Aftrcoma. Somewhat later, but
befi>re the blo<jd exaiuination had been finished, the left thigh wa.-* also inoi^^d, owing to a
suspicion of trouble in that location, and a piece of periosteum covering the left femur was
removed* This was also reported aa a probable oeteo-^arcocna, and the infant wa* dis-
charged from the hospital m a hopeless case^ and was taken homt* to die. The Bub.sequeni
histtiry tvl" this case is of extreme interest, in reference to the value of bloud exBniinatiMns.
for the infant stMtn began to improve, the swelling was absorbed, and, nlthough the infant
I was late in walking, it i*t now, after an internal of some months ♦ well and strong, and
» presents no appi'unince of disability in the legs*. The growth was probably a sluggish
periostitis of an unusual type, which fiimulaled sarcoma very cJoeely. The case is a
unique one.
SCORBUTUS* — Nothing distinrtive hm as yet 1:ieefi found in the bl<>od
examinations wliieh have Iieen made in cases of infantile scorbutus,
ICTERUS KEONATORUM,— The simple benign form of icterus
necinatiimm, which I have dc^seribed to you in an earlier leettire, is ]>ra^^i-
cally a physiologiiml condition. Up to the present tijiie tJiert^ have not l)een
frmnd any pathological changes in ttie blood. *
SCLERJSMA NEONATORUM.— Ill tlie lieginning of sclerema neona-
tnnnn tliere is no especial change in the blc»od until the tissut^ have Ix^en
drained of their fluid. In protracted cases, however, through dinii tuition
of the hiemoglol)inj caused by insufficient fluid, a gradual sinking may
ocxnir in the specific gravity of the hhxKi without any change in the f^rnm*
380 PEDIATRICS.
1
LECTURE XVII-
PARASITES OP THE BLOOD.^LITBRATURB OF THE BLX>OD IK
BARLY LIPB.
As in other parts of the eoonomy, so in the blood are fband pandies,
which may be of the vegetable or of the animal kingdom.
Of the vegetable parasites, such as (1) Moulds, (2) Yeasts (Saocharo-
mycetes), and (3) Fission-fungi (Schizomyoetes, Bacteria), the latter (FissioD-
fungi) are the only (mes which would be likely to occur in the blood of
early life, and even they do not especially concern oa in our discuflsioD of
the bliMKl.
Of the animal parasites (Hsematozoa) we find two dasBea, (1) Protont
and (2) Vermes. The former class (Protozoa) is the only one with which I
have had any ex{)erience, and I shall therefore confine my remarks to die
micro-organisms of malaria.
MALARIA. — ^The term malaria should be liTnited to a definite dideue
in which we know there is a s])ccific infectious origin. This specific infection
is ])rimarily shown in the blood in the form of certain micro-organisiifi
which, like the amceba coli, belong to the class of protOBoa, and inhabit
the M(xkI of the infected individual. We must, however, understand that
in the s|)e(ific micro-organisms of malaria we have not as yet proved the
thn>o conditions re(]iiired to show that a given disease is caused by a specific
micro-organ Lsni. These three conditions, as formulated by Koch, are k
follows :
(1) Tlie pn\sen(x; of the organisms in all cases of the diaftfu^ and in
such distribution as will explain the lesions.
(2) TIm^ isolation of the organism in pure culture.
(3) The repHKluction of the disease by inoculation with the isolated
organisms.
When, JUS has been said by Welch, all these conditions have been fiil-
tilled, there will Ix^ no doubt that the disease has been caused by the especial
organism. In regaitl to malaria, therefore, you see that only the first of
Koc'hV three rc^fjuired conditions is present. The micro-organism of malaria
has not lK'<»n found in any other part of the body than the blood, and
malaria may therefore justly be said to be a disease of the blood. It has
no known means of exit from the lx)dy, and its mode of entrance has not
\)CQn definitely determined. The germs of this parasite may be contained
in the blo(Kl-j)litsma, or in the sul>stance of the erythrocytes. The name
plasm(Klium has been given to the germ found in the red blood-disks.
Aeconling to Thom])son, in acute paludism (malarial fever) the planmodini"
THE BLOOD IN INFANCY AND CHII*DHOOD.
381
is found in the form of amoeboid bodies, occupying a place in a certnin
I numljcr of the en^throcytes or adhering to them. These bodies derive pig-
ment (mt*lanm) from the erj'throevtes, aud» after nndcrgrjing a certain degree
I of development^ increase in size at the expense of the erytbrotn^e?* They
I are fonnd to oontain this pigment in distinct granules and rods. They
vary io sizc^ am! ^mic an^ as large as the ervthrijcytes. Tiicy are at
first colorless and transparent, and at the height of their development
[they undergo segmentation. This aniceboid form of the jmrasite i» the
one commonly found in what is designated as the tertian variety of mal*
; aria, and is the most common of all the known forms of tlie parasite of
mahiria.
In addition to these amneboid forrasy crescentic shapes of the germ,
'acc!<irding to the investigations of I^averan, are common in the bloml of
I certain types of palntlism, irregular forms of the diN:^ase» and malarial
Ifjachexia. Like the amrebt^id ibrms, they ai'e transparent and colorless,
exc*^j>t for the pigment-granules which they ctintain in their tx^ntres. They
[are larger than the am«el>oitl lbr!ns, ai'e much more i"are, and are much less
I affected by the action of quinine,
Councilman describ*^ flagellate botlies as Wing most eommonly found
I in blood which has lieen aspirated from the splct^n ; and in acute eases of
miilaria they may sometimes apjiear in other situations. They exhibit from
three to eight vibmting eilia.
It is still a matter of dispute whether the plasmfKlium malariae is i>oly-
imorphous and thus may prmlucH:' the differeut tyix^s of malaria, of* which I
ehall presently si>cak, or whether there are <x*rtain distinctly separate organ-
[ isms to which the name pla^nuxlium malarite is applied.
There Ls no drtubt that two distinct Ibrms of parasites of malaria can \je
[diagnosticated by the appearance of the plasmodium in the blood, and that
[these* two forms can be sc^parattxl clinically.
Golgi is the investigator who has most clearly shown that there is more
Itban one parasite of malaria, while Laveran is the exponent of the poly-
] niori>hous theory.
Method of Examination* — The techuiijue of tlie examination of
I the hloffd for the purjiose of detecting the plasm^jdium malarias is very
simple. I shall descrilx^ the method which has Ix^n used more largely
» ft)r children than any other, and wOiich has been found satishictory by
[Dr. Kopllk, of New York, whose work on the bIfMxl of malaria in early
[life is more extensive than that of any other investigator up to the present
ftime.
The blood is first examined in a fresh condition by placing a drop on
I a slide, ct>vering it with a cover-glass^ and stiulying it under a microscope
[without a heatt^I stage. Another s|KH:*imcn of IiI<hh1 is spread rapidly on a
mosceu or eightct^n covcr-slii>s by Ehrlich*s method* The blcMid is then
lallowed to drj^ in the air, protected from dust. It is then placed on the
|!EhFlich brass plate and heated for an hour or an hour and a half. The
382 PEDIATRICS.
(MiviT-jrla.ssc's are then stained in a ven' dilute solution of methylene-blut.
Ensin is not usikI, its some varieties deoolorizc the blue and tlubi intn-
d\uv an element of uncertainty. The blood is heated at a temperarirv
al)ove the l)oilin^-|)oint (120° C.) on the plate. The variety of dvf k
im|M)rtant, as some blue d(K:»s not stain. Grubler's blue ixnvder, ^<Juble
in alcNiJiol, has |)roved to lx» satisfiictory. A few drops of the saturait^J
s(»lntion of this blue in alc»ohol are added to 30 c.c. (1 ounce) of waie:.
The eover-jrhu<'*<'s should not be deeply stained, as certain apiiearaiurs
may, under tiuse eireumstanees, lx» lost. They are to be rejx^atedly wa.-hwl
in water and then drie<l in the air without heatings, as heat decoloriztti
them. In this way the bl(Hxl-eell is well hardened^ and its prot^ipksin
an<l hiemo^lobin stain mort» certainly than when hardened with aloM
sublimate, or osmie acid, (^her specimens, again, may be stained by EL:-
lieh's anilint* methcMl to study the different appearances. The erj'thromL^
ol' malarial eas<*s, when stained in this way, show the plasmodium iu bk:*
and the protoplasm in yellowish green or colorless rings, if there Is aD»mk
If tli(^ Khrlieh dyes are useil, aurantia, orange G, and others (preferaliy
the s<»lution in ^lyetTin (»f e<»sin, indulin, and aurantia), the plasmodium
<l(K's not stain, but the ha?moglobin of the erythrocytes is stained iu shad^
of varying intensity.
As in every eas4' of })ronouneed malaria, whetlier in earlv life or h
adult-^, the eharacteristie feature of the disease is a paroxysm, we natnnilk
sliould Hrst examine thebhxKl at a time when this jMiroxysni is taking placv.
and Irom this j)oiut study the changes which the parasite shows in the initr-
vals iH'tween the paroxysms.
(lolgi was the fiivt observer who actually described and diffcreniiatf!
the more common forms of paludism, and his observations coincide praoti-
eally with those which have l)een made since. I shall, therefore, deseribt-.
as ol»( rved !>y (iolgi, the main features of the changes in the blood wliiii
are (•aiisc<l by the development of the plasmcxliuni, and such featuRS !•
will explain the resulting symptoms of malaria and will thus be of clinicil
iinjxntance. These ehanges in the ])lasniodiuni have been so well dt*-
seribrd l)y Dr. Thayer, of Haltimorc, that I shall quote what has Ixt^
>'A\d l)y thi> ti(liniral)le investigator. It will, however, be necessary* fiM
to e\|>laiii crrtain terms wliieh, having l)een used in connection with mal-
aria, ami haviiiii beeome established l)efore the specific parasite of nialam
was known, are really more adapted to the symptoms of the disease, ai>i
are lienee givi'M iimre prominence than is in accordance with oiu* pre?=eiir
knowleilge of it.
The |>i"oiniiient symptom of malaria Unng the paroxysm, earlier autho^
naturally ela-^sified malaria according to the time \vhen the parox\'sms ap-
peared, using the term qu«»ti(lian where they ocxiurred with intervals of
twenty-four hours, tertian where tluy (K-eurnd with intervals of fortv-eiirbt
hour>, and tpiartan where they oeenrnHl with intervals of seveutv-two
hours. The term tertian is somewhat misleading, unless we undeRtaud
THE BLOOD IN INFANCY AKB CHfLUHOOD.
383
that it is a word derived from the Latin nietliml of tiounting the day
[ of the beginniog of the febrile maiiifetation as the first day. The terms
■ tertian mid quartan, theiTfore, are sim|>ly used empirieidly to reprefieut
! intervals of forty-eight and of seventy-two htmi^ between the jmroxysms.
Again, the terms intermittent and remittent have been used eommonly.
The intemiitfent form is ehanioterized by entire absence of fever between
the paroxysms. The reniitieni form is charaeterized by the pree^nce of
more or less fever of a continued tyi>e whieh does not cease between the
I paroxysms. You will presently see that these terms should not be used as
classifications of distinct tyjx^ of raalai'ia, as the conditions whieh tliey rep-
resent may, aecording to chance, api>ear in miy of the types, and are mei-ely
caused by a variation in the behavior of the parasite.
If we examine the blmwJ from a tertian ca^^ where there ih a deeidcf!
interval bf twenty-four hours betsveen the paix>xysms, we find that just
after the jwiroxysm some of the erythrocytes will contain small, round,
colorless bodies, which appear to have a slight depression in the centre^
and when stained in dry sjieeimens show a pale central area witli a dark
periphery.
** These bodies, examined in the fresh si>ecimen, show active amceboid
movements. A few hours later the organism will \>e tbund to have in-
creased si^mewhat in size and to c^mtain a few fine bmwnish pigment-
gnmules which dance actively imder tlie eye, the motion ]>robal)ly Ijcing
due to undulating movements in the pnitopkism. On the day k'twt.Tni the
paroxysms the bodies will Lie founil to have half fillc^l tin* «*rvthrucyte8.
They are still actively amceboid, and the numlx'r of pigment-granules is
considerably in(*reiised, Th(^ erythrocvte at this stag<^ will l>e seen to lie a
trifle larger than its unaftected neighbors, and to Ix? consideral>ly decolorized.
Ou the day of the pan>xYsm the organism is foimd to have entirely filled
almost to liave diatroyrHl the ervtlin>eyte, which is representetl onl}' by
'« faint pale rim ab«*ut the full-gpnvn panisite, if indeed it has not entii'ely
disapi>eaiXKh The jiigment-grauules may show at thLs stage a very active
motiim^ but the amtebi>id mo%'enients of the organism, as a whole> are but
little markt^d. At the time of the paroxysm a change takes place. The
pigment gathei^s t^^gether in a nuirt^ or Ici^s solid clump, usually in the
centre of tlie erj-thrtK-yte, while the rest of the pmtoplasm looks somewhat
granular, and shows a suggestion of liiu^s nuliatiug outward from the
ocmtre. This ai»jiearance gradually changes, the lines Ix-comiug more dis-
tinct, until finally \\q see the eentnd clump t»f pigment surrounded by from
fifteen to twenty small, ovoid or round glistening segments, each one having
a central moiT i-efractive 8|xrt, and restiubling stn^ngly the hyaline IkkUcs
which we sc^ immediately following tlie chill. This segmentatiun of the
organism is always tMiincident with the pamxysm, and the presence in the
blcMxl of a segmenting body is a suit* indiriitiim that the paroxysm is pr«js4:'ut
or is aUiut to occur. Immetliately fi»l!owing tl»e pamxysm fn^h hyaline
bodies appear in the erj^throcytes. Though the invasion of the corpuscles
384 PEDIATRICS.
l>y tlu-st* t'voAi siHTiiKMits hiis never Ikvii actual! v ohr^ei^-ed, the evidence tk:
this (Kviirs is so stroiiir that we can safely aix-ept it a.s a fiict. Bej^Uts tb^
i;.rms, we stH' not iiifhiiuently small or large extra-<?el hilar pigment Mi-,
—that is, niyanisms n's<'ml)lin«r I'xaetly those witliiu the emhnjc}-!.^.
rxtipt that tliey an* tree in the hl<MKl-eiirrent. Tliesse mav be ^seen at tink?
to l»n'ak u\) into s<'veral smaller IxKlies, while at other times thev mav ^L-.w
a loiitr tail-like n<»n-motile j)roeess containing !«oiuetinies a few piijmtm-
irrannlts. Tiny are prohahly orjranisms whi(»h liave escti|K<l tn>m theen--
thnMvtes, or t'ull-L^n»\vn IhhHcs which have broken up. Thev are tvn^idt^iJ
to U* a <le;i:i'nerativ<' form.*'
At tinifs wv find the flairellate Ixxlies which I have alreadv reftm^to
as dtsrriUil hy Connrilman.
A<*<'onlin<r to Thayer, the <*haraeterLstics of thi.s form of orfiani-n
wliieii is ohstrvcil in tertian fever alone, are .so marked that with a link
>tn<ly of the |»anisites one (»iui make a definite diagnosLs of the tvpe of ftv-f
fn»m an exaniinati»»n of the hltMnl al«»ne. He also obsierves that the qiiama
fever is not eoninnm in this oMmtrv, bnt tliat where he has seen it iht
ori:ani>m< differ di-tinrtly from the tertian parasite, and their apiiearaDi^
c<»ineides exaetly with that d(s<-rilHil by Golgi. For instance, the first >X3^
of the (juartan <»rtranism is >imilar to that observed in the tertian, exctp
that the amo*l»oid movement> an* not so aitive ; as the body develop^ thr
pmIs and elnmps of j»it:nient aiv larj^i^r and darker than those which appear
in till' tertian form, while the annelM»id movement of the onanism i? nh-
tively >liLrht. The tnll-irr«»wn ipiartan forms are niateriallv smaller tlm
tho-e f'oiind in the tertian, while the erythnnytes, instead of beintr expandni
and (h-t-olnri/t-*!, a|»]K-ar at times shrnnken alxnit the Ixxlv and of a s«im-
what deeper njd-hrass ei»l«»r (Mes>inirfarlHT). Thayer also states that in the
(jiiartan fl)rni the se^mentatii»n of the organism is into fn.>ni sLx to tec
ilitVeniit parts, instead of fn»ni twenty to thirty, as is seen in the tertian
fl»riii.
Although Marehiafava and C'elli have described an organism which
they a--ert <-:iu-<-; a <lelinite form of pahidism represented by the paroxr^m
iXHiirrinir at interval^ of twi^nty-four h(»nrs, this has not lieen a.)rroborattJ
hy other inve-tii:atMrs. A\'r aiv not jnstifKxl, therefore, in assuming thai
there i- an e*;jMtial ])ara-ite whieh ranses a distinct disease represented hv
the term inioti^Iian. In like manner, we do not at present reoc^:nize that
tht-rr i-^ a -rparatf para^ii** whieh may <-anse the symptoms of remittent tever.
iinle<- it -hall U- j.rov.-^l t<» he the iv-tivo-antnmnal. I shall therefore ft>n-
tiiu- my remark- h^ th.- two form- of dis4*ase represented bv intervals iu thr
paro.\y-m> ^^t' tin*ty-eij:ht h<»iir< and >eveiity-two hours.
It i> evi«leiit from what I have already told you coneeminst the changes
whieh the ]>lar'mndinm malaria- undrririK's in the process of its developnxwt
in the irythroeyte- that it eau-(- the ditten^nt symptoms which arise in
nialaria l\v it- action in the ditlirent stairt's of its development. We see
als*> that the seirmentation ot' the t»ri:ani-m is always coincident with the
THE BLOOD IN INFANCY AND CHILDHOOD.
385
jxysms, and that the interv'al between the paroxysms is charactemed by
diBtinct and early stage ul" development of the parainites.
K(»pHk hiLs made so especial a study oF malaria as it apjieara in early
life that 1 sliall quote ireely ivom hLs writings on this subject.
In pure types of paludism^ either tertian or quartan, one generation of
the plasoKidiuin will be found to |)redoiiiinate» In thoH<^ easels of tertian
, where the panjxyi^ms are ibuud to Ije of duiJy occurrenc'i% ?^»veral gt^nera-
ions of parasites, each with a diflerent cyele of developnxent, will be
[fotirid in the blood. The sjime (rl^servatitm will Ix^ tuinul to be tnie where
tirre^ular ty\n^ r>i' iever ^\ itli the tertian parasite are earefully examined, and
[also where the bliMxl in (juartan levers is examined. If more than one gen-
ation of |mrasites exists in the blood in a tertian case, the fever may be-
'oome qnotidiau, with daily paroxysms doe to the ri|>ening of distinct sets
of jmra^itt^s on tlitlereut days, eaeli set of parasites taking ISirtv-eight hours
Bto mature. In like manner, in cases of quartan fever, tlirough the ripening
Bof distinc-t m^^ts of parasitc*s on different days, different i\mibiuatioiis ix'cur,
B accNjrding to the numlx'r of sets of parasites. Thus, while in the form in
Bwhieb tliere in only one parasite tlie intervals between the paroxysms are
seventy-two houi*8, in that in whieli thei*e are two para'^ites there may tie an
r interval between the paroxysms rrf only iiirty -eight honrs, and where there
l«re three parasites there may Ix^ an interval of only twenty-four hours,
■thus representing the quotidian irhills des<^ribed by Mannaberg, This will
[be more clear to you if yon examine tliis table (Talile HH)^ which I have
[arranged lor the purptuse of detiuitely explaining the different ty[>es of
paludism as they are now under8t4:Mxl l>y the most recent investigat^jrs.
TABLE 88,
The Principal ChmbinaHoM of Paroacy$m» eau$fd bij (he HoMmodium MtUarm.
Tertian.
Pure t«:'rtiun * . .
Intermk.
Utday.
aflday.
8ddar
4th day.
48 houra.
Pflpoiysm*
No pHroxyfttD.
PaTwxyBoa.
No paroxysxai
{Ow pumsite.)
Dt»uhl»' iLTtinn , ,
24 haurs.
Paroxysm.
Paroxypm.
Pafoxysm.
Paroxysm.
Two narasitea.
QfJ4JITAIf.
Pure quartan . . .
72 hours.
Paroxyam.
No piirux3*sm.
No paroxysm.
Paroxysm.
(One pamstie.)
Duuhle qunrtan . .
46 boura.
ParoxjHin.
Paroxyem.
No paroxysm.
Paroxysm.
(Two pamfiilea.)
Tnnlti quftrtan . ,
(Ttir^G piimsitee.
24 houra.
Paroxysm.
Paroxyam.
Paroxysm.
ParoxystQ.
Quotkiiiin.)
The table, a^ yon gee, explains^ how tlie different intervals in the pan^x-
ysms are cauj^ by the development of the para'^ite on different days. It
will thei^fore l^e easy for you to nnderstand tbat it is according as tlie para-
site happens to develop that we have a re^lar or an irregular perindieit)%
26
386 PEDIATRICS.
Thus, it niay hap]x^n that wc have two parasites, and these two pansites
may develop on the same day, but at difierent hours. In this case, sop-
l)0»ing that they are of the tertian type, two parox3rsin8 may occur oi
tlie same day, followed by an interval of forty-eight hours from the time
of the full development of each of the parasites until this developncot
occurs again. In this way different broods of parasites may canae a
almost infinite variety of symptoms. Again, we must reoognize that it
is probably tnie that it is only when the broods of the parasites are »{»-
oially large in number that a pronounced paroxysm is produced, becauttif
the bnKKi is small in numl)er and insignificant it may cause only a greaier
or less rise of tem{)erature in place of a pronounced paroxysm. Yoam
that in tliis way we can probably explain those difierent forms which hue
been designated as remittent fever. That is, on the intervening day, da
tliere is no ]>aroxysm, but only a continuous heightening of tempenitaie,it
may be that the broods have developed only sufficiently to produce fever vi
not a imnixysm, and we shall probably in the future, by a more extended
study of this parasite in all its phases and under all circuxnstanoeB> be able
to show that it is a variation in numbers as well as in the kind of the pvaale
which causes these distinct, diiferenoes in the symptoms of malaria.
It has lxH.'n noticed that the administration of quinine tends to interfiR
with the regularity of the time of the paroxjrsm, and in this way othff
variations may (Kxiiur. It ha^ also been noticed that if the paroxysm ooidb
earlier in the day than it has been doing, the disease is apt to be of a sevof
ty|X! and to l)e growing worse, while if the interval is lengthened and die
atUu^k is found to crime at a later hour in the day than usual, it is a ^
that tlie dis<*a^' is amenable to treatment, is of a benign character, and is
tending towards rtKM)very.
The tertian form is the one which is by far the most common in thii
country, and the (me which is most influenced by the administration of qm-
nine, the other form, represented by the quartan, being peculiarly difficoh
to manage with ({uinine. In young infants the tertian form in its qnotidiia
variety is met with most wmmonly. In older children, in my experioioe,
it is the pun> tertian that is most common. It will be noticed, by glancing
at the tal)l(» (Table 88, ])jige 385), that the quartan form of paludism gu
nev(T repR'seut by its intervals and paroxysms the pure tertian form.
Patuolocj V. — Thert^ are no especial diiferenoes between the patfaologieil
lesions found in tlie malaria of children and those which occor in adnh&
I shall, tlierefoixs not dwell on this |mrt of the subject^ bnt ahftll merek
state what Thayer has said concerning this disease.
In (icufe cas(s ut' malarial fever, on examination with the microsoope^
the rcrchral eajnllaries are found to be crowded with niitlfLwnfil parwite
Then^ is usually a markcKl granular degeneration of the endotheUimi of tk
vessels.
The ttplee}) is always enlarged. The ca])sule is tense. The parenchTBi
is cyanotic, of a slaty-gray a>lor, and almost diffluent. The palp of the
THE BLOOD IN INFANCY ANB CHILDHOOD.
387
PPfcen is found to contaiii enormous numbers of red blooilKx^rpuscIej^, many
fcf wLk'h coiitaiD parasites. It also contains nnmeroos large white elements
kich in protoplasm, with usually a single bladdor-like nucleus and at times
koarse granulations. These element ai"e aimraonJy latlen witli pigment,
Ewhteh at times has the same arrangement as it has in the IxhJv of the j>ara-
bite itself. Theiv may Ix* free pigmentatifju in tlie intereellular spaees of
phe pulp. The small mononuclear elements and the lymphocytes of the
llbllieles never contain pigment The eapiUaries are usually filled with
hhe plasmtxlia, while the splenic veins show relatively few, though they
always contain large cells enclosing pigment or the remains of red blood-
corpiLscles.
I The liver has usually a slaty-gray color. The capillaries are filled with
peueoeytes, which etjutain uumrrous pigmental IxKlies. llelatively few
Iplasniudia mv ftjund in the bliHidniHirpiLseles in the vessels.
I The lungs show in their capillaries numerous cells containing pigment
[dumps and well*preserv€*tl parasites, although it is nnusnal to find pigment
nn tlie endothelial cells, in the eaj>illaries, and in the smaller veius.
I In the areas of broueho-pnenmonia wliieh may occur, |xdy nuclear leuco-
Icjte.s are often found, while the large pigmented cells take no part apparently
lin the active inflanimatnry pnx'e^s.
I The vessels of the kifimjA c*<jntain i-elatively few organisms. The glo-
meruli may be considerably pigmented* There may be marked degeneration
fef the epithelium of the capsule, and at times changes in the jmi'enehyma,
kspeeially an^as uf necrosis of the epithelium of the tMmvfilutc^tl tubules*
iTbe other viscera shiiw no Sf>ecial characteristic changes, except, at times,
Ithat of melanosis.
I In the moj'c chronic form of malaria the muania is usually pai'ticularly
lliiarkwl. The »pleeii is always enlai^xl and very firm. There is marked
Itbiekening of the capsule, which is often adheiTut to the neighboring
■tissue. On s€*etion the spleen is generally of a dark brownish-gmy color,
■the librtius tissue throughout the organ l>eing greatly thickenetl. The liver
pB considemlily enlarged, and usually has a grayish-brown or slaty wlor,
■At times there is a considerable increase in the connective tissue. The
\kidnci/ii sliow no |tartieularly characteristic clianges, though thei-e may
Ibe considerable pigmentation. The pigment is most marked about the
I blood-vessels and the Malpighian bodiei?, and sometimes in the region
■of the convoluted tubules.
I There are no characteristic changes in the other orgarm^ except the slaty-
Igrayish pigmentation.
I DLVGNasis, — Malaria as it occurs in early lite is far more diificult to
|diagnosticate by its symptoms than where the disease nins the typical course
iusually seen in the adult. It is the most protean disease which we are called
|iip<m to deal with in young children, ami it simulates so closely almost every
Lpther disease we are likely to uki:! with that we should always h>e on our
fcoftrd, and allow the jmssibility of the existence of tiie plasmodium malarise
388 PEDIATRICS.
ill making a diagnosis in a d(»ubtful case where a periodicity is notivvd !:
tln' symptoms.
TIk' only rational method of determining that we art* dealing witli a 'a*
oi' malaria is thi' examination of the bl<.K)d, which at ouoe settles the 4Ufeti:
if the {)lasmodinm. Ik' fonnd.
SvMi'ToMs. — The symptoms of nudaria as it occurs in infants ai>l i
ymmg ehildren are nuieh nmre varit'd and tiir more uncertain than Vjf)r.
whirh we are aeenstome<l t<» miK't with in adidts.
The younger the individual the mort> likely are the pronomieed ihu
to 1h- rej»laetM[ by H»me other symj>tom, such a^ vomiting, delirium, an-loii-
vul>ious. T!ie i»aroxysms <'ome more frHjiicntly in children than in aJult.
and in yonng eliildren a condition of aj)athy and soniiiolenw, sometinn-ftri
i'ever, and soniethnes ai-etjmpanieil by <'oldni*ss of the extremities audacv!-
la|»Mil eiiutlition, very e<nnnionly rejdaets the chill of the adidt. Tj^
symptuius, H'presenting the onset of the disease, may often disappear a^ t*
disease iMt-omes estal)lishe<l, an<l in their jdac^e we may niec*t with the ^im
toms of some other disease, such as bronchitis, torticollLa, and nianyetkr
atlei-tious. The sy m|)tt»ms oi' thes<» other disca^^es will often continue z^iti
ho very intractable until ([uinine is given, when they will disapjiear, a?i
thus \\r shall be h'd to U'lieve that we have lKx*n dealing with one of tin:
maskul au<l misleading manifestatiims of the plasmodium malariie. (Yii^
Case -Jil!), pa'j-e <;]().)
My exjM'rienee with malaria in young ehildi-en is so similar to tliatn:
Dr. Holt, of New York, \vli(» has written more fidly on the svmptom*f
malaria in early life than any one else of whom I know, that I shall ip'te
from hi-i w ritiugs on this >ubje<'t.
The >use( ptihility of the nervous and respiratory systems in vmicj;
children to |)r<Mluee variations in the form and type of malaria is luo-itmir
leading in regard to diagn(»sis, the symptouLS referable to a particular orjM
often eomplctcly overshadowing the real disease, malaria, and prodiicinii an
entirely new eliin'eal picture. The symj)t(mis otlen are so indefinite and tLr
disease ire(|Ueutly e()mes on so insidiously that the physician does not x^
the <a-e until it has made e(»nsiderable progress and the diagnosis thib i?
nnieh ol)M'ured.
In adilition to the other symj)toms of which I have already spoken,
sevei-e paiu in the head and sometimes in the epigastric region is met with.
in the l«>rni in which the invasion is gradual, the prominent svmptonL*aft
aiueiuia, loss of ajjpetite, and frontal headache of moderate tvpe. The
spleen in the majority of ea-cs is fonnd to \xi enlarged, but the well-knovt
ditlieulty of deieetiug jin enlarged splcH'U in young children makes it p"^
sihle that in many ea-es there is enlargement of the spleen without our
being ahle to chtert such eulai'gement by jKTcMission or palpation.
Tlie time and character of tiie onset of the disease and of its pamxv*in?
are very irregular, h) uniej] <o, iudee<l, that it would not be practicable to
dwell ujM)n the exact ditlerenees which occur irom those in the adult
1
THE BLOOD IN INFANCY AND CHILDHOOD.
389
■ Splenic and hepatic tentlerDe^, and pains in tbe back, exti*emities, and
Hnecky are oceaiiionally observ^ed, and genei"al cutaneous hypersesthesia is at
H times notictid. As tbe cap'^nle of the spleen Is le^s re^ii^tant in young chil-
■ dren than in adults, the organ seems to eulai"ge more rapidly, and aLsti to
■ subside more quickly, in children than in adults.
I The couditirm of the intiAstfnal tract vai'ies as much aj^ do the other
I symptoms. Scjmetimes cx>nsti|jation is present, and SDmetimc^ diarrhtea,
the latter being the more prominent the younger the child.
Dr. Holt's observ^ations on tlie pulmniiary symptoms oc-curring during
attacks of malaria are so iuteiTsdng and imjxjrtaut that they i^honld he
recorded. Bronchitis was found to be tlie most im|neut of all the conipli-
cationjs cxxMuring iu the course of malaria, and again and again proved to
be intractalile until its mahirial origin was distHivered. Certain acute cases
appeared to he pulmi>nary (xmgcstious unalogous in their pathulugy to the
cxiogeBtions of the splet^n and the liver. The pulmonary symptoms in these
Cittses were quite iinifivrm and eharacteristie. The invasion was acute and
the tempeniture high, ranging irom 40'^ C. to 41.1° C. (104^ to 106*= F/).
The respirations were very rapid, in three or four cases reaching 1 00 in a
minute, and resembling the supertit^ial breathing of lobar rather than the
labtred bit»athing of lobidar pneumonia. The face was often cyanL^tie, and
tlie pulse varii»tl from 1(}0 ti» 2(M} per minute. In one or tw^o cases there
was market! drowsiness* The physical signs were usually a slight increase
of vocal fix'niitus and slight dulness on percussion. The respirations wci-e
always higli-pitched and sometimes bmncho-vesicidar. Vocal resonanc*^
was exaggerated, and there were sonorous rales and occasion ally coarse and
fine muwnis ritles. These signs were sc»mi*times gf^neral iu li(>th lungs, but
were usually most marked Ix'hind and towards the api<x^. They were at
times found to lx» confined to a single lung and once to a single lobe. When
first seen they were* diagnostieatf'd tus cases of pneumonia^ Ijut their subse*
quent progress and termination eonvina'd Dr, Holt that they were tem|)0-
rary manifestations of malaria^ for patients who w^ere seen in the afternoon
with tht^e sympttims M^onld Ix* found tlie folkiwing morning running al:N»ut
the house with a normal pulse and ix»spiration, and with only the signs
of an insignificant broueliial eatarrh in the chest. These attacks would
recur on the following days until quinine was administered. Marked
I splenic enlargement was detected iu these cases.
Pneumonia, l>oth lobar and lobular, was iK'casionally found as a compli-
cation of malaria.
Spasmodic asthma of malarial origin was seen in some cases. These
attacks were atvompanie*! fitijuently by marked splenic enlargement, and
were promptly relieved by imtiperiodies.
Prognosis* — The prognosis of malaria in children is good, providf^
that the child is removed from the malainal district and is treated with
quinine, R^^lapses occur, even after long intervals of apparent immunity,
■ and the diaease can recur a number of time^
390 PEDIATRICS.
Whcu a child has been once attacked by the plasmodium makiris, it
seems to be ])ceuliarly vulnerable to a second attack of the organism.
Treatment. — Quinine is the only drug which can be relied upon t»
eradicate the plasmodium malaria from the blood, and is the only medinv
for this pur{K>se which I shall mention.
It may be given to an infant under six months in doses of 0.03 gnmnx
(^ grain) ; at one year the dose may be 0.06 gramme (1 grain), at two veus
it may l)c 0.12 gramme (2 grains), and it can be increased up to 0.3 or Ow3i
gramme (5 to 6 grains) at five and six years. There is little danger of gi^in;
too large doses of quinine to children, as they tolerate the drug very weiL
The latest investigations have shown that the plasmodium is most sensitin
to the action of quinine when it is excorpuscxilar. Hence the quinin
should be given shortly before the paroxysm.
The manner of administering quinine is rendered somewhat difficnhuD
a(xx>unt of the bitter taste of the drug and its insolubility in water, h
very young infants, and in fact in the first six or ei^t months of lift, it is
well to tr}' the eifect of sup])ositories. In older infants and in childrai it
can usually be successfully concealed in a small amount of chocolate craun.
The time for the administration of the quinine does not have to be r^
lated so carefiiUy as in the adult. The dose can often be given with effiet
three or four times in the twenty-four hours. It is commonly given im-
nuKliately after a paroxysm. I have been in the habit of giving it about
eight or tf^n hours I)efore the ])aroxysm is expected. It is wdl to cob*
tinue the treatment with quinine for some weeks after the paroxysms hive
ceasc^Kl, as the symptoms often return if the quinine is omitted at once.
The anaemia which alw^ays accompanies the disease to a pronoimced
degrtK? slioiild l)o treate<l with arsenite of potash, or with some mUd form of
in)n, su(;h as tlie sacclmrated carbonate or the tartrate of iron and potash.
Those prescriptions, varied to suit the individual^ are what I am in lk
habit of using in cases of malaria :
Prescription 42.
For an Infant under Six Months.
Metric. ApotAeearv.
Gramma.
B tiuiniip sulphalis 0 30 R Quinin Bulphatis p.ti;
(>»l«i ibonbroiiKu 11'26 Olei theobtonuB
M. M.
Ft. suppos. no. 12. Ft suppoi. no. 12.
S.— One suppository to be used every 6 houn.
Prescription 48.
Apothecary.
Gramma.
B Ferri carlwnatis saocbaniti .... 0 90 R Pern carbonatis — ^^^hatirtl
Ft. pulv. no. 15. Ft. pulv. no. 16l
S. — For an infant under 0 inontljs, 1 powder three times daily.
For an infant fn»ni 0 tu 12 niontbd, 1 powder four times dally.
For an infant from 12 to 18 months, 2 powders three times daily.
3^
Metric.
THE BlXOn IN INFANCY AN© CHILDHOOD.
391
PEEBCBIPTtOK 44.
Metric.
B Ferri et pote&sii tartralis .... 3
Glycerini . , , . , . 18
Aq. d€5atil tid 90
Gmnuna.
00
75
00
Apothecary.
B
Fern et poiosaii lartratb . .
Glycerini .......
Aq. destil
M.
8. — For a child 2 yeftrs old, 2 c.c, or | dmchni, thnce timea daily.
For a child 4 years old, 4 c.c, or 1 tiriiohrii^ three titnei! daily.
For a child 8 y«ars o!d» 6 c.c., or I j drachm», three times daily.
For a child 12 years old, 8 c.c, or 2 drachim, three times daily.
ad Jiii.
Frkbcbiption 45.
For a Child Tu)o Fears <M,
Metrie.
Apoihemrtf*
B Liq. potaaaii areenitii 0 1 96 R Liq. potasaii arseniUs Tr\^xvi ;
Aq. destil ad 120 j OO Aq. destil ad Jiv.
M. M.
S. — 4 c.c, or 1 drachm, to he given every 8 hoUTB.
In my exi)eric^iice, malaria may occur at auy age.
Dr. Daii^j has recently meiitionetl to me a case (Case 150) of probable
malaria (the blood wa^s not examined) in an infant a tew days old.
The infant's mother had malaria during her pr^^nancy, and ^*me of the manifefttatioiti
^f the dij^ease apjieareti ten days Iwfore the birth of the infant. The infant from the earlit.«t
days of it? life shBjwed syinptomfi of jsevere digestive disturbance, chiiracten^ed bv vomit-
ing and diarrhcea, and far bej'und what could be accounltKl for by the lack of equilibrium
of the function of the mother's mamnmr)' ^Itind.
Dr. Dune n;nde a ctireful physical examination, hut failed to detect anything abnormal
ia tt*i thorax or abdomen.
Ohservations of the temperature in this case, taken lx»th in the axilla and in the rec-
tum, showed that it waii of an irremmlar typt-, varying fmm H7 2* C. to 88.8*» C (90* F. to
101' F.) n^tal, and that at Hmm in the huttr part of the* day it roM to 89.4«' C. to 40<» C.
(103* F. to 104° F.) axilkry.
Kvery day at about 1 a.m. there was a paroxysm, represented by cyanoala, coldueaa of
the entire skin, both of the Ixniy and of the extremities, collapse, and soninolenee. These
attacks, beginntnjyj at the seventh day of life, luMt^d until the twelfth day, when quinine in
0.03 gramme (J grain) do&es, leriven in nuppoi*it<»rieH and administered everj- two hours for
seven dose«, at once and completely chet^ked the piaroxysms.
From this time the attacke entirely di?«ap|>eftred, the food was well digested, and the
infant seemed perfectly well.
I have here in the wards to-<lay two eases (Cases 151 and 162) of
malaria to show you.
One IS this boy (Case 151), nine years old, who was admitted to myterrice on the
18th day of February,
He lived in a malarial district until one year ago. He had a slight cough, anorexia,
malai&e, night-sweats, Hr>d mpid loft.>? nf fle!*h for several weeks. The movements of the
bowels were rather irregular. According to his mother** report, he had never before
bad any symptoms of malaria. On examining the cbild you will ^ee that be is pale and
emaciated.. On physical examination 3'ou will find that there is reaooftnce over both
lungi, and on auscultation you will bear a t&w moiai r&les and an occasional sibilant
392
PEDrATRICS,
rile. The ■.rea of curdiac dulnee^ ivnd the souiidft of the htart Are normal. Thi: fiivl
nut enlarged, but tin? 6|>l4H*n, tu j<hi *iee, U very rowch irvcreased in else, and I havri
the liniit« of ite enlargement in black. You aee that the upper bf>rder rues m hifl ■
the 8ixth rib in tbi* axillary I in*?, and extenda down iulo tl»© left inguinal repvitL Am
exaaiinaiiou of the urine shows it to be normal.
Case 15L
Boy, 9 years olti. EnlArv^
rioBiDfxIiuiii tuaiai \.A. ifiund In blood.
This is a case which r«^'preh<nt'i the tertian form of nmlnria. The child had new
hiid a L-hiiJ until 8 i\m. two ihya aft<?r entering the ho»pitnL The chill lasted aboul »•*
huurj fliid waa fV>l!owed ly Hwoating. A panoxyfitn of some kind, represented dther htt
chill or by a decided rise in tempemture with chilly seusjitions^ occurred on the 17th, l^Ji
21 It, 23d, 25th, 27tb, and 2dth of February , Miirch 2, and March 4, and on March 6^r9
was a decided rigor itt 4 r.M, On Munh 8 the parojcysm occurred in the mornin*' At hilf.
past twelve, Otj the morning of Mnrt^'h 10 the paroxyftm oi-curred at about hilf-ni
eleven p and was folluwed by nmrk<?d ifiWcntiTig. Between the panixysmB th« boyha*ip-
peared to be very well He has had a fair iippetite^ and hns gndually gained in wifM
and streDgth.
On March If)^ immediately alVr the paroxysm, the blood was examined by Dr. "W^fti-
worth, and the plasinodmni malaria* was fcnmd. A spi^clmen of the blood which tk
Wentworth hna prepared to show you, id under thit* microscope (Plate V., p ZMf(
You will aee the eluiiterd of pigment in the crythnjcytejs in the Tarioua staees of the<
opment of the parniiites.
Here is the result of the examination of the blood :
BLOOD EXAMINATION 35. (Wentworth.)
Erj-throcytea , 2,9S/V.nOO
Haemoglobin 30 per cent
Leucocytes 25,600
Small mononuclear , . , , ITpori
Large '* * 27 **^
Polynuclear 56 **
Eoflinophiks * . .
THE BLOOD IN INFANCY AND CHILDHOOD.
393
A lATge number of the erythrooyte« contnincd the Plasmodium malifcriae.
The liirge number of leucocytes pointed toward* some complication, but none wns at
' lime digcuvered.
Tht? chills continued on March 12, 14, nud !♦». On March 17 0.36 gramme (6 grains)
of quinine were tjivcn »ix hours befure the punuicy^in wiis expected to ret^im. On March
18 there was no paroxj^sm. The quinine wa* given I'egularly three or four times a day for
several days, and the paroxysms huve not returnwl,
Hen? is tbn chwrt (Chiirt C) reprotienting the temperature and pu!se of this case. The
days representing the diseu^e fire nece^4!a^iIy only appi'^jximate ft»r the first twenty-two
days, and he is t^upposed t<j have entered the hospitul on the twenty-third day of the dia-
euie. The first chill occurred on the twenty-fifth day^ as b shown in the chart
CHART 6.
j[)a//s at Disease^
?r
24
Z5
Td
27
2S 2
» 30
31
12
a
34
3i
36
3f M
3) ^
«t
42
43
♦ 16^
4! ('
40 5<
40 <?
»4<
US*
sail
3J7«
ITT"
17 0*
36 l«
33 or
1
1
m
W^
fi
iri
1in
WJ
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rt
tf 1
i V
U ITlf
tiei
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n
C
M
MM*
^
1
ID?"
r
f
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1
V
Jl
A
h
10^
f
P
iL
J- J
i\
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i
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i/
-}'
/
Sim
7
^
t.
...
^
^[
-N
r/J-'
i/
t
IT.
..1^;
|1:f
r
r.
WF
/
\\
K
1
w
ISO
MO
\v>
120
no
m
fO
so
ro
60
90
45
«0
39
JO
29
ao
Jl.
"
1
\
h
A
\
(\
J
\
^i-
\
j\
■v
J
1 ' '
y^
*S
L/
W
f
/
^
\
lJ
'
Kr
rff^
f^'^
?ii
fW
m
/a
^^
1
—
—
^
^
—
I'erUiui furm of luoliiriJi. (C nieiuu cbilL}
(The subsequent history ot this t^isewas that the quinine was omitted, the chills did
not return, the spleen recovered its nomml *iz«s the anemia disappearedi and the child
grew fat, and left the hr]«pital in go<Kl of>ndit»on.)
Here m the second case (Case 152) of malaria to which I have referred.
A girlf nine yean old, who enterei) the hospital also on the 13th of the month.
She represents, in contradiBtinction U* tht* tertian f<tnn of nmlaria seen in the boy, a
I of the double tertian ((|Ui:*tidiiin) funn* She has been living in a malarial dbtrict, but
< hmt never had any previous symptoms of malaria^ although a skier living in the
S94
PEDIATRICS,
hoow hM been afTected by the disease. Fotir weeioi before eotefing th» botptil ^
hMd an attack of vomiting, naogea, and h<^adachv. without any »pp««iit omae f« llitt-
Theae sympu>fm i>cciirred at interval for two weeks, when she began to lui^e dliUs cwa^
ring every day at about 5 p.m. These chilU continued, with tho exoepliodi of fiao dt.a
until ber entrance to the hospital.
Un examination you see that she u Ikirly developed and b very Miwinic. On phyibl
examination moiit rale* are heard over the ba«ei of the lunga behind. The heart Acm a
Cahk 152,
Glrl^ 0 yeaimold. Eni»TV»*il NpUfn. rna^tmnliiiiu malAria: Touod In the
increase In the area of dulnc««, hut there is a soft systolic mumitir over the whole pmcddia
This mummr h moat intnnwp over the pulmonic area. The pulmonic second sound liw*
acceiituiiti^d. The murrnur h hmn\ in tht? jugular veins. An examination of the abdmit
«haw8 it to he soft and tympanitic. The liver is enlai^ged, »o that it extends 2.6 cm, (1 wk\
below the border of the ribs. The edge of the spleen h plainly felt, and the peauwiii
dulness extends downward to the level of the umbilicua and upwaid aa far aa Ihv muk
lib, I have deaignated it, as you »ee» by a bkek line. The urine is higb-oolored and ta>
a specific gravity of 1026, but is otherwise norrniil.
On the day of entering the hospital (the IfJth) the child's temperature wma raiiel* W
there wa« no chill On thp followint,^ day, the 14th, there was n chill at 4 p.M* On ^
16th there was a marked chill, with a eonsidf mhle rise of temperature.
Immediately after the parosyflm an examination of the blood waa made by Dr.
worthy with the following reiiult:
^^^^^^P THE BLOOD IN INFANCY AND CHILDHOOD, 396 ^^H
" BLOOD EXAMINATION 36. (Wentworth.) ^^H
Esythrocjtea 2,396,260 ^^^|
Hs^moglubin 30 per cenL ^^^^|
Leucocytes 5,000 ^^^^
PUsmodium malariie present. ^^^H
It Wtta noted that the splenic enlargement was greatest during the eMU. ^H
On tlie I6tb there was a cbill, and tbe temperature rose to 40.6° C (105.2^ F.), the ^|
maximum attam«id during the course of the disease. ^^t
Un the 17th uiid 18ih the chilli recurred. ^^^H
On the ISth 0.36 gramme (6 grains) of sulphate of quinine were giyen at 12.80 p.m. ^^^H
Oa the 19th there was no rise in the temperature, and no quinine was given. ^^^H
On the 20th and 2Ut there were no chilli, but a sMgbt rise of temperature, and 0,12 ^^^H
grauniie (2 grains) of quinine were given four times daily. ^^^H
Tc^av, the 22d, she baa just had a ebill, and the temperature is 40.6«» C. (lOS" F,), ^^^|
Here is the chart of this case. ^^^H
CHAKT 7. ^^H
jPqi/s ofDi^ease^
f
Of
38
2» )0
J> %2
n
^
!5
S6
37
38
mI^o
41
43
43
44
4J
4*
47
49
0
\\ 6*
w\
W%Wt
njTi
ri
ri
rt
IT
rt
rf
n
rr
tl
n
rr
n
B-f
*T
B%
f7
IJ 1*
1
K)5*
lOt*
i
^0*
19 4>
sas*
vn*
J
-J -i
104'
96»
W
ISO
MO
/
\
/ /
1- 1
M
■
h *
\ i
/
i ^
J
/
/
i/l
I
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ill
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^
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...
l<
[^
M
/.
^
-^
s
^
1
*
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/
J\
■
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MM)
/
iJ
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\
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L
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90
BO
JO
m
40
»
15.
J
r
■
\
\
^
^
'V
\
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Y
u
^
V
N
^
^
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1
1
1
1
1
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[
1
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V
|L
f, .
•i
/
L
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i\
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H
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Ji
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z
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r
_
■ (The ffubseq
■ were given in tb
■ gradutdly growii
Bincr^as^ toO.72
■ and then was aga
Double tertian form of malaria
uoiit btst*>ry of this Ga»e was as follown. 0.6 gTBinme (10 gt
e et^urse of each twenty>fbur hours for the next sixteen c
ig smaller. As the temperature was still irregular, the q
gramme (12 grainiV The tern pern tu re remained normal
in slightly raised and irregular. Two weeks later the quini
luns) of quiniiM ^^^H
lays, the spleen ^^^H
uinine wha then ^H
for three duys^ ^^k
ne was omitted, ^H
396
PEDIATRICS.
uiul the sj)leeii was found to be normal in size. Ten days later the child left th*;bsp:-jl
ill iruod ronditii'ii.)
I hav»- h»n' to show yf»u the chart (Chart S) of the teinperatiiK- and pulse of 4 kj
(Case 16:i) nint* uiul ono-haU' years old, who was under my care with zualaria.
CHART 8.
/?ays ofPisease
F
7
3
* 5
« J 8
4
10
)i
12
13
(4
35
-i^
IT
IB
la
20
21
sa
^^
m ■
1 i
■ a< •
A 1 H la
■ Hi
m
■1
* ■
■ 1
Its
u.
■ ■
■ E
■1 n
V 1
mm
m m
* ■
• Li*
iOfi-
1
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(no*
i
'
J
^^
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r T
1-
-
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i^
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y^
—
—
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..
„-
^' 1/
/
1/
w
3G. J*
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110
»0
IJO
190
TO
_
_
^
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j
;1
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,'
//
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;
//
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A I
y
bj
Ll
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i^
■_
Tertiiin fonn of umhiria.
n»' hnd Ikmti w«'11 and ^tnniir, and had not hoon livinj; in a malarial district, but hiC
pp'Tit a iVw <ljiy- in tin- •arly jiart of May in n place where malaria had iK-en known t
(K'«nr o('('a>ionally. (Mi May 7. aftrr n-turning to his home, he complained of feeling ured
and di//y. (hi tin- follMwinir day. May 8, ho complainiHl of headache aiui of fi.>elinir chillT
III- li.iil no a[»p«tit«'. and in tin- cvcnini^ was found to have a temperature of 38.6' C
(hH..V K.). 11.' Iiad two nn»v«'in«-nt^ from the bowels on that day.
On tin- n«"\l day. May '.». liis t«-nijnTatunf at 7 A.M. was normal. At 8.45 A.M.he
('••inpl.iinrd «»t' naii-<M. of h«'ada<-ln'. anil "if feelinj|j^ chilly. He had no appetite. Histof--
p'lMtiin- at 1 I'.M. wa- 40. y^ c. (lOo.o® F.), and his pulse 120. He appeared to l« Vi-ry
rn r\i>u- ainl irritaldi-.
On tin- f'-H.-win-.r d:iy. May 10. In- f»'lt pi'rfoctly well and briiijht, had no headache. 1
^'o.ul app.tii.-. a t.inp.ratnrr ..f ."J-li^ ('. (U'.»^ F.), and a puUe of 80. He continued to f^
Will nniil 7 ".<) p.m., wlun In- i-omplaini-d of headache.
On Ma\ I 1 lii- nn.rnini; ti-injMi-atnp- wa>^ found to Im» 88.8** C (101® P.) and his pu:««
HO. Hr liad n.. app«titi-. \v:i.> r-->tlr-- ami nt-rvous, ]»ut .^lept for two or three houK. Hii
trinp.TMtmv at s i-.m. \\:i- 11- ('. 1 l(>.'>.So F.) and hi.s pulse was 120. At 10 o'clix*k, after
lia\in'4a -pnnm- l.atli i:iv.!i t-' him at a l«-nijM'r;tture of 35** C. (95** F.), hia temperituit
f.ll t.. :is :;■('. , loi K.>. [!<- -1< ]»t wll durinir th«' niirht, and perspired IWhjIv. Thesplew
wn^ f..nnd to 1.,- -..niiw li:it rnlarL^.-d on tlii^ day, and nothing else abnormal was discorend
on pliy-ii':d r\aniiriation.
On tl\.' nn.niin.r ..f May \'2 tin- t.-ni]Mratuiv wa-? 30.5® C. (97.8° P.) and the puhcwtt
♦;o. Ill' r.'li p.-ir.-.tl\ w-ll .and iTiLilu, and had a irood appetite. The moyementfl of the
lii'Wi'l - \\»n' rat In-r l-n'-f-.
On May j:'. tin- iiinvninir i«'nip.Tatnr»' wa- normal and his pulse was 60. Hefeltw«n
aral hrijclit until no,.n, wht'U U.- had a vi-j;.ir la-lini; twenty minutes. After the rigor he Vtf
THE BLOOD IN INFANCY AND CHILDHOOD.
397
ftleepj ftDd tired, and at 3 p.m. tbe temperature wa« 40.5^ C. (105^ F,) and the pulse 120.
At 6 P.M. he telt perfectly well again, hi^ appetite returned, bis temperature fell to 88,^^ C.
(101 8° F.) and his pub^ to 100.
Oti the following day, May 14, he felt perfectly well^ had a g-ood appetite, and at 7
- A.M. had a temperature of 80.1** C. (97** F.). On this day he had 0.06 gramme (1 grain)
Mf quinine given to him three ttmt* a day.
Oil the following day^ May 15, the record was that he h»d pushed a quiet night, and
that he woke *-*arly und »eemed nervouij. 0.3 gmmme (5 gmins) of quinine were given to
him at 6 a.m. Hi* U^mperature at 7 a.m. waa 37.1° C (98.9^ F.). Al 9 o'clock h^ be^an
to gmw sleepy; at 9.30 hi»f^ teraperaturfj was SB.6^ C. (101,6° F.), and at noon it wiif^ 4P 0.
(105.5° F.). At 7.30 A.M. hb puUe was 82, at ».80 a.m. 100, and al uooii 120. At the
time that he was having the high temperature Lis urine was large in amount and pale in
oolon At other times it was nonual.
0.12 gramme (2 grains) of quinine were given on the following day, May 16, when the
record was that he had pa^ised a quiet night and tliat he waked at 2 A.M., seeming to be
exhausted and complaining of feeling weak. IIia Lempeniture was 8.5.6° C. (96° F.) and
Ma pulse 48 and very weak. Thirty drops of brandy were given to bim, and his pulse
aoon rose to 75 and wns of a better character. Ho then alept until 7 a.m. At 7M) am.
hU t«Mnpemture was 35.8° 0. (t»6.6** F.) and hb pulse was ♦jO. He appear^ to feel bright
and well nil day, had a good appetite, and for the first time had a normal movement of tbe
bowels. The temperature in the evening was 86.6** C. (98° F.) and the puUe was 50. At
7.80 P.M. he ecmiphiined of &light pain in tbe bowels.
On tbe following day, May 17, 0.36 gramme (6 grains) of quinine were given at 5.16
A.V. His temperature remained normal all day, and hh pulse varied from 70 to 80. He
felt a little sleepy ut nm>n, but his skin was natural. The bowels were moved regularly^
and there were no abnormal svmptomK,
On the following day, May 18, be was given 0.36 gramme (6 grains) of quinine at 5.80
A.M. He was pi^rfectly well and bright all day, and had mori- upp'tite. He waj* given one
grain of quinine tliree timee during the day in addition to the 0.86 gramme (6 grains) fti
6.30 A.M.
On the following day* May 20^ he was out of bed and dressed all day, feeling perfectly
well.
From this time until the 27th he continued to take 0.8-0.6 gmmme (6-10 grains) of
quinine during twenty-four hours^ and be hue since been perfectly well, with no recurrence
of the malarial symptoms.
(No examination of the blood was made.)
I have also here to report to yon the reronl? of two infants who appaf-
ently were suffering fixim the etfecls of the |)l»>mtKlinm nmlaria% althuugh
no examination of their blood was nuide.
The first one (Case 154) was one year and ten months old This infiint bad lived in a
malarinl district until within a few weeks of tbe time when I *nw him in Boeton.
The history which wa^ given to me by bi^ mother was that for several week* he had
had attacks, represented by a chill or chilly senwition.^, recurring every dav' at about noon.
These attacks had recurred for about a week or ten day* before I saw him. In connection
with tbe chill and the fever the infant usually became unconscious, and its feet and hands
were cold and clammy.
0.06 gramme (1 grain) of quinine was given to the infant on the 29th of April, and on
the following day none of the ut^ual manifejitations tM'curred at noon, but at about 4.80 P.M.
he had a chill and a fcligbt rii*e of teinpeniture, but wa^ not unconiicioua. 0.08 gramme (J
^rain) of quinine was then given, and on the following day, April UO, 0.06 gramme (1 grain)
of quinine at 10.80 A.M. On this day there was a decided chill, and the rectal temperature
rot*e to 40.5° C. (105° F.). During the attack the ohild breathed rapidly; iu feet, hands,
Rnd nose became cold, and it was practieully utieon^-ious for some minuter until its circu-
lation waa restored by injections of warm water and brandy. 0,08 gramme () grain) of
398 PEDIATRICS.
(|iiinine was thon i^ivon thrco timoj» during the twenty-four hours. On the followinjda;
iioiM* of tliise Hbiiornuil »«yniptoins iKfiirntl. On the next day 0.03 grainine (J s,Tiiri; >A
quinine wii.s given in the morning and ugain at night, and this doM?) was contimc^lf-ri
few days.
Fn»ni thi-i tiuit* the M'niptomt* of nmlaria entirely disappeared, the infant grew le^k:;d
Krss iMnat-iatrtl, luM-aine stn»ng«'r, had a goiKi apjM^tite, and continued to thrive.
No i'nlstrgfint'nt of the sjileen wjik detected in this case.
The next infant ^C'tuiie 156) waj* nineteen months (»ld,and wa« hrought from a dtviJVik
malarial distriet.
It had previously lu'en well until three weeks before it was brought to l>e treated i :
the f«illow!ng synipt«»ms. At the time when its bath was given to it, which was l-etw-^
11 and lli in tlie nmrning. it had >ymi)tom.s characterized by drowsinefr* and cyaniijU. ind
it would fall ash'«>p, and after alN»ut half an hirnr would wake up brijrht and well. Tbi^^
attacks, tlnmgh >liort in <iunition, were very alanning and apparently serious, a», allht-u^'h
the infant did not have any jmin or convulsions, it could not be roused while in thn atu^i^'.
and heeanie so bhie and c*old that it was feared that it might die in one of them. Attn;
time of the attacks the n»etal temjK'nitun^ varied somewhat, but was usually about 38.?= C.
(101° F ).
The treatment of tliis case was with sulphate of quinine, sometimes given by tr.*
mouth and s<»nietitnes by means of ni-tal suppositories. After the adniinistrati*>n 'A 'It
quinine t\)r four or tive days the attacks entindy ceased and did not return. The inikLt
from tluit time continued to thrive.
This table (Table 89) contains references to most of the imjx^rtant articles
which u|) to the pnstMit time have l^een published on the blcxxi. Yc»ii mii?t
n»meinlHT, however, that it is not a general literature of the bUxxl, but ovly
that of an ejirly jHTiiKl of development. It is the soiiroe from which I have
drawn most of my information in the endeavor which I am making to eliioi-
<lat<' the subjci't for you, and in this way I acknowledge what I have rcceivwl
from other authors.
TABLE 89.
1. Alt INI) Wkiss Ana«niia Infantilis Pseudf»-Leukapniica. CentftlbliS
fiir die Med. Wissenschafl, 1892, Xos. 24 u. i'».
2. Andkkkskn ... Ueber die Ursachen dor Schwankungen im Vir-
haltnisse der rothen Blutkorperchen zum Pla?!:!*.
Dissrrf. Dorpat, 1888.
3. Akmikim rsi) Widowitz . . Sourlutina. Morhilli.
4 Uaoinskv An^hiv fiir Kinderheilk., Bd. xiii., 1891.
Tj. Haykk Ueherdie Zahlenverhiiltnigse der K>thon und weisen
Zellen im Hlute von NeugoboTOnen and Sam:-
lini,'en. Dissert. Bern, 1881.
«;. Ho IK IV Heitratr 7A\r pnthcdogisehen Anatomie der Milz ■•a
Pneumonia Croiiposa. Dissert, St. PeteHl-uj?.
1892.
7. HnrcnuT KT DniKisAY .... (iazette MMicnlede Paris, 1878.
8. C'adkt Ktude physi.dogique des Element* flgup^ du 5«w;.
7>/".w/'/. Paris. 1881.
0. Canon Ue])er eosinophile Zellen und Mastzellen im Blut*
Ciesunder und Kranker. Deutsche Hed. Wochen-
schrift, ISirJ, No. 10.
10 ('«»iiNsTKiN UNI) Ztntz . . . . Plliiirer'.- A pi'hiv, Bd. xxxiv., 1884.
11. Daviuoff Untersuchuniren uher die Beziehungen dee D»nn-
Kpithels zum lymphoiden Gewebe. Arehir fir
mikn»i?kopiriclie Anatomie, Bd. xzix. 1887.
1
^^f THE BLOOD £X IKFAKC7Y AND CHILDHOOD. S99 ^^^|
V
"^
TABLE %9.—amhnnr4L ^^^H
■ l2.
Demms
. * , 17. unci 18, Bericht des Berner KinderepitaU, 1880 ^^^H
und 1881. ^^H
Bl3.
DfiMMi:
, « Zwei Fiill^ vun f>ernicioeer Anamie. Jithresber. a. d. ^^^^|
Bernifr Kinder&p,^ No> 28. ^^^^|
^Pl4,
Dekis ...
. , , Rec'hercheii exp^riment&Iej! ^ur le Bang, Piim, 1830. ^^^^H
■l5.
DUPftRIE . ,
. . . Sur los VarmtioriB physiolo^iques dans FKUt uuato- ^^^^H
mique du Sang. These de PariB^ 1878. ^^^H
Hid.
Khrlich
. . . Farbc*nau0.]vtischc UnU^r&ticbuiigreD zur Hi(iiolo£p<^ ^^^^^^H
unti Kliiiik de.s Blute^. Berlin, 1891. I. Theil ^^^B
^BjT.
ElKBORK
. . . Ueber das V«'rbalU'n der Lympbdrusen zu den ^^^H
■^
weig«en Bliitkorpercrfapn. /. D. Berlin, 1884. ^^^H
K!:
EVOILSBK *..,►,.
. , . Virchow's Jalirt'isboncbt, 1884. ^^^^^^|
Ebcberich ..*,,..
* . * EjiTi Fall Ton ix^rnjciosor Anamift. ^iTicJti. IClin. ^^^^^^1
Woebenecb., 1892. ^^^|
^Kso*
Fako ..*...,..
. , , Lo Bpenmentale, 1880. ^^^^H
^pi.
FiftCHL. . ♦ *
. . . Der ^egcnwartjge Stand der Lebre von kindlicbem ^^^H
Blule. Samtiielft^ferHt. Pmger Med. Wochen- ^H
Bchn% Nu. 12 u. r, 1892. ^H
■S2.
FlSCHL
. . . Zur Hktoloirie deA kitidtichen Blutcsa. Zeitsclirift ^^^1
fur Heilkunde, 1892. ^^^H
■ 2S.
Flemmiuq
. . , Zellfiubstanz, Zellkern, Zelltbeilun|i^. ^^^^H
Gabritsichewsky . , ♦
. . . GmndriM der numi. und patbolog. Morpbologie des ^^^^|
BlutcH, 1891. ^^^H
fc:
GurrsR ,♦.«,.,.
. . . Revue Mensuelle, 1876. ^^^^H
GuiTDOBrw .
. Ueber die Morphologie und Patbologie des Blutes ^^^^H
H
bei Kindeni, Jahrb. f. Kinderbeilk., Bd. xxxv., ^H
H
^H
I
Halla. ..»..«.
. . . UeWr den Hamoglobin$;elialt dee Bluteft und die ^^M
quuntitativen VerbHltiiiftse der mtben und weissen ^^H
Blutkorpi^rcben Un acute Qelterbafte Krankbeiten. ^^^^t
Zeitt^chria t H*.'i1k., 1893, Bd. iv. ^^H
^■^
Hammeder ......
. . . CentmlblHtt fur Gyimkulogie, 1879. ^^^B
i
Hammerbchlao ....
. . . Ueber das Verhnlteri de^ i*j>ec. Gewicbten de« Blutes ^^|
und Kmnkheilen. Wien. Klin. Wochensob., 1891, ^^^^t
uml Cenlr»]blutt fur Klin Mtxl., 1891, Nn. 44. ^^^|
■so.
Hayem ♦ ♦
, . , Thi Suntr i^ de eeis Alterations anatumtqueBf Paria, ^^^^H
^^^1
■<1.
Haykm
. . . L^Anemie des Nounifisonf. Gajcette dei Hdpitaux, ^^^^^|
1889, No. 80. ^^H
Isz
Hetaquboff
. . . Pntbologtwhe Anatomle de« Blutes b4<i Unterleibe^ ^^^^|
typbu.*. r>i9^ert St. Peterebiirg, 1891. ^^^H
■88.
Hock ttnd Sohlbbinosr
. . . Blutunleri^uc bun^en b«i Kindem. VorlauJige Hit- ^H
tbei]un<;eri. Centmlblutt fur Klin. Med,, 189L ^H
■ 84
Hock vtsv ScRLSfiiirGKR
. , . Hiiinululogi^ebe Studien. Franz Deuticke, Leipzig ^^H
und Wien, 1892 ^^
■86.
Vow Jakbch
. . . UeWr Leukainie und LeukocytOie im Kinder*- ^H
alter. ^M
r
Von Jaksoh
. . . Ueber Diagnose und Tlierapte der Erkrankungen ^^M
des Blutc«. Prager Med. Wocbeni^cb., 1890, Noe. ^H
22, 23, 31, 33. ^^^M
^■87.
Llotx> Joxes , , , , ,
. . . Jcnirnal of Pby^iology, vol. Tiii. Part 1, 1887. ^^^H
r
KtXODSX
, . . Patbobigische Anatomie des Bluti^ Ixii Pneumonia ^^^^B
Croupoaa. Disacrt St. Petersburg, 1890. ^^^B
i
Klkik .,,.,,...
, Centialblatt fur Med. Wi«aeiucli.f 1872. ^^^^H
400
40. Klein
41. KHlmkek . . .
4*2. KoTSJ'UKTKDFF .
4:J. KRlNiKR ....
41. L.v.vruK ....
4'i. I^KHIITEN'STKRS
40. JjKpine ....
47. VnN LiMBKCK .
48. Vmn LlMHKrK .
49. Von LiMiiEtK .
W). Luten ....
61. ,1. Loos ....
6li. J. Loos ....
r)3. LrzKT
M. MANinurR . .
O.'). M.\RA(iI.IAN«)
o»». >roLKSrn()TT . .
.')7. MuNTI IN I) HKR(fGRr
oS. MClJ.KK ....
;V.». .M i*i.i.KU ....
m. .MCiJ.Kii . . .
01. MCli.kk l'Nd Riedkk
i\± II. MrLLEFi
64. Nas-^k . . ,
r.O. Nainyn
PEDIATRICS.
TABLE 89.— O/n/inurt/.
Unt«Tsu<rhungen iiber Formelemente d** BIut»«c:!
ihn? UiMloutuni; fiir die praktisohv M«-Jicin. lr<'.
ITt'bor di« BIutkurptT eines inen.schlichvn ErLlrr.
ZiiUchr. fiirmt. Mwl., 1846, No. 4.
Morpholoi^itk'he Veraiidorunicen dt-^ BIui»-i VI
Scharluch. DiMcrt. St. Petersbun;. l&I'l.
UoIht das Vorhulten des fotalen HIute!> iiu MiiD#r.
dtT (loburt. Diasert. Dorput, 188ti.
(2untitl by KfiiH'rt.
Unt«'iMichuii^en iiber der Hamoglcibingebalt. Lfip*
zi^, 1878.
Coinptf.>i-n*ndu>« do la Sociote de Biolii^ie. ISTrJ
ZiMtschrift fiir Hoilkunde, 1890.
UoIkt t'litziiiidliche Leucocyto^e. Wieiirr Mr^
Pn-.-iso, No. 43, 1889.
Grundriss eiiier Klin. Pathologie des Blutf*!*. .Jrri
18l»i>.
Zur Pjitholo£ri«» des Blutes. Berl. Klin. W^ith^iisi,
1883 uiid 1880.
Die Ananiif lM*i horodi taper S\-phili*. Y.Tl.id:e
Mitthriluiijx. Wien. Klin. WoobcTisoh.. No. 3l.
1802.
Uob(>r diw Vorkoinmen kcmhalti&^r K>iher Bla>
7.i'\Wn \m Kindvrii. Wien. Klin. W'-oheQjca.
N... 2, 1891.
Etudt^ .<iir les An6niie8 do la premiere E.n£i>.*
Dissrrt. Paris, 1891.
Vorkomnu'Ti und diHi^nof^tischo Bedcutunir deroiv.
I>hili'n ui»d basuphi It'll Leucocyten im Sput-2L
AVi«'!i. M»*<1. Wochonschrift, N<.»#. 7 bis 0. 1?*'''J.
Britnii; zur Pathi»Ioirio des Bluti». Bi-rliinT Kiii
W.K'Iiciisfh., No. 31, 1892.
Wi.n. M*-*!. W<H?heii8cb., 1854, No. 8.
I)i<* chroni.^oho Anjimio im Kiiidcifialter. Leipar
(V<..un.l), 1892.
KliiiiM-lio Hoobachtunpfon zur Verdauungsleiik^x^-
t«'.s... Z«it.-*chr. fiir Heilk., 1890.
r«*]K'r Mit«>si» an eosinopbileu Zellen. Aivhiv f::
Kxj). Path, und Pharra., 1891.
UelMT Lt'ukaniie. Doutscbes Arch. fGr Klin. Med..
Bd. xlviii. Hvd i. u. ii.
UiImt das Vorkonimon und die klini^cbe Bed»nitaiii
d<r fn^iiiophilt'n Zellen im circulirenden Bluwd«
.Mt-n.'^clh'n. Doutsohes Arch. fGr Klin. Med., Bi
xlviii. Ilolt i. u. ii.
l)io ]>r..i:nvssive pcrniciose Anamie. Zurich. 1877.
Rlutl.ilduiii:. Sitzungs-Bericht dep Akad. der
Wis.-., 18S9.
Unt.i--u<'huiiir,.n zur PbyBiolo^e und Patbol.ieip
ih'< Hlut.'s. Wagnep'8 HandwOrterb., Bd. i- S-
V.-Imt don Haniofiriobinjirebalt dee Blutet bei An
v.-r-i'irn'tlincn Kninkhciten. CoiTespi-Bl»tt ftr
Srhw.-izrr A.T/tf, 1872, No. 14.
^f THE
BL(X>D m INFANCY AND CHILDHOOD. 401 ^^^B
TABLE m.— Continued. ^^^B
Hee.
Nkumaitn , . . ,
...... Centrulblatt fur Med. WUtions^h., 1869, und Archiv ^^^H
d. Hcilk., Bd. z. ^^H
NXtJSSKR
. . * • . . ILlinis^bc hatutitrjloffjachf) MitLhpiliini/pn TVipu ^^^^^^I
Kiln. Woehen&ch., Nos. S und 4, 1892. ^^^|
Otto
fnaug, Disaert. Halle a. S,, 1893. ^^^B
Fanum . . . . .
, . , , . , Die Blut 111601^6 neiiiijeboreiier Htind6 uod dfts Vor- ^^^|
■
haltcn ibrer Blutbestundt belle ver^liehen tiiit ^B
F
denen der Mutter und alterer Geflchwister. ^^^^H
Virchow^^i Archiv, Bd. zxiz. ^^^^^|
■ 70.
Parrot
, L'AtbrcpBJe. Paris, 1877. ^^^^H
■ 71.
R. Pick .....
Untorsuchungeii uber die quantitativen Verhalt- ^^M
uisse der Blutkorperchen bei Tanolii. Arehiv fiir ^^M
Dermat. u, Syph., Bd. xxv., 1898. ^B
B72.
POPOFF
,,♦,,. PatboIogMvliff? Anatomie dej» Bluleji< und d*T blutbe- ^^H
reitendeo Organe miter dem Einflusse cler Hariio- ^^^B
globtnurie bervomifenden Substanzen. Dissert ^^^^M
St. Petersburg, 1892. ^^^|
Wn,
Pruykr . . . , .
Pbysiologic dea Embryo^ 1886. ^H
■ 74.
Quincke ....
...... UeW pemtcioee Anamie. Yolkmann's Samml. ^B
Klin. Yortrage, No. 100. ^H
"75.
QUIKCKIC
Weitere Beobachtungen liber pomicios€ Aniimie* ^B
DeutsebeB Arch, fur Klin. Med., Bd. xx. ^^M
m 76.
BllKBBT
...... Die Zahlung der Blutkorpercben. Leipzig (Vogel), ^B
I ^^*
RlKDKB .....
Beitnige 7.ur Kenntnis« der Leukocytose. Leipzig ^B
(Vo|rel)^ 1692, ^^^B
■ 78.
■ 79.
■ sa.
Saenoer ....
Arehiv fur Qynakulogie, Bd. xxjc:iii., 1888. ^^^^M
Sahli ,..,,,
Ari-'biv fur Oyn-akologie, Bd. xxxiii. S. 18L ^^^^^H
BCBAFFSB ....
...... Beitriige zur Hititologie d(^r menschlicbeTt Organe. ^^^^^|
Sitzungs-Bericbt der Akad. der Wis&enschafleD, ^^^^^
Band c.« Wieu, 1891. ^^^|
mm.
SCBXRSIVZIBS . . .
. . . , , . TJnter^ueliuiiijen uber das Totale Blut. DisB^rt, ^^^^^^|
Dorpat, 1888. ^^^B
■ 62.
SCHIFF
Ueberdar*qLiiintitiitiveVerbiilt*='n der Blutkorpercben ^^M
und de?; narnojjlobins U*i n^-ui^eborenen Kindern, ^^^^H
etc. Zeit^obria fiir Heilkunde, Bd. xl, 1890. ^^^B
■b8.
SCHMALZ . * . ,
Zur Unt^rsiicbung des »pec. Gewicbtes des mcrificb- ^^^^^|
Ijcben Blutes. Deut^bee Arcb. fur Klin. Med., ^^^|
Bd. xlvii, ^^^B
Is4.
Ad. Scuuim' . .
, Donion^tration mikroikopigcber Praparate zur Patbo- ^B
Ipgie des Assthina. Verhandl. des XL Intemat. ^^B
Congpwwes fur innere Med. ^^^^B
mm.
SCHtTECKTNO . . ,
Berliner Klin. W«>eben»^cbr., 1879. ^^^B
■ 86.
SCHWARTZK . . .
...... Ueber ensinophile Zellen. /. £). Berlin, 1880. ^^^B
■ S7.
■ 66.
Senator .....
Birlioer Klin. Wocbenscbr., 1882, No. 86. ^^|
SlLBERMANN . . .
Zur Hanifttc>lo|^io doa Neugeboreneii. Jabrb. fiir ^^|
Kioderb., Bd. xxvi. Hea ii. ^M
I 89.
J. SOMMA ....
...... Ani^niia Splenica Infantilis. Allgemeine Wiener ^^M
Me4l. Zeitung, 189L ^B
1 80.
SOrenson ♦ . . .
..,,.. Jabrt'«bericht ubntr die FortK'britte der Pbysiologid ^^^^^H
mid Anutomie, S. 192-197. ^^^^
I 9L
■ 02.
Stierlik ....
...... Deut'^ehes Arcbiv fur Klin. Med , 1889. ^^^^|
Troje ..*.••
• •«... Ueber Leucaniie und Pseud uloucaiiue, Berl. KUn. ^^^^^|
Wocbenscbr., 1892, No, 12. ^M
^^
^^B
402 PEDIATBIOB.
TABLE 89.— OmemiiMi.
98. TscHiHTOWiTSGH Bolnitschmja Omzette, Botkin, 1890.
94. Tt)MA» Gazette, Botkin, 1885.
95. Uhkoff Blut als Oewebe, 1890.
Wl Weihs Das Vorkommen imd die Bedeutung der eonnopUa
Zellon und ihre Besiehungen zur BiobURo.
theorie Altmaniui. Wiener Med. Pnsk, >'a
41-44, 1891.
07. Weiss Beitrage aur hiitologiachen und mikrochemlxte
KenntniBse des Blutes. Wien, 1892, AIM
Holder.
98. Wkisb Die Wechselbeaiehungen dea Blutes su den Oifiues,
etc. Jahrbuch fiir Kinderheilk., Band xxn.
1898.
99. Welokrr Prager ViertelJahnchrift, IV. Jahrgang, 1851
100. WiDowiTZ Hnmoglobingehalt geaunder und kranker Elate:
Jahrb. tar Kinderheilk., 1888.
101. WisKKMAXN Zeitschrift f^r Biologie, Bd. zii., 1876.
102. Wuino-Okanskt Beitr&go zur Morphologie dea Blutes der Koigft'
borenen. DtMert. St. Petersbuzg, 1892.
DIVISION VIII.
DISEASES OF THE NEWBORN,
LECTURE XVIII.
MATERNAL IMPRESSIONS,— THE HEAD.— THE NECK.
Under the dt^ttigiiatioa ** dii?4^ases of the tiew-born' ' I shall now describe
[to you a H^'rii^s tif ejtst's whicfi owur sd early in life that they are most
[cjouveniently platted in a class by themselv€!i5» I shall not attempt to dwall
I upon all the t^inditions which are met with either at birth or within the
first few weeks of life. That would rec|iiire more space and time than the
[fiCfjjM? of these let-tnres will allow.
The dLs<:*a^*s whieh we Bpeak of as ** diseases of the new-bom'* are
[distinct from thoae whieh are acxjuired later in life, in that they repre^nt in
falmfjst every citse an arrest of the normal de\Tlopmt*nt which should (xxnir
[during intra-uterme life. ThLs I have already referred to in my iiitit>duc-
itory lecture (I.*ecture I»» pa|je 19), and I oaly wish to impress again upon
your minds that a stage of development which is normal at a tvrtaiu |x^ri<xl
of intra-uterine life becomes abnormal if it pfM^^ists to a later ptTiod, and that
I this persistence of an early stage of development wmstitntes in the great
'majority of cases what Ls known as eongtniitiil malformation. Such a failure
[of development may be the result of iotra-uterine iuflammatioUj which,
[either by crippling the vai'ions functions or by arresting the normal intra-
uterine growth, producf^s a condition of disease at birth. In many cases,
however, the causes are so obscui-e as to elude our usual methods of exami-
nation. *^ Diseases of the new-born'' ma}' nl^y he made to include cf^rtaiu
[abnormal conditions which arise immediately after birtJi or io the early
[days of life.
Although many of these affec^tions ninst pass into the hands of the
[surgeon for treatment, yet it is very im|K>rtant for the medical practitioner
[to Ix^ al>Ie to recognize at once their true nature and their significance. I
[shall, therefore, in this lecture attempt in a few words ttJ tell you of some
[of the more cM>mmon surgical affections of the new-born, as well as of
|thoee tliat are of a purely medical nature. In speaking of these dis-
I fihall^ for the puqxuse of sim|»licity, classift* them into diseases of
•108
401 PEDIATRICS.
the hrad and neck, (list'as<s of the trunk, dlsea^ses of the extreraiik-?. mi
^I'licral discasi's.
MATERNAL IMPRESSIONS. — A few words should be said iimi^n.-
in^ the subject of uiaU'rual impR^ssious. For many years therf ha- bt»j
arcunu dating a couskh'rahk' amount of evidence shownng that a vi/n;'
inrntal iuiprcssion nuuk» u|M»n a woman who is at the time earning a it.:
may 1m» follnwcd hy a |)hysiral or mental defect in the child which \k-^
a strikinir rchition in cliararter to the iniprej^sion made uixm the nn'ii>r.
Thus, Sir Walter S-^ttt narrates that King James the First amid m
endure the sijiht of a drawn sword. This fettling has been attrihutd U
tliose who U'lieve in maternal impressions to tlie terror which his nnjiiitr
ex|M'rieneeil at witnessing the nunxler of liizzio. Still more uumt^r"!*
are the i'aets ad(hu*(Hl to prove that bodily defects, such as harelip, dub-
foot, and hairy inok', may l)e (»aused by strong impressions of pain ortenf
ex|K'rienee<l by the mother at the time when the foetus is in a Ltni
statue of intra-uterint^ (h'vek)pment. Interejsting as these instances an, I
think it is th(* ijeneral In^lief that nothing more has been pix>ved thaurha:
they d(»|H'nd on a e<»ineidene(\ Tlie final decision on this obscure subj^i
nmst rest on futuix' investigatit)n, and may cause us to guard a womsa
during her pn^<rnancy from all unpleasjmt impressions with tar mon? <^
than we do at pn»sent.
THE HEAD. — The normal average head at birth mav be mLsshaptD
fn»m various cau.ses. Of the wndiiia-
which may cause unusual ap{)earaii<^. I
shall n^ier merely to the mt>st a>mnni.
One of these conditions is called capnt if'y'-
crdancum, a case of which I have here t-j
show vou.
Cask ir)0.
Caput Succkdaneum. — This infant (Ca^elV
11 iiisilf, two hours old, presents a swellin.-i ..vr: t>
riixht pariL'tal bone extending bnck to the oc«:ipuuri
cau-iiii: an invgular tuiuor and o greai inoivirri'
tli»Miiit«'p»-j»of;tmor diameter of tlie head. Y.-url
iintio* that the tumor doos not fluctuate.
('.put ^,:..v.i:M,.,nn. Mai..-. J h-urs Th,- pn-sriitaticm WHS occiput left ameri.T. aiid .:
. I., ni-tniiiM'iit.-* wrn* used. You see that the jWr-fc
«'..rn'>jM.n(ls t<» the phice where there was the la--.
|)r.-Mii.'. iliMi i^. tlj.. i,iv>riitiriir purt. It is mM-tH.-ss to say that this cjaput ftUfCidiTHi r.
n-.|uirv- i,.. tiv.itiii.nt. a- it i^M-a.liially di>ai)iM'ars cf it«elf by absorption in a few da\>. Ii
i- .-imply a •^\\.lliri- of th-- ^alp .mu^mI l.y a pa>>iv«' coni^e^tion with extravasation of Wi*^
and IviMj)!! iiit-' tli.' ronriciiv.' ti-siK- f'xt.-mal U* the pi'rioranium.
('(fjHff .<tto'rrtlunrum uuist 1k' caivtiilly distinguishcil from another swt'll-
iuir of thr scal|>. nj,hnlhn:m(tfrnn(i, whirh may oecur in oonncction with it,
and which app('ars as the raput suct-cMlauouni (lisap{>ears.
(■Ki'HAT.n.KMA'i'oMA. — 1 )iiriiiir lalnn' a hemorrhage mav take pi**
from tht' 1)1o(k1-v('>s('1s of the head which gives rise to a tumor in oneof
DISEASES OP THE KEW-BORK.
405
bree situatioius : (1) between the ocjcipito-frontalis aponeurosis and the peri*
>steum ; (2) between the periostt^um and the skull ; or (3) between the sktill
land the dura mater. The first tyvo aiT known as external oeiihalha^matoma,
[the hk?t as mterual oephalhsematoma. The cause cannot be entirely prt^jssnre
lover the presenting part, as they have been found in bretx-h presentations.
External CephalhaBinatoma. — By far the most common form is that in
which the tumor has lornitd Ix-tweeo the skull and tlie iieriostenm. It
shows itself as an iri^egular circular swelling over a parietal bone, and gives
^on palpation a distinct feeling of fluctuation. The skin over it is not
Idiscolored or RiildeniLHl. In those that have existed for a few days a lx>ny
I wall can te felt surrtjuuding the tumor, the edges of which give a craekliug
leensation under the finger. In this stage it may strongly suggest a fluid
j tumor coming through a eireular hole in the skulh
The case (Case 157) wKicb I have here to ^how you to-daj is one of double cepbalhie-
tinatoiiia of tbt? external variotv ; that is, it is an (ixtravasation of blood under the pericranium.
It* buiif', corresponding to the dt*nuded bone,
ill ovul or d renin r. You will notice tbi' bulging Case 167.
* tumois on vavh side of the sugitUil BUturt- with a
I deep sulcus between theui. On palpation you will
[get Huetuatitm^ and on fwling the circumf^ronce of
1 the tumor an elevation and eraeklliig semution a^
I though yc)u were tcaiching fine crystals of ice on
I ibe ed^t' of water which is beginning to fireese.
Ce|ihalhiematoma Ls diritingiiLsht'cl irom
caput sncotHlanenm hy its sharp limitation
to one (>f the jiariotal bones, by its fluilna-
tion, and, if st'en latt% by \ti< t^urn»uu<liui^
b<niy walL It can be diagnostk'ated jwisi-
tivply bv the withdrawal of some of the
fluid l>v a hyptwlermie syriujrt*. Another
iMpndition whieh may simidiite it SHniewliat
IS a depressed fracture. The differentiiil
iKmis fi'oui thi>i hitter rt>iiditi(U» ean
be made by rememi>tTing th** faet
tlmt the rt*sistant rim of the cijpludhpe-
matimia in rai>4ed al)ove the level ol* tlie ?<iir rounding bone, and is somewhat
com|irt*ssible, while on the iu.sitle it am Ix^ felt to slope evenly towards a
fluetnating centre. In frm*tni*e no sn<*h armugeraent occurs^
T shall now call your attt^ition to tfii.s jirejiaratiou (Fig* 86, page 406)
of a doid>le external <*ephalhirmatonia frcKm the \Varrt*n Museum,
You see on the left .side i^f the ^iknll (the riglit side of the pieture) the
integument has been netirly i-emoved, sliowing a raised bony rim.
< >n the right side of the skull (tlie \vi\ side of the pietnr**) the integn*
ment has U^en eut off and partially deflected, showing the cavity which
contained tlie effused blcMMl.
fVjublu cephttlhsfniatoinA, Infant,
4 days old.
406
PEDIATRICS.
Fio, 86.
external eo jih ttlliiLiiia tomiL Bol h [ m i h etii! I x m i-s, \V n rrt 1 1 >I 1 1--*- 1 1 m . IliirTftBl Cnl wssity
Fl«. 87.
External cefiJiAllisKmfttomiJ., Parietal b-ioe dtsnjf (^^1. Warren Mui*Gum, Hars ard l^nivii^ity
DISEASES OP THE NEW-BORN.
407
The next specimen (Fig* 87) is a panetal bone dissected so as ta show the
condition of the bone in a case of external eephalhfematoma.
This si_»ecuiien shows well tlie raised rioi and the porous condition of tlie
bone underlying the tumor. In two or three places the bone substance has
entirely disapjie^recL
Internal GephalhsBmatoma. — Internal cephalhjematoma is situated
between the inner surface of the skull and the dura mater, and is rare. It
is at times found in connection with the external variety.
The prognosis in this class of cases is bad. They are usually fatal, and
there Ls no known treatment which can save them» I have here to show
you the preparation (Fig. HS) of a sknll taken from a case (Case 168) of
internal and external oephalhiematoma.
Internal &u<l eztemiil ceftbalbiematoma. Warren Museum, Hkrvard Univenitf .
The specimen was taken from an infant which was born at the Lying-in
Hospital. Its deatli w^as cunst^ by a large cerebral hemorrhagt? resulting
frt)m the internal oepbalhfemat«»ma. It .<howr^ iinly the external cephalha?-
matoma, which occupies the left parietal and ociupital regions (shown on left
of pirture). Corresponding to this external cephalhjematoma was a large
effusion of bliXKi *x^upying a spac\' alx^nt 2.5 cm. (1 inch) in diameter,
and Iving betwwn the dura mater and the brain substance, %vhich w^as
compressed by it.
Mentng<K?ELE. — By the term meniiig<»eele is understood a protrusion
of some i>art of the membrant*s of the brain through a hole left in the
crania] wall by defective ossification. In some instances this is caused by
408
PEDIATRICS*
Cask \m.
ED intra-iiterine hyclnxjephaliis. These tumors generally oovtiiiii
the cerebro^ijinal fluid in die bag of membrane^ Such fluid cms oflal
rc^Iucecl into the skull by gentle pressure, but at the ridk of briai^Q
symptouis of cerebral disturbance.
This case (Cafte 169) shows n smiiU nieningocele abov^e the l*-*^ ^*'
(1 inch) in dlanieU?r,
Some fluid wufi withdmwn fh>m it by mi aapimting needle, ano m*- f^.m-nx* :#j
sac proved to bo seroiw without oelk. Tin* mt r§.h
»tlvr tjipptn^. Nt) more extensive cipemtioo (mUbii
fur l>(»f»n uudcrtttkt»n.
Thu hiHtory of thui ca&e is thfit
It bad u full i)ome time ago and eXr
ing abnormal wna noticed about the child pretioQifeu;^
ftill, hut since the accident this swelliog^ ap
and behind the car. The swelling increaitsi^
when the child crio«, ie soft, fluctuating, and M41
rhe knet?-jerka and «eosHtion art* mumal. Tb» opIHi^
rnosoopio examiimtion di^cloeet^
A much more serioui c^« iA I
nicninerocele of this infant (GaAo 1<M>)*
It 18 a male, and wi^ two weeks old when uom^^
upon. Behind its left ear was an iri«g\jljir
7.5 cm* (3 inches) long. The ear wus pushed forward, und appeared to bo g:^ v,inv .
the tumrjr. The labor waa normttl, and ihe infant at birth wm perfectly heallhj ikSiA ^d
formed^ except f^^r the tumor, which was congenituK On examination the tumor wii Mai
Ui be fluetuuting nnd trans^kcent. There were large veins on its &u^fart^ pTY<«Kur» lo tb
tutiiiir cuus4m1 no syniptoma. No impulse could he ^It on crying, nor did prvsHUi* CHi
any cerebnil syioptoms. On aspirating it, 45 c,c. (IJ ounces) of a cl<^ar r»*1'li»T> frij
wert^ withdmwn, Thi?i fluid contained red blood'Corpu^cle*?- and a few end*
No unfavomble Rjmptoms followed the aspiration. After the witlidrawal of '
openings oould be felt, the anterior probably conntwting with the extf^rnal aoi:
and the jv^sterior with the anterior fontanelle. The tumor was increasing in w^ •• « nii»^t
that an itperatiou was decidt>d upon. On removing it an opening in the skull largt«»<itk
to iidrjiit two fingers wna found.
The child made a nipid rt^covery from the operation, ftnd now has onW • (
the ear. There were no eerebml j^yniptomg* During convaloBoenoo and u|> Ui llii>|
time the child huA seemed to be mtntiilly bright.
ML-iiiitK'
ul±
ENCKPifALocELE.^ — Stil! moro oomnion than the pure Dif^ningott^ir 1
that eoiiditiDU in whieli tlie hernin fonttiins some of the cerebral ml
m well a.s the membranes. This condition is ealkni eiicephalocelc * (ifi^j
is often tlie ea.se^ it enntaios a portion f>f a dilated ventral util \
tumor m lilletl with eerel>ro-ripiLial tluid, it Ls known as hydr<»
or m hydro-entx^phalrHmening<KM:4e.
Hen* are some photofj:raphH of a rt^nKirkabK^ exLse (Case 161) of l*)«
enee[)lialoeeIe wliieh was treated by Dr. Lovett in the hospital.
The infant fn_»m the time of its birth had tonic and clonic convul-jMr,*, oiriinil
usually as often as once in three hours. It was brought to the hospi::4j wVjrn i* wt*
months old. It was well fornied in ever>^ way» except that it had a tumor
hciid which was at leant nue-third a^? large as \U skull. The tumor wa* *>rji
with skin, the upper part of jt being a thin translucent membrane. It cotnmtitiicateii wA
■llM
y
\
l\\
i^ '
■J \
DISEASES OF THE NEW-BORN.
409
I the bmin through a largo equftre hole lo the back of the akulL The tumor fluctunted
' fllightly iLiid upp.^Hred to be ii nmUilocular cyst| for when it was aspimted only a part of the
, con tail lod fluid could be withdmwn.
The tumor was removed by Dr* Lovett and the wound sewed up tightly. The cyst
waa found to contain a viscous fluid with Blight fliftkes in it which proved to be particles nf
I cerfbml subt?tance.
The convulsions immediately twcame less frequent, and ultimiitely on tpeatnient with
bromide of potash disappeared almost ontrrL4y.
The infiiiit hi other respecU was very little affected by the operation^ nnd recovered
] mpidty. After remaining in the hoBpital two weeks it waa taken to its home, where it died
I.Aoaie months later of «ome intercurrent affection.
Rc'gurding these tumors in general, it is enough to say that you should
[view with suf^picion any fluctuating swelling that seems to have a deep
attachment in the neighbirluKMl of one of" the cranial sutures. The most
frefjucnt seat of these tumors is in the occipital I'egion and at the mot of
the nase. Their treatment has not proved very successful. Some few may
steadily decrease of thenij^^lves and ossitit^tion may block up the abnormal
ojM^ning, Pressure and the injwtion of Mort<5n*s fluid have l>oth been
tritxl, and in some cases have l>een attendtnl with success. At present the
oiM*rativc plan of treatment is ci>nsidei*ed the best. Without interference
the tendency is usually towards rupture of the hernia, ctinvulsions, and
deatlu
Anencephalia. — ^As you have been taught in your course on embry-
ologVt the cerebnt-spinal systt^m is formed fn^m the mednllarv tulx\ which is
made by the infolding of epibla^^t along the medullary grcMjve : if tlic for-
I mation of the medullar)^ tutje m for any reason incfimjtlete, or if the dorsal
wall of the tube is destroyed, the ecifbruni or part of the cen4>nd axis will
remain rudimentary. Ace*irding to the amount of interferentx* with the
I development we may find more or less of the brain remaining in a rudi-
mentary conilitioii, and thus producing greater or less degrees of what is
I callt^tl anenccphaba. Total ancnct^phalia is rare. Partial ancncc|)halia is
much mort> cimHUon. Th<3se t-ases are not of esiK'cial interest to us, as it is
exceptional for them to live beyond a few days.
Congenital Hvnwx'EPiiALTrR.-^Oue of the more common malfor-
mations of tlic head is a hydnwepliahc condition at birth- It is adled
I congenital hydrocephalns, and I shall descril)e it in a later lecture (Ijecture
I X X X » , page G 3 4 ) , on d iriea.st\s of the l* i-u i n .
Harelip. — The clearest way in which I can describe to you the malfor-
I mation which I am now to consider is to remind you in a few words of the
[manner in which the parts arrumd the mouth of the embryo arc formed.
You can then sec at a glance how a failure of any part of the priKt^ss in
the development of that region will give rise to the several defects known
las single or double harelip and cleft |»alate. At first the ff»re*gut of the
I embryo does not communicate with the outside, hut ends blindly undtT the
anttTior region of the hind-l^niin. Over the end of the foix*-gut curve the
[mid-brain and fore-brain, causing a prominence on the ventral surface* of the
410 PEDIATRICS.
enibrvo. As the heart develops, another prominence is formed Mow tb?
end of the fon'-jx»t, and Ix'tween these two prominences a wide shallow fh
is fniiiid. At the Iwjttom of this pit there is but a single velum, whkh
*s<'parates the end of the foR»-gut and the primitive mouth or stom«Klitiiia;
latiT the velum is broken thnaigh and the two cavitit^s form one caaoL
AlM»ve, this primitive mouth is Ixnmded by the fronto-na-sal process. Bclovf,
the lK»nndarv is made by the first visceral or mandibular arch, which b?
grown around the ibrt?-gut inm\ each side and has join«xl in the mi«MltiL
front. The sides of the upi)er part of the buccal cavity are made bvtlie
maxillary pnKtsses, whieh growing from the base of the mandibular airi
fill up the gap lK*twwn it and the frouto-nasal process. The sides of the
mouth an* eompletcnl by the formation of the cheek-plates. The beginaiic
of what in later life is to l)eeome the organ of smell is in the form of two
small depressions, ealle<l the olfactory pits, in the sides of the fronto-na-ral
pnMt'ss, and imnuiliately underlying the fore-brain. In the proce?? "t
development these pits de<*|)en and are partially surrounded by asemicirmbr
ridge. Th(» thickeutHl inner wlge of cat^h olfactory pit now grows dM\*Ti-
ward into the onil cavity, forming the mesial na;ml process, and ends in
a bullH)us enlargement c^lle<l the globular process. The mesial pnxwMe*
then grow backwanl along the roof of the stomodoeuniy forming the naal
lamiuje. The lower ]M)rtion of the frtmto-nasal process, which i*^ originally
situated Ix'twcHMi the olfaet4)rv pits, and includes the globular processe?, givt?
ris<* to the intermaxillary region, the middle jiart of the lip and the Imwkf
part of the nasal septum and th(» [M>rti(m of the fronto-nasal process lK'twr«
them. Tlie bridge and point of the nose are formed by a pushing oui'j:'
that part of tlie fronto-nasal prcKt'ss which lies inmiediately ab(jve. S» ti'
we have lK'<'n following th(^ development of the internal rims of the oliiiclon-
pits. Th<! external rims grow also, but less nij)idly, and project dowL-
ward iu^ the lat<*ral nasal pro(»esses. From them are formed the ala? •'!
tlie nose. Tluy iH'gin by curling around the lower part of the lut^il ]»it»,
but so(ni mcM't and coalesce with the maxillary processes of the mandihula:
arcli, which you will n'memlxT 1 descrilxd to you as growing around t-aili
side ni' the roof (if th<' primitive mouth. The lateral nasal procesT^e* acl
the niMxillary processes eventually join in front with the interumxillaiy
process, and tin* union of all thesi? mak(>s the upjxT boundary of the in-'Uih
and shuts it oil' from the anterior naix^s. Behind this anterior bridnt'the
nose continues to comnuuiicate frwly with the mouth. Finally the jmlaiinf
processes grow like two shelves from the inside Iwrder of each of the maxil-
lary proci'SM's. 'i'hese by their union with each other in the middle line and
with the nasal septum complete the division of the nose and mouth. The
me<lian union of the palat<' begins in front by the eighth \veek and is com-
pleted by the thirteenth wn-k of intra-ut<Tine life. Prom what I bavcsaiJ
you can easily picture how an arrest of this process would result in wveral
kinds ol' delbrniity. Il* the maxillary procc^ss on one or both sides fails to
luiite with the intermaxillary, a ch*ft will remain open in the contour uf
DIB£A5j£B OF THE NEW-BORN.
411
the upper lip on one or b<jth sides of the intermaxillary bone, and hence we
shall have single or double harelip as the case may be. If the cleft extends
the whole distanc* fnmi mouth to nostril it is called complete, but if the
nostril Ih not reaeht*d hy the opc^niug it h called partial harelip. If there
is a failure of the palatine pro<:^*sses to join, one or both nostrils will open
into the roof of the mouth m well as into the pharynx, and we shall have the
malformation known as elell palate. This may be a huge chasm running
the whole length of the v^mf of the mouth, or may be only a amall ojx'ning,
or nothing but a biiiircation of the tip of tlie uvula may be left to show
that the normal process of development ha* not gone on to completion. An
intt*reating and ils yet unpublished oljservation on the persistence of an early
condition of development in the lip has been made to me by Professor C.
8. Minot, of the Harvard Medical School. If you examine the mouths of
any set of men, you will be struck with the fact that in some of them the
even contour of the upj^ier lip ap]>ears broken by two rounded masses, each
about the size of a |iea, situatt^l side by side nearly in the middle line.
These are the remains of the two globular processes which have tailed to
be obliterated in the formation of the intermaxillary region.
Besides their unsightly apijearanee, which always causes the mother
great c«>ncern, tliese malformations may so interfere with the infant's
taking the bi^ea-^t as to rendtT sucking impissible and make it necessary
to feed the infant with a spoon.
I have here to show you a typical case (Case 162) of double harelip uncomplicated hy
cleft palate.
You will notice the larjEre dae of the int^rmaxinary bone, whkh protrudes considerably
beyond th*3 margin of the lipA and is somewhat twisted upi>n Itself. Tliifi iiltenititui of the
position of the inteniiaiullary hone may cause the teeth that grow from it to appear in very
unusual placeSf as, for instance^ protruding f^m the ncwtril.
Casi 162.
Double honsllp.
T>r, J. C. Warren, who has examiiux! the ease, will now tell you what
his ideas are as to the pmixr time for and the method of opiTatin^ on
barelip ;
"The operation for the core of the deformity of harelip coasiets in
412 PEDIATRICS.
ri'inoviii^ the «h1i^s of tho deft with the knife or shar]) scissors, and b
briii^in^ the jwn'tions of the lip together by sutures.
*' The eut may Ih' made so that the lower edge of the wound will pnJM
slightly, so as to avoid an indentation of the border of the lip when ck-atri-
/atioii hiL< Uikvn place. This may 1k» aeeomplished by making a s%bTlj
<nrved or V-shaiK-d cut in each margin of the eleft. When tJiere L? doubk
harelip, the portions of the lip adherent to the intermaxillary' bone shndJ
Ih' rel'reshed, leaving a V-shajKil flap hanging from the septnm of the ni«*.
Tlie \vonn<l when bronght together then forms a Y.
" 'V\\r sutnres which aiv iisnally a])plied produce almost invariably
iinsightly s<ai's, owing to the traction which is exerted when the child erirty.
J have therefore devis(Hl a i)lan by means of which external sears are
avoideil. This e<nisists in pa^vsing a fine wire through the cleft at the
margin of the ahe of the nose and foiling the {Mirts into apposition bva
jM'rforat<Hl shot, which is then clami>ed to the wire. In the case of sinjL'i?
ban lip the wiiv passes thnmgh the ala of the side aflected and the septiim.
One of th<' shots is therefore comx^aled in the nastril of the other sile.
My otiier sntnres are of silk, and are so taken that the knot^i are tied in the
mouth and the r(\st of the sutniv is buriid in the deeper portions of the lip.
Tlire<* sneh sutnns an* usually sufHcieiit to hold the lip firmly. A few\'«^r
fine sutures such as are us<il for intestinal sutures may be applied on the
e.\jM>se(l surface to make th<' coaptation of the edges of the wound wmpltir.
A band of ere|H' lisse last<'nc<l to the cheeks by (Hillodion removes the strain
sullieiently to enable healing to take plac(» promptly. The wire sliouU
remain in place for ten <lays, but the fine suturt»s should be removed in rv
or three <lay^ and the remaining sutures at the end of a Avcek.
'' The<e operation^ sliould 1h' jK'rfornud during the earlv weeks of litn,
as tile growth of the laeial musclo^ is not then sufiicient to interfere wia
the healing of tlie wound.'*
The method of feeding these <*ases is imiH)rtaiit. Various deviivs have
beeu n>e(l to promote the power of sucking, which is so much interlenxl with
by the eoinieetiou iMtwceu the nasal and bucwil cavities. Rubber nipples "f
p^vuliiir >hape^ liave In^en use<l, with th(» idea of artificially closing the opt-n-
luii in the hard |>alate wliile the infant is ])eing fed. I have alwavt* pre-
ieri-ed, however, to have the infant tcKl by the s[K>on, and not to have it i^uck
at all until alter it has been operated u|Mjn and the wound entirelv h«il<;il
In this way we avoid the ii-ritation ujmju the fl(K)r of the na^f^l cavitv which
W(Mil<l be eauxd by the introduction of rublxT nipples or any other apw-
ratu-. The inlimt^, a> a rule, have no trouble whatever in swalloAving milk
introduc'ed into their months by means of a sjM)on.
The method of feeding ]»rematun» infants by means of Dr. Breek's tuk
(Fig. -iL^ page :>]:\) is also a rational way of feeding cases of harelip, pn.>-
vided that the infant does not insist on sucking.
(^LKKT Pai.atj:. — In speaking of han'lip I have described most of the
conditions occurring in cleft palat<*. Tlu^ difficulty of feeding, if the deft
BISKASEB OF THE NEW-BORN.
413
involves the hard as well m the soft imkt^, is very great, and miist be met
ID the manner just destTitxxl. The difficulty in articulation and the
anpleasant i^oand of the voifx* are retLsons which lead the parents to demand
early treatmetit. We iihoukl wait a lunger time Ijetbre o|R^rating than in
c^ses of harelip, as it Is seldom wise to operate upon thl^ defurmity Iwfore
the eh lid h thrw years okl*
Tiie ojieration for eleil of the mil palate i^ ealled Htai>hyhjrrhajihy, and
is periorme<i iu this way. When the ehiki lias lieen |jut fully iiniler
the influence of an anft.\sthetie, and the mouth held wide open with a irn^,
the surgeon sei/x*^ the tip of the uvuhi with hin IVirtH:-!)^, and l>y the aid of a
sharp blunt-pointetl history rapidly pares off a thin strip from the tip of the
uvula to the angle of the cleft. Theu^ changing his forceps, he takes a
similar parhig from the opposite s^ide, carrying the knife from the top of the
cleft to the tip of the uvula. The fresh edge^s are then brought into appo-
sition by a series of fine wire sutiu'es, which are twisti-d tight and cut otf.
The levator and tensor palati muscles, together with the palato-pharyngeus,
are then cut, in onler to lessen the tension on the flap. This is aec^impllshed
by passing a thin-blad*-*! knife ot^mpletely thruugh the soft jjalate close to
the inner side of eaeli hamutar prtx^^ss : the handle is then raised a little
and the knifi* withdrawn with its cutting tdgi* downward. The anterior
wound nt^nl Ix' <»nly slightly louger than the widtli of the bkide.
The operation for closure of a cleft in tlie hanl palate, called uranoplasty,
is mueii more difficult, and, owing to the great sueeess which has lately Ixen
attained by fitting artiiieial |»alates, Is now parsing into disrepute. For
wide clefts uranoplasty is almost hf^peless, but narrow ones may be success-
fully cIos4xl by its aid. It consists in marking out two side flajjs [Kirallel to
the eletl on the nxif of the mouth. These are disse<'t*xl up with as nnieh
periosteum as iKmsible for a distance a little in excf^Rs of the length of the
cleft. The median edges of tliese flaps are rt^freshixl and brought together
by a row of sutures, just as was done in operating ii|M>n eleft of tlie soil
palate. The final step of dividing tlie palatal museles is tlie siime in each.
By many surgeons the lines of suture are in all these eases |)rote<*ted by a
mblM^r plate made to fit neatly into the ivxjf of the mouth,
TIm* larger the oj>eniiig in the palate the more sutx-essful will Lie the treat-
ment by apparatus in mmparison with that by tlie knife, for in the large
openings there is s(i little op|H)it unity for rt^fi'eshlng the edgt*s of the ojxn-
ing iuid bringing them tngetlicr that the o|)€Tation is very apt to l»e unsue-
eet^ful. In using the appjiratns, on the c^^ntrary, the larger the ojxning tlie
greater the en^^ with which the artiflrial palate can be adapted. The arti-
ficial palate ban also a uvula edge to it, and has in many i-ases prfived
eminently siu"cc»ssful wlien applied by the hands of an exfM^rt..
Ijet me hert* emphasize the fact that afier any ofjcration np^m the month
of an infant the afkiwtire, and esjKM-ially the fVnxling, are of the utmost
importance. The infant must Iw^ watclu^l night and day to see that it does
not put its fingers to its mouth and thus interfere witli the stitches. Of
414 PEDIATRICS.
c'oursi' evtTv time it cries the strain is greatly increased upon the stitches.
We must, therefon*, impress upc^n the nurse the imixirtance of oontinuallT
amusing the iniimt.
ToNCJUE-TiK. — 111 ([Uite a iiumlier of eases the fraenum of the tr^ngoefc
abnormally short at birth. In extreme cases the tip of the tongue isfo
closely lH)au<l to the lower jaw that it cannot be protruded beyond the lint
ol* the jrum or touehetl to the r(X)f of the mouth. The mother usuaDy
notices that the infant does not nurse rcatlily, and brings it to the physima
to disi-over the cause. In most cases on passing the finger into its m(»nt!i
tlie infant is found to suck iairly well ; but there can be no doubt that tli
condition, whicii is called tongue-tie, interferes somewhat with the process of
suckinji:.
Tiie tn^atment is to cut the frsenum. This operation should be followed
by no hemorrha^' and rtH^piires no dressing. Having the child's head held
in a fairly pmkI light by an assistant, and guarding the lower portof tbt
tongue with the iKTtbratiHl flangt* of a director, a small cut is made in the
tense fnenum with a pair (»f blunt-pointed scissors. By making the cot
closi' to the ^um there is no danger of wounding the ranine artery. The
cut is j>rolon^<Ml as far Jis is ncHHssary by tearing with the finger-nail.
Children who hav<' not learneil to talk at the usual time in the second
and third yeai-s an* fre(|uently brought to me with the statement that the}'
arc ton<rue-tied, and the pan^nts wish me to treat this condition. liar^'e
nuinlH IS of chihlren are brought to the physician under this suppositi^Hi
but in very few instances avo they tonguc»-tied. These children belong to a
cliL'^s which I shall dcscril)e when sjK^aking to you of retarded s]x>ech (L«v
turc XX X \' I., |)a<j:e 740). I shall merely say at present that the condiii'C
is a central one ol' the brain, and not a loc^l one in the mouth, and that it
children hear well and are bright and mentally well developed, even though
tliey do not sjM'ak at the thinl, fourth, or even fifth year, as a rule the^
learn to sjH'ak hiter.
Kanm LA. — PxMieath the tongue we sometimes find the mucous membraDe
bul^in^ out as a bluish, translucent tumor wdiich is soft, painless, and semi-
fluctnatintr. This condition is calknl ranuloj and is a retention cvst caused
by the Mockintr <>1" a mucous duct. When o])enedy a small amount of glairy
fluid cscajMs, but tin* collapse of the walls of the cyst brings the edges of
the cut toir<'thcr and thiy (|in'ckly adhere*. The fluid will soon re^<X)llect;
tlicrclorc the only sure way of dealing with these cysts is to pinch up their
anterior wall with line forceps, and with the scissors remove so much of it
as to Icavt' no opportunity for the ed^^ to adhere. A gentle application
ol' nitrate of silver to the edixes and interior of the sac aft^er the cut has
IxM'n niad(» with the >eis>(M*s materially heljis t4) promote the cure. It i?
not eiunnion in new-born children, but it occurs often enough to deserve
mention.
Ka i:s. — A deformity wliich is (juite frequent at birth, and which increases
as tlie infant ai)i)roaches ehihlliood, is the protrusion of the ears. The ear,
DISEASES OF THE NEW-BORN.
415
I
I
besides at times being placed in an irr^ular position on the head, has, in the
cases to wiiich I am now referring, a tendency to stand out from the head
farther than is considered normal. This poi^ition of the ear usually aunoya
a mother very much, and you will frequently be eoDj^iilted m to the means
by which the deformity may be rectifletl.
In a large number of eases the |KTsistent ap|iHeation of pressure by
means of various devices, one of which is a feuestratttl eiip, wnll i^ii ii.se the
ears to be flatteued against the side of the head. In intractable ciisc^s an
o|>erati<ni will have to be p«-Tformed, but it is very simple aud dot^ not leave
an unsightly star. Dr. Warren's method Ibr opemtiug lor this delbrmity
is illustrated by one of my cases (Ciise 1(53)^ a boy eight years old, in which
the oj)eration resulted in a marked improvement in his apj>earance.
Dr> Warren dissects off a flap fn>m the Imek of the c^r tliat is shaped
ver}^ much like the wing of a butterfly, A similar flaj* is taken imm the
side i>f the head just back of the ear. The two raw surfaces are then
bmught tiigt^ther, aud the edges of the wound unit<xl with fine sutures. Dr.
Warren tells me that the amount of tissue remove<l must l>e cousideral>Iy
lai^er than would seem at first sight to be necei^sary, because if the ear. is
not uuit4HJ t*» the head by a baud of C4>nsiderable thif*kn(»ss the sulisequeut
strc*tching of tJie citratrix allows u( a return of the deibrmity.
(>i*HTHALMiA NEONATORUM. — This disease has l>ei^n divided into two
forms, the catarrhal and the purulent.
Catarrhal OphthaJmia, — The catarrhal form may be c!ause<l by any
elight irritation of the eyes of the iulaiit. It runs a very mild c^^urse, the
inflammation attacking chiefly the pal[K?bral conjunctiva. Often tlie only
symptoms notieed are a slight phot^ipliubia aud a collection of the secretion
in the angles of the lids and u|m»u tiieir btirders. Its whole course is mild,
and often it is all over in a few days.
Purulent Ophthalmia, — Although a consiflerable number of causes for
purulent ophthalmia in the new-lw>rn iuive been given, such as traumaj ex-
posure to light aud cold, aud others, wrtainly ninety-five per cent* of all
cases are caused by infwtious material i'mni the gc uito-urinar)' tract of the
mother, and in most instances it is by gonnrrhfca! pus. If inft»ctiou takes
place during the birth of tiie child, the svnijitnms usually l^egin on the thirtl
day ; hot, as contaminated linen and tiugers may carrj* the infectious material
to the infantas eyes at a later jiericMl, the sympt4im8 may be delayed indefi-
nitely* The disease begins as a retbiess of the conjunctiva, with a slight
discharge from the corner of the eye. This is suceeeded wnth startling
rapidity l>y intense inflammation of the lids. In twenty-four hours the upper
lid may bec^mie so much swollen as to fjverhang the cheek and rt*uder opening
the eye impossible. On separating the lids, a little greenish pus, which may
even bt» tinged with bltwid, wells up bi^'twei'n them. At first the cornea is
miaffected, but if the pus atx?unuilates under the o^dematoiis lids it sc»on
shows signs of ulceration. In the second twenty-four hours the ulceration
may perforate the cornea and evacuate the aque<:)us humor, thus bringing
41 <; PEDIATRICS.
the iris into contact with the }x>stcrior siiriaoc of the cornea. The inflam-
inatioM may extend an)nii(l the eye and well over the forehead and iiiak
prominence, hnt it d(K»s not hb^t in the latter region very long.
All the symptoms disapjK'ar slowly, and recovery takes place, exfei^tis
thos<» casts wlicrc from nUvration the cH)riiea has been permanently iujimiL
In tn-atin^ this discitsi* we must Ix? very prompt and energetie. It utifi
may Ix* averted by what is known as Cred6's niethixl. This oonsb^- in
dn>ppinjj: one or two minims of a two jx>r cent, solution of nitrate of silvr
hito <*ach eye of the new-l)orn infant. Although this has been kiiovTiro
cjuis<» even a C(msidend>h* amount of irritation, yet it undoubtedly exert? s
|H)werful inthiemv in wanlinjjj off this dangerous clisea.sc.
Aller tile diseiu^} has one*' lx»gun, two indications must be kept in mind:
(1) to HKluce the inflammation, and (2) to prevent the pus from accumu-
lating iH'hind the tightly-close<l lids. By far the best way of applying
eohl to the eye is by comj)ii»ss(»s of thin, soft pieces of linen cut into ?raall
s([uans. Not uku-c than two thieknesst»s are to be used at once. Tbttt
eom[)ress<'s an* to U' <'ool(xl by laying them on a piece of ice or flriaiing
them in ice-water. They nuist he constantly changed. To remove the
pus, a <rentle irripition, such as can be easily obtained by using a mediciDe
dro[)jH'r, is suflicient.
KememlHT that this secretion is highly contagious, not only for the
infant's other eye, but for youi-self. Therefore you must avoid all s^jiancf-
in^, and should cover the infant\s well eye before you begin the irrigation.
You should tii-st turn the cliiUrs head a little to the diseased side, a»l
with the fiiitrers of the left hand ^ntly separate the lids as far as jrjssibie.
Tlicn, holding tlie (b'opjver with the right liand, irrigate between the M<
directinii' the stream frrnn the nose. Alter each irrigation vaseline shouii
Ix' a|)|)lie(l to tile edtrc of the lids.
This should 1h' done at least eveiy half-hour, day and night, until the
swellintr has so llir Mibsith^l as to preclude the danger of anv secretion hmi
retained.
For irri'!:ation many solutions have kien advocated. The most simpk
and pcihaps the Ix'st, is a saturated solution of boracie acid, or one of
birhloiidc iA' mri'cury in the strenu:th of 0.0') gramme (1 grain) to 480 cr.
(1 |)int) of (li-tilled water. In the later sttiges of the disease, where all the
ti->ii(> are rela\<(l, a solution of nitrate of silver, 0.5 gramme (10 graiibi
to :;n i-.c. d onmcj of <listilleil water, may cautioiLsly be used once a dav.
Thi^ >.Mine solution |)ainted on the conjunctiva with a eamel's-hair hni^i
<»n«c «l:iily early in the disease is very eil'ective in shortening the coun^eof
the dix'ji^e.
it i> not within the scope of thes<' hn'tures to describe in detail scarifii-a-
tion of the cornea or other measures which may become necessan' to ^Vf
extensive -louiihinj^ from strangulation.
THE NECK. JI.KMATOMA OF THE StERNO-ClEIDO-MaSTOID Mc?-
c'LE. — l)urin<r the birth of the child, either from the violence of the expul-
DISEASES OF THE NEW-BORN.
417
Hsive efforts of the uterus, or» as more frequently hapjiens, from the pressure
Hof the forceps in head pre^entatiuns, or from too vigorous traction upon the
HifiHi^t iu brcfx4i pres(!utjitiuns, or fiir tio asj^iguable reaison, tlie Htcruo-uuistoid
Hiuuscle may be {mrtitdly ruptured iu its sheath and a hfiematoma form bo
Btween the torn ends* ThLs tumor may be either in the stenial or in tlie ck-
' virular jMirtioo of the muscle, or may Ix^jiist alx>ve the junctiou of tlie two.
tYor a hhort time it is i^oft and tender, but gnubuUly it loses its sensitive-
neas and l)ec=(jnie8 converted into fibn>u.i tissue, wliich then tends to contract,
'It may ap{>(*ar t\s a small tumor, but in inlaiit« with fat ntK*ks it may not
l)e noticeable at Jirst. As turning the hea^^i towanls the aifectt^l side lessens
tlic tension upon the swelling, the infant will rigidly hohl its head in that
sition. It is iu this way that cases of infantile torticollis are tliought by
Ixnost writers to arL^.
Treatment. — ^At\er the painful stage has passed, the treatment is by
entle massage and manipulations addresstii ti> stretching the shortened
f muscle. If these methods fail, the child must Ije pkiti:! in the hands of an
Drthopiedic surgeon for more extended treatment, either by apparatus or by
livision of the tendinous attachments of the stemo-mastoid muscle,
BuANCHlAL FlSTUL^E,^ — ^At an early jicriod of development the neck
^f the icetus has along its sides a series of four branchial eleils, which
imuniL-ate frecJy with the a^sophagus and represent the gills of aquatic
lanimals, The upper one of these forms the tympanum and the Eustachian
[tube, the rest are normally f>blitcratt\l, Sometimc^s we tind traces of these
[branchial clefts in the form of small fistulous tracts which admit a probe
ehort distance and end blindly. Their most frequent seat is just above
fthe sterno-clavicular aiticulatir^Uj but they may l)e found anyw^here along
[the anterior Icjrder of the stermvmastoid nius(*le*
If they do not cause any inconvenience it is better to let them alone, as
J they often [irove vcr}" intractid^le to trt*{itnient* If they are annoying from
[causing a slight mucous discliarge, we can try to eradicate them with the
galvanoeautery, or by passing a probe into the wound and dissecting from
I around it t!ie lining of the sinus.
Sometimes the entrance of th(*se fistuhe becomt^ stopjied, so that they
l^ilate and form large cysts containing nmcus, hlotKl, and athcnjmatous
jdetritus* These form at ti:nes large and unsightly bunches, which re^^piire
surgical treatment. Often the oj)eration of obliterating them is not an easy
I cine, lur tliey are apt to have deep and complicated attai'bmeut^.
418 PEDIATRICS.
LECTURE XIX.
THE TRUNK.
MASTITIS. — In certain infants dnriug the early days of life we find*
swelling and hardness of one of the niammse. This oondition appears to be
an inflammatory one, and is abnormal. In conuection with the swolk
condition of the mamma, a sec»rction is found to come from the nipple whicli
corrt\s[K)nds closi^y to milk, and which has been called ** witches' milk."
A numl)er of analysers have been made of this fluid, and here are wioe
(Analyses 57 and 58) which represent the composition of it very well. Of
course only a few drops of the fluid can be expressed from the mammas;
one time.
ANALYSIS 67. (Schlossberger.)
Fat 0.82
Casein, sugar, and extractives , 2.88
Ash 0.05
Total Bolids 8.70
Water 96.80
100.00
ANALYSIS 58. (V. Gesner.)
Fat 1.45
Casein 0.55
Pn)tf*i(l.s 0.49
Suyar 0.95
Ash 0.82
Total Kolids 4.26
"Water 95.74
100.00
This condition (K'curs in boys as well as in girls, and, as £ar as I know,
has no esjxH'ial sitrnificance. With ordinary antiseptic piecautions Ae
inflammation usually subsides in a few days, leaving the afiected bresst the
same size jis the other.
1 Iiav(> here a female infant (Case 164) who represents this oondition of
the mamma.
Shu is <mo work old, and the swollin^ of the mamma was noticed on the fourth diTt'f
hi'T lit*'. Vf.ii SCO 11 little fluid lookini; like diluted milk can be expressed fiom the mammi.
TIh' troatni.-nt of the cn^^^ will >iniply he t*) Tceep it thoroughly clean by washing itwiik
storilizod water, eunfuUy drying it, and applying a compress with a little simple ointmait
on it.
DEPRESSED STERNUM.— There are a great many oongenital nul-
forniations wliicli may oc<'ur in different parts of the thorax. I ha\-eheR
DIH£ABES OF THE NEW-BORK,
419
[to show yon a boy (Case 165) who was liorn with a depression of the lower
I part of the sternum.
He ifl now six years old, and has thig rounded depressum, abnut 4 em, (IJ inche*) in
IdiAmeter, begtnninjL: at the thini costal cartilage und extending to llie eiif^iform i?artilaf^e.
fHe u perfectly heiiltbj. The cardiac dulnes» extend* to 2.6 t-m, (1 inch) to the left of th«
mammary line, and it* impulse is in the fourth left inter^p^ice. The spinal column is straight.
f The epiphyiie:* of the wrists are slightly enlarged, but thert? is no oth^r evidence of rhachitis*
When he wtia two months old he had a severe attack of pertu^sis^ which lasted for over two
months. At five ycaw of age he had a aevere attack of bronchiti*.
Case 165.
Ccn^nltal flt^-preffilon of rtemtim. Male, 6 years old.
I
Tou see, therefore^ that he b«i been subjected to influences which would tend ti* increase
a malformation of this kind.
Although this deprewiion of the Ptertium was present at birth » and has since increat^
i In depth and in circumference, it now ^eems U^ have ceased to enlarge. The circumference
r of his head and thai of his chest measure 60.6 cm. (21* inchea*).
The heart geeme to be Romewhat displaced upward and to the !e(\, but is apparently
unaffected by its abnormal position^ and the boy's, circulatory sytitem will probably not be
iryured.
I have ordered for trc^atraent light gymnastic exercises to brtiaden I he cheet and to
itrengthen the thoracic muf<eleu.
8uch a mill formation && thU eomt^timea resultii aj? one nf the changes .«?ubste<iuent to
Pott's di«case. More often the sternum pnjtrude*, but octiisionally recession take« place,
•cloiely resembling the condition in this ctt$e.
PROMINENT STERNUM. — A pmminenee of the sternum, callwl
pigevn^breaM^ oeciiPH mfU'O cjften than tlio tlepivssioti. It may happt'ii
without an assignable cause, or it may Ik* doe to rliaehitis, and may also
result from st^me spinal di.st<»rtion, sueh as that of Pott's disease, or lateral
curvature. lu the latter case the stenxum is often tiltetl to one i?^ide.
SPINA BIFIDA, — I sliall next j^hnw you a s^Ties of that ela.?s of
malformation ealletl npina bifida. Spina Inlida I'onsists of a \m^\i of elosiire
of the laminie of the vertebme. This condition is normal at a eertain
420 PKDIATRICS.
jM'riiMl ol' intra-utcriiie Hto, hut when jx^rsistiug to a later jxriiKl, andvLf:
<M'rnmn^ at hirth, Imm-oiius ahuornial from a developmental jK)int nf vir-n
iiikI represents a distinct inaliorniation. As the fusion of the laminae at i-
hase of the spinous pnKtss takes i)lace in st^qiience from alxive duwiiAjrl
the most ire<|uent seat ior spina hifida is in the lumbar aud ]umbi>-suia
rejrions. 'Hiere it apjM'ars as a tnnior situated exactly in the niiddli* lii.
covered soinetinus with heaUhy skin, hut an frequently roofed over U
ntithinjj: hut a thin adiiei-ent transparent membrane. Rarely the tiim -r :•
solid, (■ontainiu'x notliin^ hut an empty sae that has been wailed off fn-n:
its c-onneetions with the spinal canal, it is then i*alled »pina bifida ui-(^\il''
In true spina hilida the tumor is filled with oerebro -spinal fluid, whicL'^n
1k' seen to inciviL^e in amount as the child eries, and can, by pressnn* upi.t
the sa<\ Ik' lorctnl hack, in this case* often giving rise to cerebral sym|»i«>n>.
According to th(» contents of the tumor, spina bifida has been divided iiit-
st^veral vari<'tii»s.
1. Spinal MEXiNcorEL?:. — When there is a protrusion of the mcc-
bnines filial with fluid the tumor Ls called a npinal ineftinffocde,
2. MRNiN(i()-MvEL()('EL?:. — The most common f<>rni is where the ?pak
c<»rd, as well as tho mend)ranc»s, is found in the tumor. It then beo.ime^a
mcninf/o-nii/rlorric.
The {M)sition ol' the i\ml in these tumors is a very variable one. It mt"
run dirci'tly tiirou^h the tumor, and even be 8us{)ended by a kind of me^ea-
terv, 01-, as is usually the case, it may be spread out like a fan over tk
surface ; in any instance it is rudimentary in character.
:\. Svrin(;o-Mykl<)('Kle. — Si/rinf/O'inyelocdc is a rare form, in whb
the sac is formed of nieiiiuires and conl, the central canal of the cord luring
dilatecl to make the cavity of the tinnor.
Spina bifida oc<'ui>^ usually in j)oorly-developed infants, and in a lar:-
majority of cases it is it-sociated with other malformations, such as congeuiti
hydroccplialiis, harelip, <'luh-foot, paralysis of the lower extremities, and in
seviM'e cases there may 1m» incontinence of urine aud of faeces. Sometimi^
the inl'ant is well formc<l and healthy in every other resj)ect.
If left to itself, the course of spina hifida is in one of two directions:
(1) s|)outa?ieons closure aud obliteration of the sac; (2) ulceration of tbe
sac, nsually loliowed l.y convulsions and death. In the first case, which L-
very rare, tlie -a<* slirivels up and thus efiects a sixmtaneous cure. I
to iiave iii're one of the first class of cases to show you (Case 166).
This ],..y, nnw fniir mikI .»iio-hnlf yoais old, shows an elevated cicatrix in theluniUr
n-irinn, ^vlli,•h MiLri;v>t^ ih.- f.TiiuT ••\i>t«'n )f a spina bifidii The caae was of such inier«4
that it \va. ropnrt.-.! hv Dr. Lov.tt in tlu- Hnsfnn Mrdiral and Surgical Journal as a fomoi
s})ontaTi.M,ii. mv.vprv iVm,, .pjna l.itida. Tlir- rase was seen by him when it was eiffht»-c
inontli.^ nM. nn.l ..,. far a.s ,miiM 1m- l-arnod thm- had been a large tumor present at bint
fiimihir t.) tliosr. whirl, I shall pivsmtly show y..u. Th." i?ao buret in this case, and, wntrs-r
to th... -rTi.Tal rr^ult. the .-hil.! did not di.-. but was left with paralysis of Oie I<^, whidi
niakcs it stand in thi^ <'iiiiou^ and abnormal ])..sition. Ho also suffers from incontinen« of
urino and of far^s. Th.- rhild has n.-vr walked, and it seems probahle that the pwa:
DISEASES OF THE NEW-BORN, 421
iiaabilitj Ib cAUsed by th«« ttict thiit the nerves were Apret&d on the wfills of the saoi as It
AUal in nukiiy cMSi, and ihtit they were incorporuted in the ciciitnx.
Case im.
Spiuii I'lti^lfi^ Hf<)ntant'uu« cnjre. Malt, 4'„ yenn^ old.
A reBult like this h, however, veiy exceptional. The rule is, either that
iere is an ult>enition of the sac, followed by a l^r^e Ior^ of eerebro-spinal
tfliiifl, eonvuLsioo}^, amt th^atli, or that the ojM^niiii!: in the spine liein^ very
li^mall the loss of fluitl is eonstnnt, and the ixsult is the sitme. In {^»me
Im^tances there is an infection of pyogenic organisms thron|i:h the walls of
ithe sac, which eaus€*s a i^]>tie menintriti!^ in the eonl nod Hnally in tJie brain.
ISnch a vixsi' has bcx»u rt*|K>rtwl and l>cantifu!ly ilhistratiti by Dr. Holt, of
[New York, showintj the pres?enoe of the l:)acteria and a resulting purulent
■bydrocephaliis.
Here ls a picture of another ca^ (Case 1G7) of spina bifida whi<4i will
^ illustrate the ordinary course <if the ntfeetion.
It shows a largre spina bifida in the dorso-lutJibHr i^gion. The membrane covering: the
iimor wan so translucent that the spinal tsard could be plainly seen through it. At birth
422
PEDIATRICS.
there wa« a smikll tumor. It filM with fluid at the end cwf twelve hours, aiid cl i
of forty-eight haun it looked as it dew* in Ihb picture. The tap of the tumor i
the fluid began ta leak away, aud the child died within ten days.
Chsu 167.
Bpiiiii Ijlfltlfi of domo-lumbar region^ infant 4a hours old. Died wlm*u 10 days oid.
This is the course piiiisued by the disea^ in the majority of eaem
are not oi>eratt>(l iii>oii.
The next ease (Oaae 1G8) is an illustratinn of a 8pitia bifida in the I
doj'sal region.
Case lOS.
I
Bj>latiL hit\d& In lower doTsal region. Infant 5 days old. Dieal when 7 <1aym old.
The ^ae was not au teuse ha in the cajic (Case 1*17) of which 1 bavi* jiu^t ^pukm,^
H waa poMible by feeling de<*ply with the fingers to find the ofienirig^ iti the sT^nal i
This opening wa> jibout 7.5 cm. (3 inches) long und 8.8 cm. (IJ inches) wide. TV I
WIW4 not c!overed with wkirii as in the case prvviously mentioned, but with a thin, I
membrane.
The infant was ^ecn by Dr. Lovett in consultati<>n twelve hours after hirih i
operation wus detVrn'd for a tVw days to !?ee if any favoruble ohauge would occur,
operation wiw nndertaki n nn llie tiftb day, as the ^ixc showed sig^ns of ulcerating and)
ing. The nac was cxrisfd without appareiuly injuring the nerves, and tlie wo
closed by a plastic operation. The infant died in convulsions within fortj-eighl
the operation.
The next patient I have to show yon (Caae 169) is another
spina bifida.
The boy h now five years old, and ha** had this large tumor since birth. It i* ni
over the lumbar re^-iofi of tb>- spjiml cord, and k in the nu^ian line. The flui
withdrawn seveml time^ fop ptirpoRPH of examination, and when the aac b lax
DISEASED OF THE NEW-BOBK.
423
i cm. (2 inches) long can be felt in the spinal caaal. It is elliptical in shap4?. From the
llkct that the child auffeni from incontinence of urine and hiis a certain degree of paralyeia
lof the lega^ it is fair Ut inf*.rr ibul Ihe nervv-suppl y of the leg8 and pelvis is incorporated in
I the tumor.
Case 169.
9piim bifida of lumbar ruif^cm. Male, 5 years old.
Thw wwe haa been tjipprxl nnd trt^atpd with m\ injection of Morton's flwid^ but thU
Itreatment was entirely un^uert'^i^rii], and nltlinugh the sac has been Hspin4t<xl fii^vurul times
[the fluid ha» always returned. There is little hope of the boy's being relieved by an opera-
Ition ultimately, and be will pn^bubly continue to be a cripple for life.
Treatment^ — VarioiL^ metlimls iur tivatiug spina bifida have been
[proposed, and stune of theni wiirnily ailvocjitinl. Ke|M^ate(l aspiration is one
lof the mmt simple, but its rt^siilts have imt Ikvo satisfactory. Ligature of
I the neck of the sac, if the sac is small, or the application of a clamp, has
cured a few cases. EkHtriritv has l>een iM-iniiiinieudetl for tliis affection, as
for al>out everything else in the held of uietlieiue.
The two meth(xls that ai^ in the best n^piite art^ the injection of Morton's
fluid ami the pkistie ojKTatiou. Mortoivs fluid 18 a solution com|io^ as
h shown io this prc^scription (l*n*seri[>tion 46):
Metrit.
Prescription Af\,
Apotheaarf,
B lodi ....
Fotassli iodidi
Glyoerini . .
M.
m
m
m 00
B lodi , , . gr. X ;
Potassii iodidi ...,.,.. gr. xxx ;
Glycerin! Ji.
From 1 to 4 e.c, (15 miuioi^ to 1 drachm) are ui^ at each injec-
tion, which may V)e rej^eated several tirnt^ at intervals of a fortnight The
1 reports of the Clinical Society of England shgw that moi-e cures and fewer
424
PEDIATRICS.
deaths have U'en imported following the use of this solution than fmn
oilier method.
Another metliml is the pla**tic oj>eration. This is performed m I
The tumor h u|)tnitd, the uervt^ iire di^sei-ted carefully from thei
tlie Stic and are returned to the spinal canal : the sba^ is then sewed up J
if (M>ssihle, used a;^ a pltig for the ojiening. It has been reeoDimeiideill
the laininie of tlie vertebnu ou l><ith fiides of the cleft irshould he brokoij
turned in. Finally, after the excision of aJl the thin ojvering, thu I
edges of the sound skin are united. To accomplish the closure of
wound, and yet to avoid dangerous tension on the stitches, it mar, i
ease of large tumors, be neee^an^* to dissect up two lateral flaps of (
from the loins and slide them inward to join in the median line
majority of trases whieh have Ix^^n so o|>erated upon have died
week, but the few suecevss**s that have been attained k^d ujs to hopci
with a mom j^erfeet technique the resulta of the operative treatamn
spina l)ifida may 1m' sneti ils to warrant our advisinor it iu any case wliaf I
tumor thi'eatens to rupture iind where the child is otherwise lairly i
You must clearly understiuid, however, that tlie 0[>eration will in nu^tc
not help the pumlysis {>r iiKH>ntinentx\ and may very jK>B8ibly increase in
of diminish a hydn>ceplialus, if this iattei* condition exists as a compile
HydTix-ephakiH, donsal ujilntt bUkUi, dob-frx»t
This photf^grapb illus^tnites the t*<jndition of liydnxH^phaliis aceomc
spina bifida » wliieb I have just desc!rif>e<i. The infant (Cai^e 17 Q\
Dr. Osler^s, i-eprc^sents a eombiiuition of spina bifida, hydrocepl
paralytic deformity of the lo^^ei- extremities.
DISEASES OF THE NEW-BORX.
426
PHLEBITIS AND ARTERITIS UMBILICALIS.— The eau^^- of
\ both of these c"f>nditions is a septic infei^tiim of the umbilical stump. It is
c«iiisidered by must putliolop^bt8 to beghi as an iiifiamiiuitiuii of the peri-
vascular tt^liilar tissue, aud only j*eeoudarily to iiivatle the walls of the
f vessels. The a^gitin around the umbilicus is red aud hot, aud we may be
able by gentle pix*8sure to squeeze a few drop.-^ of pui? froiu the stump of
the aird. It Ls a very dangerous afJeetiou, as se[)tie enilxili readily pass
from the infeetefl vessc^Ls into tlie general circulation and set up metastatic
mflaramatiou in the thoracic as well as in the alxlominal organs.
Treatment, — The treatment is tosustaiu the infant's vitality" by stimu-
lation and thoroughly to disinfettt the umbilicus with solutions of bichloride
^of mercur}^ or carlMdic acid, followed by the application of boracic acid or
iodoform ]M>wder. A flaxseed poult i(3e is oiten of service, and some authors
refx>mmend placing the infant u[K>n its alxlornen in order that gravity may
aid ID draining away the pus.
CONaBNITAL UMBILICAL HERNIA INTO TKEl CORD.— Dr.
Howard Marsh, in the Report of St. Bartholomew's Hos|)ital for 1874,
calls attention to the " familiar anatomical fiiet that fmm ab>nt the sixtli to
the twcHlh week of intra-nterine life the eaN:*um and ncighlKiring iiortions
, of the ileum are ccmtained in tiie part of the umbilical cord whic4» is next
[to the l>ody of the embryo, and that they should subserpicntly \\iihdraw
int^j the cavity of the al)domen. In some cases, however, this nx\^siiju tails
to take pla(X% and the intestine remains, even up to the time of birth, still
Itxlgeil in the beginning of the eord^ which is ililatt'd in the form »*f a
I membranous sac.'' Not only may |)ortions of the intestine be thus left
outside of the alxlominal wall, but, as in a case neently ojx^nited upon Ijy
Dr. Warren, the liver may be found lying in a hernial stic made from the
[dilated l>ase of the umbilieal cord.
The infant (Cash 171) wtis pent to Dr Wnir^n nt the Massttcbusettft General HospiUil
Im f<*w hf>iirs after its birth. At the uniliilitti^ wa^ g<?eii the cord, which was greAtly di»-
tended iit it» point of ineertioD into the uhdomen, forming a tumor 6.5 cm. (2| inches) in
diameter The coveriti|2^& of the cord wen? inserted into a raised rim of »kin, and were
qii»?, iio that the content* of the hernia c<^tuld not be detennioed.
Whon tho infant wa^ one day (*Id, Dr. Whjt^t\ enlarged the vimbiheal nng eoniewhat,
fai?pamled the liver from the myxoma tons tissue of the cord, wluch was in some plnee^
I firmly adherent to it, and returned the ma** wit Inn the alnionien. The wound wus lit^htly
rclosed with strong «ilk sutur^^. Then* was cnnHiderable shix'k follnwinj< the openition^
j but there were no uymptom* of peritonitis. In two weeks the wound had healed, and the
Inlknt recovered.
PUNG-US OF THE UMBILICUS.— The umbilical eord, after being
[ligatured at birth, falls otF by the seventh or eighth day, leaving a clean,
dry cicatrix. After the separation of the conl we sfmietimcs-fiiid a red prn-
trusion, \vith a moist .surface, that may even have a t^hort central canal. This?
is generally due to an im|xTft*ct dir^intcgration of the cord. It may bleed
very readily if toueiied, an*l may give rii$e to a diHcharge so irritating that
426
PEDIATRICS.
the i*kiu for t^ma distance arauud the umbiJieits becjomeB eexemiitiias,
ei»nditioii Is eaJIed fun^is or polypus of the unibiUcutr,
The treatuieiit is very siniple. The largiT oiiea* are Ijt^i nm nvni a
ligation j die .-^mailer ones c^i Ix* tlestruyed bv the ap|»Iication uf nimir *i
fiilver or tlie actual cautery.
MECKEL'S DnnSETICULUM.— A eouditinn which may it lis
gimulate umhilieul polypus, and of which umbilical polj'pus nuy k i
symptom, Is the persistence of a J/fdtc/*« dweriictUutn, This
in tlic ijersistence of a pie**c* of intestine, usually patent, connecting dii
small intestine with the urn bi liens. It rcpi'esenti? a vitelline duct that 6uW
to atrophy wlien the plaivntal cinnlation became e&$tablJBhed, and bctrr?
itfl pi\»sen(^ liy an escape of faece^s from the umbilicus. It is a ran? mt^
formation, Init (»ne which you should recognize at once.
I have here to show you the? picture of n cji»e (Cue 172) thai came to Ih^ Ia&cH
HoipltHl liuit winter during the service uf Br, Lovett.
Gass 172.
FfirslsUnice of Mi^ckd's dlviutk ulijiii. laf^nt 3 cUkyi oilcL
Tho infant at entranee wafl three days old jyid wa« very well nourinlsed, Y«i »t|]
notice the jrrotnisioii at the umbiUen*^ on the top <tf which is a bright red graiiulatioetiir^
appearinjEj black in the picture. Tht-ro wiis a couisidt^'mhle fa?e»l clitK?har^ from til*' polj|^,
atid the akin of the ubdoniet] was much irritiiti^d in it« vicinity. A inediam^l^ m^
oouid with eme be passed 6.5 cm. (lij iocheti). Lnparritomy wn^ performed by Dr L/avc
The diverticulum, which was found to arise from the niiddle of the ileum, was meetidtfrf
th<' intei»tiTi!il wound scwiM up. The polypus was not distvirbed at the first ap«9it3oiui^
blind Btump kinp: sewed off even with the inside eurfiice nf the nbdoiDirial wall. 1l\» to
of inci^iun, whirh wu<i about 2.5 cm. (I inch) to the left ctf the polypus, and 8.7cm ^^
inehus) lon^, heitled by flrst intention. A week afterwards the poly|>us wa» remoT^^K
two ttppliciitionK uf the actual cautery. The infant was allowed to return hfttno baia»
hack ten day« later with a double pneumonia, from which it died.
L
UMBUJCAL hernia,— The onlinary umbilical hernia, which is
Himply a protrusion of a knuckle of the intestines tljroii^h the uiid««d
alKlominal opnin^ left by the scfiaration of the n»rd, is of* vcrv coiiuii»«
OiriHTence, The lighter grades tend to rm>ver sjx^ntaneou^lv, and it b »»t
advisable Ui oi^erate upon them, or in fact on any nmbilieal hernia, until tl
has proved U^ I>c al>sohitely intractable, for it is an oi>eration accumpankil
DLSKASES OF THE KEW-BORN.
427
r coiLsiderable ilau^cr to the lite ol' the iufiint. The lighter gradtis of
llimbilical hernia are usually easily reduced, but there is oflben gi\*iit trouble
[in keeping them so. Various deviees are eDifilovfNl f5>r thi:^ purjmse, but
th.
Jhihireii'ri Hospital
most of them are very imsati.siactory,
ill the habit of [ji*oeeediug in tlie tbllowiiig niaJiiier,
I Having gently red need the lieroia, the skin of the altdoraeii Ls so pusht-d
up betwet^n tiie fingers that it makes a vei*tieal ibid, at the h>ttom of which
lies the innljiliios. The hole should be deep enough to lay *»iie*s (inger in
it. The tenjjiifm is kept up by applying a wide stri|> of adhesive plaster
tnuisvej-sely aeross the alwlomeo. This makes a pad of flc^sh, which clos<^
the ninbilieal oj.>ening and retains the intestine in plaee. The cure is a slow
one, and the treatment must be continued for many months in severe cased,
without onee allowing the hernia to ei^me out. The mihler eases are a!»o
aided by exereises whieh tend to <levelop the akloinirial nius^ides. This caji
be very simply etfet^te*! by having the ehild lie itn tlie tltxir, and, while the
feet are held down, making him rise to a fitting position with the baek held
straight. This is aeeomplisheii by the reetus ams<:?les of the abdomen, and
if thf ojK'ni ng is a transverse one it tends to eh»se it.
Thii case which I have here to diow you. (Case 173) b an infant five moDths old. The
hernia, as you see, is very largt, and has caused an eversiun of the whole unihihcal region.
It represents an extreme grade of the disease.
Ca8K 173.
UinbHirnl tiemia. Infant 5 mcmtba old.
Cai?es of ineant'inted and even strinigidati^l undiilieal hernia have l>tM^*n
[reported, but are ver>' ran*. A iew have been operate^] iii>on sueeessfnlly.
[The danger fmm all snob pr(K\»diirt\s is usnally eonstdertHl great, liut there
' has Uvn sneh an advance ma<le In the niotlern methrids of al>fh»minal surgery
that the ojM'ration is loi>kHl upon with iuen*asing favor.
INGUINAL HERNIA. — The most eommon forms of inffHinfti heniia
that cKvor in yoinig ehildren nve (1) the a>ngenital, (2) the fnnieular, and
(3) the infantile or eneysteil. An on! i nary aequini.1 form sneh £l< is the rule
' in the adnlt niav Im* met with, but it is not so eommon.
428 PEDIATRICS.
I
(1) ('<)N(iEXiTAL FouM. — The Congenital form is that variety iu vLicis
the knot of inti'stine hiis made its way along a still patent funicular pn-i-i^.
It* it rt»aelu»s into the scnitnni it will l)c found oompletely to envelupthe
t4»sticle.
(2) FrxKU'LAU FoHM. — In the funicular form, the tunica vaginal.'
having lK'eoni<» shut ott* fn)ni the funicular process just above the toTkk
the hernia comes down the pat^'ut i)nxvss, but does not envelop the tertlA
as in the prci-eiling variety.
(:>) Infantile Fohm. — Compared with the two forms jui*t menti»»D^.
the infantile nr encystc*! form of hernia is quite rare, nor can it be diagwisti-
cated witli certainty without an oi)eration. In it the funicular procesL^
c1os(h1 alM>ve but not Ix'low, and the intestine encased in a pouch of jxri-
t<meum fonns its way into tli<» proc*ess and dc^sMX^nds.
Th(? diagnosis In'tween din*ct and indirect hernia has little importaiK-eiD
childhood, as the inguinal auial is so short that the rings are practically k
the sjime level. Most of tlie lierniic that you will meet in children are easily
re<lucil)le, but you should rememlwr that in attempting to get them baci
into tlie abdominal cavity you must use tlie greatest care, as nowhere cac i
littl(> rough manipuhition do more harm. If the hernia cannot be easily
replaced, you must not tliink of leaving it where it is, simply becau* it
gives rise to no alarming symptoms on the part of the child. No intanti=
sate with an irriHlucible luTuia, and the sooner you put such a case in the
hands of* a surgeon the l>etter. Stnmgulatid and incarcerated hernia o«iir
at times as in adults, although they are rare. They demand the ^mr
treatment.
Tiic condition with which you will most readily confbimd hemi:i ij
hydrocele. l>oth give rise to an elastic tumor in the inguinal region aud ia
the M'i'otnm, and in fact they n^semble em^h other in many ways. Ix-tnie
point ont to yon some of their diiVerc^nces.
Ilydroeele is translucent by transmitted light; hernia is opaque. Hv-
<lroeeIe i> always dull on j>ercnssion ; hernia is usually resonant. It' vifl
can reduce I hem, iiydrocele will go back slowly and noiselessly, heniia a:
tlie la>t (|uicKly and witii a gurgling sound. Hydrocele gives no imimk
on cnnghinLi ; Inriiia usually (hn's. 1 vastly, in feeling for the inguinal riy
in lierniM you find it filled with t\w iuH*k of the tumor; in hydrocele it i?
either eui|>iy or tilled by a narrow stalk.
TiMiA rMKM. — Altliouiih the treatment of inguinal hernia, M'hether l«v
actual op.nition or by the application of the usual trusses, should bt' in
surgical hands, yet one method of tn»ating tlu^e hernia? is so simple a»l
safe that every medical man should know alK)ut it; in fact, in our chil-
dren's clinics here in lioston it is nmch used for all children under a
year an<l a half. This nieth(Kl is th<' application of a worsted trusv like
thi> one.
Tin- inlaiil {('n-i' 1 7 Ti wli-.m I am iil)ont to tit witli this tniss is eig:bt months old. Too
SIT iln' l.iilu'irii: of tli«' hi-nu'A h.-i n tli.' \vt\ sid*-. Below it, feeling like another little ac
DISEASES OF THE NEW-BORS.
429
r
it the taeUcle. We are, therefore^ deulitig with the funicular form. The mother tells
m© that Bhe noticed the hernia when tb« infant was twa we«jka old, and that it has grown
ateadily larger.
On laying the infant on his li»«?k on the table, you see that after a minute of gentle
tnJiis the hernia can be reduced, but it comes out again with a jerk when the obUd begimi
tu cry
I shall now ask Dr, Dane, who has had much (^xp^rience with these ca^ea on the surgical
aide of the hospital^ and who has givi?n me much valuuble iidvice on the turgkftl bearing
of alt these eases which I buve been des^^ribing to you, to reduce the hernia again and keep
it in piac<^.
Dr. Dane J as you see, having reduced the hernia, and having the nurae prevent it
from coming down by placing her finger over tliti inguinal ring, paases a skein of Ger*
man town yam under the infant's back »nd brings the left-hand end of it around its left
side, with the strands separate sa as to form a loop, till it rests over the nurse's inger.
Through the loop he puts the right unf^epunited end of the skein , and carries it down the
left groin, and up on to the back, where he flnishe* by tying it to the middle of the skein
fts it crosses the hollow of the back jUBt above tlie buttocks. As you eee, he has, by thus
threading the right clo«ed end of the skein through the separated strand,i at the left end^
made a kind of soft isHp-knot wliicb lie* directly over the inguinal ring, and, when the whole
U put on tightly^ make* an excellent truss.
Having told the mother to buy some skeins like this on^i and having shown her hnw
to adjust it herself, she can keep a clean trass, by washing them, on the child for a period
of months^ and if she is faithful in carrying out her part of the treatment the bernise,
which do not depend upon an actual malformatiun of the ring, will pnibably be cured.
If these hemiie are not cured within a year, the surgical treatment of the present time is by
operation*
The nejct ca^ (Case 175» facing page 430) whieh I have to show you came
under Dr. Lovett*9 care at the Infante* Hospital, and had to be operated iiixjd :
This boy, who is now four years old, first came to the hospital two years ago. He
[ then had a double inguinal hernia, both rings admitting the end of the index finger. He
fitted with worsted and pad trusses, but failed to return after the firet few weeks. Ai
! you now see, the left ring has grown ao much jjmaller that the hernia no longer descends.
' The right inguinal ring eariily admits the middle finger, and when the hernia comes down
it is quite large. Below it you can feel the testicle. As the treatment with a truss bai
failed entirely* an operation will be ad\Hsed«
In connection with tliis mm I wish to >4peak of a complieatioii that may
sexist with any hernia in niah^ infants. If you will tWl Ix'low tlie heniia of
\ this child (Caf?e 176), you will find no trace of the testicle, nor do you have
\ any Ix^tter snec^ess after you have i-edueed the hernia. In this instance the
^ testicle is not adherent to the l>*>wel, and ha.^ not l>een pushed back with it,
I as IS S4imetinies the ease, hut seems never to have left the aljdominal cavity,
I shall ntnrn to this subject again when speaking of the disea^ses of the
ti^sticle,
I must call your attention to a remarkable ease that came into the hands
of Dr. Monks, my oolleagne at the Boston City Hospital :
The child (Case 177) waa two years old. Two months before he wa« seen by Dr.
Monki!^ the t:bild'« mother noticed a bard buneb ia tbe right inguinal region. Thiit became
larger »nd more pninful till, at this time, it extended the whole length of the inguinal
^ canal and into the H<irotum. The most prt>minent part wha midway between tlie external
[ring and the testicle. It was very tender, about 2.5 cm» (1 inch) long, and quite hmxd.
430 PEDIATRICS.
Thore was no impulso on cmi^hin^. On aspiration there were found a few di«p5 of pe
but on trying t<» flnil the cavity again with a director, nothing but inflammatory tifvuew
nn't. UndiT iniultiiH*!* tho tcndiTni'SK dii^appeared and the tumor was reduced fonwwb:
in size.
On opcratinn, two wifki* later, the cause was found to be a hernia of theTennifin
appendix, fdiiowiil l>y an a('Ut(> attack of appendicitis. The caput cad and the Iwecf
the a PIMM id ix werv found inside the abdomen, and in a normal oonditiaii. Am mai*'
toniy was [.HTfornied, and the child made a perfect recovety.
Fkmoual IIkrnia. — In femoral hernia the gut eecapes from th<? pen
uii(ier P(>u|)artV ligament, and, making its way through the femoral tsm
shows its(4f tis a tumor directly under the saphenous opeDing. It cid ki
diugnosticati'd at once fn)m inguinal hernia by putting the finger on the spot
of tlie pulx^ and noti(ung whetlier the origin of the tumor is to theoilff
or the inner side of that |)oint. If outside, you are sure the hcmii ca»
thnHigh the femoral canal, no matter how far it may have extended ixpmU
the abdomen. Femoral hernia is, however, extremely rare in yoiuig childim
even in girls. In infamy the spine of the pubes, Poupart^s ligMwit, mi
the anterior su]MTior spine of tlie ilium are all much nearer together danb
the adult. As a c(jn8(X|uenoe, the femoral opening is so small and so vril
proti^^ted that it is usually impossible for the hernia to force its way thrragh.
Dr. C'Ushing, my (^ollcague at the Children's Hospital, has reported a cue
(Case ITS) of irnxlucible femoral hernia in which the sac contained a mus
of omentum so matted together as to give a feeling that without special cue
might have \}Qen mistaken for that of lipoma. Such a condition miut
certainly Ixi very rdw. Dr. dishing has described in his account of his
operation upon this (uise a new incision that must prove very usefiil.
HYDROCELE. — I have already spoken of the general appearanoe of
hydnnx^Ie in giving you rules for differentiating it from IngiiifmT henk,
with whi(?h it is often associated.
S(?veral anatomicjil varieties are met with in hydrocele, a^^ in ben
Tlius, if the coIKntion of fluid occupies a freely open funicular pniooKi w
have th<' comfvniUd variety^ and the fluid can easily be itptumed to the 4^
doniinal cavity l)v placing the child on its back and elevating the icrotom.
This is true also offuniruhr hydrovelej where the fluid occupies an opJi
funicular process, hut is l^uuuled below at the point where Uie tutikai^*
nalis has Ix'coinc walled oif^ leaving the testicle in a separate comiittrtiHBt
underneath. Where the funicular process has become walled off fiwm '^
al)donien, hut is still in communication Avith the tunica vaginalii^, Vu
may Ih' a (M)llectioii of fluid, ^vhieh is then known as an im/aniiie Ayrfron^:
in this form the fluid is irreducible. True hydrocele of iJiiitnniflifc i|FMfr»l*
may l>e met with in children as Avell a.s in adults, but it is raze.
Encysted IIvdrocele of the Cord. — ^There is anodier fenn of
hydrfM*ele whi<;h often escajM^s recognition, but perhaps stiU oftener is diag^
nosticat(xl as hernia and tix*ati>d with a truss. This is the encysted hydrocde
of the <H>rd.
If in the course of the s|)crmatic cord a hard, rounded swelling appev,
DISEASES OF THE NEW-BORN.
431
fand you find the testick in its proper position in the scrotum and the
inguinal ring clear, you are very surely dealing with a hydrocele of this
kind* Having made y<>ur diag:nt)*5Ls, you can proceed lx>ldly to its evacua-
tion with a fine aspirating needle. You will probably draw off about 4 cx\
(1 drac^hm) of clear stniw-c^jlored fluid, and the tumor will disapj>ear,
A case (Caee 179) of tbis kind wa*J brought to the hospital last winter and entered in
the ijerviee of Dr. Lovett. A little below thu iiii^uintil ring on tho right side was a Rmall
tumon The mother said that she bod noticed the e welling for abcmt a week, and the day
before had carried the in font for advice to a local phyeieiaii. He had alteinpted to reduce
[ vhat he supposed was a hernia by gentle taxis. Failing in this^ he gave the infant ethers
but again waa unsuccessful. The next mornings in company with an aa^ociate^ he etherized
tlie infant and tried uniH.ucca-*6 fully ff>r an hour to etl'ect reduetion.
The infant wiu* then brought to the hospital for operation. ThehydriKMsie was aipirated,
and with the removal of a little over 2 c,c. (3(1 miuimis) of clear fluid all trace of the
iuppoeed hernia disappeared.
The infant was brought back a week later, as the hydrocele had again accumulated. A
[ second aspiration eilected a cure.
I mention this case in oi*der to impresn u|>on yon how careful the
i physician whu Is practimng amojig children should be not to meddle with
I cases which shonld at once be placed under the care of a surgeon.
Encysted Hydrocele of the Canal of Nupk,^ — Analogous to
hydmcx^e of the cord iu boys is an a*"curanlation of fluid iu the canal of
Nock in girls. The appeamnoe of the swelling is the same in both cases^
1 and the treatment should Ix^ the same.
Treatment, — The treatment of all forms of irreducible hydrocele is
I first by aseptic evacuation of the fluid with a fine canula and trocar, or by
[an aspirating needle. If this, affer repeated trials, fails to effect a cure,
' extirpation of the sac is the only sure method, althoogh the injection of a
I weak solution of iodine is highly recommended by many authors. It is,
[however, dangerous in children^ as the occasional comiection of the hydrocele
[.sac with the aMomeu is not to be forgotten.
Reducible forms of hydrocele are generally to be treated by a truss, in
I the same manner as hernioe, to try to effect a closure of the neck of the
<*anaK If this is success fnl they can then be treated in the ordinary
w^ay. The outlook, however, is p(X>r, and such treatment is generally un-
gatLsfactorv.
As an instance of hernia and hydrocele^ I have here this case (CaM 180, facing page
^) of a boy seven yean>i old, in whom the groes appearancef* are the 9Mme a« in the caie
f'(Case 179) just shown you.
You see on reducing the hernia that the scrotum remains distended with fluid, which
Icannot be reduced into the abdominal cavity by any gentle manipulation. We are there-
I fore dealing with a tnic hydrocele of the tunica vaginiUir^. The knuckle of intestine does
not descend to the bottom of the fcmtum, because the scrotum is filled with the hydrocele.
The hydrtK.vle is ImushiLent and fluctuating.
The treatment will be to try to reduce the hernia and to cure the hydroc<?lo by tupping.
If ihe«e methi>ds fait, we shall have recourse to a raditiil operation and treat both condi-
tions at the same time.
432 PEDIATRICS.
I would luTc mention that c•aK*^* of hernia, whether umbilical or i-
guinal, an» esiKH'ially diflieult to manage if tlie infant lias some such dtstsje
as jK'rtussis. Theiv st»enis to Ix? some evidence that hernia is henJitsry.
F6lizet reiM)rts eighty-five east^ of hernia ocrcurriiifr in his pnK-tice. x^m.
omitting all (u<<s in which the father pursued some lalx^rious trade, ?ucht
that of a blacksmith, he found that in 24.7 fier cent, the {larent^ hadb:
similar herniie. ^hllgaigne rei)ort*i a i)eroentage of 29 due to heredity in i
serit^s of tbrin* hundnnl and sixt^'en ea.ses of hernia.
Infants arc at times brought to our hospitals with a hLsti>r}' of oiL:
who, (jn examination, are found to have more or less incart»eration of th«
herniie. This shouhl impn»as uixm you tlie importance of making a *]rw
tematic physical examination in every case for abdominal hernia, and d
not taking it for granted that the symptoms are caused by indigestiuo.
TESTICLE. — The tt»sticle should descend into the scrotum at about the
eighth month of intra-uterine life. In certain cases it does not descfd.
and if th(» dcs^^cnt d(K*s not take place within the first few years of lifeie
function is lost fn>m its Inxroming atrophied. It is, therefore, iroportaDtin
tlios<* casis where the testicle dt^xMids and returns to the abdominal cavitr
to retain it in the scrotum by mc^ns of apparatus. Operation for this c«-
dition is not ofh^i sua^ssful. At times an undescended testicle is foiindii
combination with an inguinal hernia. A case of this kind came under mv
care alxjut two years ago.
A litth* boy (Case 181), four yoars old, was found to have an ing^uinal hernui. H*
t«'sti<'l»' \va«« also I'ouikI at tiiiK.'s t«) bo absent on the side of the hernia. Somfttime* t!:*
b^Tiiin WDiiltl ib'scrrid ami thr testicle remain in the abdominal cavity, and a^in llie ksd-
<•]<* Wftiild cniiio down witb tb<* hornia. It was exceedingly difficult to maintain the left. >.
ill tin' sen •turn, wvn wbi-n it was found to be there, as it would slip hack with the pw>^
fa<-ility.
I j)lju'r.<l tho <'asp under Dr. Lovett's care, and he finally succeeded in seeinetheb?
at a tiiiH" wlun l)oth tho tfstich' and the hernia were down, and in reducing the btrji
wliil«' lip' testicle WHS k«'pt in the scrotum. A careftilly adapted truss now prevents ih?
testiel"' frniii returning to the alKi<»minal ciivity and the hernia from entering thescrotuiL.
TiMOKs or TiiK Trstis. — We may at birth find an enlargement uf
the testis (hie to sarcoma or (»areinoma. The former is much the n>w
common. As an illustration of tins type of disease I will show you thi»
iiifiml (( a<c 18l0, who was oixTat-(»d ii])0!i by Dr. Lovett three months agix
After :i rinriii.'il Ial>or, it was notiood that the infant had a swellinir as Ure« ^^
an ei^L; nri tin- rii^ht -ide nf the scrotum. This was at first considered to be a hTdroffjf-
hut, a- if sti-adily iiuTen-ed in size, njorf* active measures were employed. On handifii*-
tlie skin <»viT the tumor. wlii<-li was at first normal, hecame so much inflamed th»t ifli
water had U) lie used as a wash. Tho treatment had no effect on the size of the sciMtna-'
on the di<ie«»infnrt wliieh it seemed to cause the little patient. The infant was nowtw
werks <tld.
As tlie tumi>r liad a sriMi-lluctuatiiitr feelini^, aspiration was tried, and 2 c.c. (Idncbi-
of !)lo(.d-«tjiined serum were olitained. A second tripping gave only a little clear blow!.
The infiirit was th«'ii hn-u^lit to Dr. Lovett for consultation. The tumor was founiw
be quit*' lar<,'«', lieiiie; 20 cm. (H in<-hes') in circumference, and it had nearly hidden tbepf*
DISEASES OF THE NEW-BORN.
433
rin iu maia. After a preliminary tupping^ which gave the same result a£ the preriom one, au
I of>emt)i>n was pf^ff^^iied. A let-ticle 5 cm. [*2 inehe*) in ditim^^tor was i^moved^ The cord,
I which wus found enlarged tu a diutnelnr uf L2 cm. (J inch), was removed aij far up as the
I external riugf but laparotomy, in order to ifxUrimte the cord ad fully 8« possible, was not
1 performed. The infant made an excellent recovery, aiid no return of the growth can be
[detected in either the aerotiim or the pelvis.
Un sectitm, the tumor was found to contain scattered throughout it* mass about a
[doxen cysts of diflerent size^. Microecopic exaniinatirm showed it to be a mixed-cell sar-
coma with fibrous and mj^xomatous tisisue in ditii'n^nt parts of it. Here and there were
scattered small areaii of cartilage and a few striped IllU^cuUr fibre** As you know, muscle
fibres are found in the tumors of only two oi^ns, the kidney and the testicle, and even in
these they are verj' rare.
I
MALFORMATIONS ABOUT THE RECTUM.— In speaking of
hareli|> I told y<ni in a irenrral way lunv at an t*arly >^tao;tMiif develriptiient of
the embryo the intestinal canal endwJ blindly and atierwaitls b}' an in-
vl^i:ination of tlie outj^ide wall a comimmication was brought alxjut and the
8t4>ni<xl;i'nni formed. An analogous jvroeess of developineut goes on at the
other end of the intestinal tulK\ and i-esults in the formation of the rectum
and anus. The hind-gut at first ends blindly, then m it d«?seends it is met
by an ascending dimple, and usually these two fuse and the protodwum is
form<Ml.
As in the mouth a series of malformations may arise from a failure in
the cfimjiletion of this process, so in the anal region we may meet with a
similar si'ries. The rectum niay have come into its normal relations and
the anal depressitm have faih^l to IV^rm, or it may Itave gone the \^•hole of
the distance between the end of the intestine and the skin and yet the
final step, the fusion of the meml)ntues, have failal to take place. To both
of these, and to any intermediate condition, the name of imperforate rectum
is given. On the other hand, with the rectum and the anus fused we may,
nevertheless, find a thin parchment-like membrane spread over the external
orifice just where the skin and the muocms membrane j^^in. This is called
imperfornte anus.
^\nien an infant is born tlie physician shonhl carefully examine it, in
onler tcj determine whether it has any malformation. The most imjiortant
malformations whicli it is necessary to nx-^jgnize are thost^ at the anus.
l"nlt»ss an infant has a passage of mtH}oniiiin soon after its birth, an exam-
ination slifjuld \w made in the rectum with tlie finger, and if the anal opening
is found to be closed, eithcT just at tlu* outlet or higher up, we must (xmsider
what is to be done to relieve this condition. If nothing but a web otetnicts
the antis, we can easily break it thmngh with a dire<"t<>r ami tlien dilate the
orifice with the finger. If there is more tlian the thinnest liiilging mem-
"brane, a cutting operation will have to be done, and [xTliaps a sin-ere one.
The general [>rinciples are to l>egin with a stafif in the bladder, and, using
this as a guide, to make a i^areful and systematic disse*^ti»:»n in search of the
missing gut. If we fail in this, we should jM-rfiirm the ojK^ration kno\^ u
as Littr^'s, whieJi consists in opening the sigmoid flexure in the inguinal
28
BISEASE8 OP THE NEW-BORN,
435
I connective tissue. The smaller mass in front (to the left in the picture) is
the bladder.
OCCLUSION OF THE VAGINA. — Sometimes we find a thin gray
velum extending across the month of the vagina from jiLst below the
urethral ojwning to tlie posterior eommissnre and blocking op the vagina.
It may be complete or partial. This condition should Ik^ dealt with w^hile
the miant is j^till young, as if lefl until pulx^rty it will caus<:' a iTtcntion of
^^ the menses, and, morBjver, by tliat time will have Kx^oje much thicker and
^P |>erhap« quite vast^ular. It is easily broken through in the young child,
antl if a piec^ of carbolized cotton be put Ix'twecn the torn edges to prevent
their adhering, the malformation can be cui'cd jjermanently. Atresia fi'om
inflammation of the labia is siiid to <K"Cur in rare instances.
k HYPOSPADIAS. — The malformation known as hyjmspadias is tlie
suit of an arrest of development in the formation of the urethm and of
e corpus sjMJUgiosum, The urc^thral gror*ve should normally be converte<l
Into a canal by the growth and joining together of its sides. This process
l»egins at the ba^^e and extemls to tlie end of tlie penis. By an interruption
<>f this process the urethra may l>e brought to an end and o{R*n at any ^xiint
tetween the j>eno-scrotal angle and the base of the glans. In the most
<:oiBnion forms of hy{>ospadias the glans alone is im|>erforate.
Treatment. — The treatment is wholly by plastic oix^ration, and it
requires the mast delicate surgery to obtain a good result in the face of the
many serious obstacles that this malformation pre^sents.
EPISPADIAS. — ^The malformation of epittimdia^, in which the urethral
canal opens upon the dorsum of the penis, is still more difficult to deal with
than is liypospadias. It is commonly associated with extroversion of the
bladder, and is vcr\* rare.
A partial plastic operation and the wearing of some form of urinal con-
stitute alwjut all that can be done for these *
I>I8EAS£S OF THK NEW-BORN.
437
Bition. 1 bave seen light cases cured by tiiis simple means, and even
aoderately severe ones si> much l>enefited that subsei|uent treatment witii
[jrthoptedie ap[ianitus V>e<?arae much easier.
CONGENITAL DISLOCATION OF THB HIP.— Congenital dishi-
I cations of idl the joints are sometimes found, the must frequent and most
I imjK>i*tant l>ehii^ dislo^-ation of tlie hip. Thi.H is now tliought to be caused
I by a faulty development of the acetabuhim and the head of the femur. The
symptoniis are of a kind tijat readily e.seape nutitx? during infancy, and are
first seen when the child should begin to walk. It is then noticed, if he
. can hold liirn^4f on his feet at all, tliat the ablomen is very prominent,
[the back airheil, and tlie buttocks seemingly enlarged : at least this is the
if the deformity is bilateral, which is the form usually met with. On
Fexamining the joint we find that the trochanter is alKJve Nt^Iaton's line, but
1 it t^an by traction on the leg Jje drawn down to its pmj^er place without
I causing any discomfort to the child. If the deibrmity is unilateral, one leg
I will appear shorter than the other, and the child wdll walk witJi a rolling
[limp. This condition shonld l>e cai-efully looked for when an infant at the
[age of fourteen or fiftt*t*n mouths has made no t^ijiecial attempt to walk, or
when on attempting to do so it docs not siiccee<l.
As operative trt*atmcnt has not proved very successful in these cases and
[ is not to Im? employetl until the child is over three years old, the best metht>d
of treatment is by massage. If tlie disease is unilateral it should in addi-
tion to the massage be treated with a high shoe.
CONGENITAL DISLOCATION OF THE KNEE,— Next in order
of frequency to congenital dislocation of the hip, but i-are in comparison, is
Cong«iiiUxl i^rtial dl^Iocatltjci of Uie kiic«. Female, 3 months uM
La dislocation, or rather a jmrtial dislocation, of the knee. In this condition
[the tibia is found riding forward upon the femoral condyles, so tliat the
4;58 PEDIATRICS.
kiK'c-jnint <an nmlily Ix^ put into hyperextensioii and the tiKr^ m»>
|M>int tnwiinls the foivhcad. Here is a case (Case 184, page 437iwiu:
illii.MraU'S this onulitioii.
Tli«' infant is !lv.' iimntli-i did, and was doliverod with instruments aft«r a Ir.:!!"
Il \Mi- a Ihad j)n-.«-»Mitati«»n. A-* \nu >*.-«', lli('i\* i? u n.>iiiurkable nin;L^iM>l'iiinti""Ti \ii\iz'v.
N.it only tan I put it int«> liy|M-n'\tt'n>i«»n, Imt 1 can move it coiifeidi-TiiMy fn-rn 'i-J^'/*"
Tlii- alin.Tinal njnl'ility i- du«* tt» a very lax cunditit>ii of till the tifisue.^ about ib^ .■ii"!'.;-;
r^jMcially .-f tin- lai«Tal liifann-nts. It ha> luiMi treated, its inuther tell> rue. liv- a |i>-^
l'anil:ii;i' tnr alMiut a inniitli. and no inipn»vcniL*nl lia?» taken place. "\Ve sLvuld rjil^i
all -nrj»ri-«il at tlii^ n->nlt, wlu-n vv«* oonsidiT that keeping the knee imniovuMv ^:IUl'.>Vl-
t" inir»-a-«' tin- ulnatly ('xi'^tini; atr«»j)liy.
A tar luttrr lorni of inatinmt is the application of a light 8te<[d aupp'>rt wbLiT.
cb'-rk all latt-nil nioiinn and l»y nu*ans t»f a **.'^t<»p j«)int'' at the kn<w will alii-w flrxi-L ■■:
will pnvinl hyp«.n\l«"nsi«»n. Thi> appanitus, together with systematic niassagc.wiilp:-
ably ••tViM't a imip-.
BIRTH PARALYSIS.— Birtli paralysis will be considered in col^-
tion with diseases of the nervous system. It may be present either in it
nius<'Us of the iaee or in those of the extremities, and is due to pn^^i'^
upon \\iv nerves niacK* hy th(» iorcej)s or by too great traction.
CONGENITAL OBLITERATION OP THE BILB-DUCTS.-Cbf
of tlie rarer i'ornis of eonjrenital malformations in new-born iuthai* t
repre>eMte<l by the oh/ifcntfinn (tf (lie bile-fluct^i. The most extended v-H
\vlii<'li lias apjK'anHl in the literature of this subjoot is that of Dr. .l-k
Th(»nipson, of K(Hnl)nrt::h, whose valuable tlR»t?is I have u.sed in mydi-HTi}-
ti<»n of tlie <li><'a>e.
Symptoms. — Tlie infants who ai*e l»rn with this dirsease are eii!«T
i(t<ri(' at first or iK'eonic so within the fii*st few wet^ks of lite. They 'jlt--
apjM'Mr (»therwi>e healthy an<l well nourished. In some cases there > i
(lix'harire of normal nieeoniuni iollowe<l bj'* eolorless dejections. lu "tjtr
<'ase- th«* iieeal movements are elay-colored from the very first and refiii
>o. Tin' urine i> <leeply >tain<'(l with bile. The jaundice is of a dark-
«:T(M'ni-li tiup', lastin<r until death. Si^ntaneous hemorrhage fnun *>
uml)ili«'al cord (•(•mmonly oeenrs within the first t^vo weeks, and in eifcr
localities in thox- infants who survive tliLs early period. The liver a^C
splrrii ai-e iuenji-ed in >ize. If the infants survive for some month* ih^y
bceoiiH- more oi' less emaeiate<l. Convulsions and vomiting are apt tocxvr.
and death usunlly takes |)lae<' from exhaustion or from some trifling inter-
enrrent »li.-iase.
1*A rnni,(>(;v. — Tlnrr are a numl)or of different morbid process^es whitl
have been sn|)j»oH'd t<» pnxliiee this pathological lesion of the duets. £*■!:
of these proeessis ha^ in certain eases, in all pn>l>ability, had much to Ji'
with eausinii' the disea-^*', but it is usually the (combination of one ormort
of them which must Iw con-idenil in determining its etiologv. Tbu.sthi'
results of intra-ntcrine |K'ritoiiitis, by eom|)rc»ssiug the ducts, or bv helu
a source of inflammation whi<'h has spread to the walla of the ducts, may
linally cause their obliteration. A primary inflammation or lesiou of the
DISEASES OF THE NEW-BOBN.
439
\
idmia themselvps may prtxluoe this result, or it may arise from an actual
BfeBt or defect of de%^ol(ipment. In tliii^ cjonnection congenital syphilis should
w reierrtM:! to an in some wlsoi prockieing li^itnis of the duct^, but this and
cither eaiL'^L*?? do not nc^cLS.-^urily pla}- an imjMjrtant }mrt in the disease.
The tymiplete discusision of the etuises of congenital malformation of the
bile-duet^ wunkl liaRlly have a plaw* in :i _;< neral work on clinical medicine,
but it is sufficient to say that in the gnat yiajority of cases tlic evidence is
in favor of defective development as being the chief cause. ThLs malf<>r-
mation prohalily affects to a considerable extent the walls of the duct§» and^
as Thorn |>sr>n has stated, it consists in tlie narrowing of their lumen. The
interfeivnce which is thus canst^l to the outflow of bile givt^ rise to a
catarrlml condition which finally blocks and obliterates the ducts» owing to
the iuflaniniatory pnx'css spn^acling to the \^'alls of the ducts and the gall-
bladder. This progressive intlanmiation gcies on slowly spi-cading, the local
<»ndition gradually bectmiing worse during many mouths if the patients live.
The obliterated ducts or gall-bladder, or {xirtions oi' them, may entirely
disapjx^ar, not even leaving a ilistinct band of tibmus tissue to indicate their
original position. The obliteration genendly Ix^^omes complete at a varial>le
but early jx*ri(Ml of intra-uterine life: CKtusionally it does not occur until
aller birth. The rKfurrenei' of |>eritonitis is probably in most eases second-
ary to the bhx'ki ng of the duets.
When the lumen of the duet ha^ become so narro^ved that the bile does
not jMiss freely into the intestin€% a cirrhotic condition Jx^gins in the tissues
of the livcT, and as it grx^s on interferes with the functions of that organ.
At the post-mortem examinations of these cases the liver usually is
found to Ix' much cuhirgcfl and its tissues to Ix increased in consistency: it
is of a dark-brown ctdor^ owing to the presence of nunierfjus masses of
inspissated bile in the smaller bile-ducts. In a large numlxr of cases
there is found a ci>mpletc ol)literation of some part or [wirts of the hejMitic,
oommon, or cystic ducts, or <if the gall-bladder, while, with very lew ex-
oeptionSj implication of tlie bliKxl-vcBsels is conspicuously absc^nt
In speaking of the exphmation which may te given ff»r the fxcurronce
of the symptoms wliich I have just nicntionc<l, Thompson rt»marks that the
reappcarant^e of the disease in sin^eral memlxrs of tlic same famil}- can Ix?
explaintil only by tlie theorj' that a amgenital defect of development is in
these* cases the cause* of the mattormation. Tlic fact that tlie on,«i:'t f»f the
jaundice is not ci>ntemi>orantx*us with the blocking id' tlie bile-ilucts, and
usually begins several days ai'ter birtli, he explains as the effet^ on the
hepatic cc41s prodinxnl by the great (^lianges in the licpatic circnlation which
occur in uew-lxjrn infants. The prest^nce of e«jhired mtx'oniiim in some
caees and of only white dist-harges in othei*s is due to the bhx^ki ug of the
ducts havmg occnrnxl at ditfcrcnt jxrimls of intm-uterine life.
When in (X)mbination with the cf»IorIeAs fa%*al dis^'harges green material
18 passed during the progress of the ilLst^ase, this (X'curiTntv is prol*ably due
to the chemical action on tlie ajntents of tJie intestinCj produced in various
I
410 PEDIATRICS.
ways, OIK' ol' whi<'h may arise if nionniry has been administered. Tl-
tnulcncy to s|MnitaiU'<)us h(iu«>rrhaj^'s may be due to the (Kvurremv ti i
(•omlitinn <»t' «-lin»ni<- l)lo<Kl-|M»is<»iiiiijr, sincv the arre:?t of the i»iitriu\v oi* l..r
(hmiajxi's the liver to such an extent that its fiiiictioiis are interlerel uL
and ortrani<* Ihiids of* a poisonous nature may thus |)ass iuto the einiikri a
The cnhirp-mrnt ol' the si)kvn, the eonvulsious, and the voniitinij: an- pni-
ahlv mon* »»r less <-onne<*t<Hl with this stune e<»nditioii of bkKHl-|>»b"Diit".
Th(» iixrt that the ehil(ln*n live as lon^ jis they do, and Uf?ually di» &:
iHH'onie cnuu'iattHl in the early (hiys of life, is tt> bi> explained i»ii thegP>w:J
that the jMescni-e of hile in the intestine is not al>s4)lutely necesisin' 1.:
ilipstion. When the nutriti(m and gt»neral health begin ti» sutTer. ir L-
prohahly due to tlu* intcrfen'uee whieh the secondary changes in the ti-Mit?
of the liviT an' eausinj^ with the rnort* imi)ortant functions of that orgaa.
'riiKATMKNT. — The tn*atnient must necessarily be symptomatic, there
U'injr no known means hy whieh we can counteract the results of this mi-
formation.
('<>N(;i:mtal Oulitkkation ok the Intestine. — I shall merely rk:
to a maliorniation wliidi is represc^ntwl by an obliteration of the intt>iiar.
Malformations of this kind nniy arise from constrictions of the f>artei a:"-
fectc'd hy fibrous hands, prohahly the remains of peritoneal adhesions.
(\)N(;i:mtai. Malformations of the (Esophagus and SrtiMACH.-
Con^enital nial format ions of the a^sophagus and stomach are rare, and cil
iK'st Ik' d<s('rilM'<l in conne^'tion with dist»ases of these jiarts.
MALFORMATIONS OF THE HEART AND THE BLOOD-
VESSELS.— I shall dcfi-r what I have to say «m<.x*ming the va^iou^ anonr
alics «»f tlie lu'ju't and ])lood-vessels until later (Division XVIL, p. 102C'.
ASPHYXIA. — T\w earliest pathological condition which is bn.uigh!ty
our notice at l)irtli, an<l one whieh re(juirt»s imnu*diate treatment, Ls ajiphyxii
'riii< conditinii, wiiicii is a failurt* of the eireulatorj' iiiechani.<ni to awsunje
its r.\tra-nt<'riu(' function of oxygenating the hk^)d, endangers the liteofrhi'
iniinit fmm <ari)onie aci<l poisoning. It may ari.*^ either from mtvhani J
pressure, ;i> In mi winding of the conl anmnd the neck, from an incomjA-K
c\pan^ii»n iA' tlic |)nininnarv alveoli, atcUvfnmSj or from other eaa^^ ci-r.-
n<"ct<'d witli tlic iinjM'rfcct oxygenation of the hlood, of whieh we liave
very little knnwlc<lge. In any <'ase the <*mise, if known, miist lie nuiekK
reMi(>vcd. Tin- class of <-as<'s U'longs so direiHly to the province of ol»^ei-
ric- that it need hardly Iw more than menti(mtxl in a course of lei'tim^-n
pe<liatii«s. Trnnipt nna-nres for |H»rforming artificial respiration, a? l-y
('niKV-i nieilnMl, and the >tinndation of the pneumogastric ner\'e bv tiv
a|>|)licaiinn of heat, cold, and electricity, should Ix* boriie in mind: thev are
well de-criUd in I)r. Kdward Keynolds's work on practical midwiferw
ACUTE FATTY DEGENEJeIATION OP THE NES^W-BORN (BuhlV
Din'asc). — An aire<*ti«)n which has JK'en (-allwl aeute fatty defeneration «»t'
the new-lH)rn was descrilwd hy Buhl in ISfJl. It is not a disease of common
ocenrnMU'c, and its etiology an<l pathology have not yet been satis&ctoiilj
DISEASES OF THE IflEW-BOBN.
441
determined. Ruoge, of Dorpat, has written more fiilly on this disease than
any odier author, and I am indebted to him for the careftil desoription
wliieh he has made of the aftection and the literature which he has collected
oouceruing it.
As the anatomieal diagnosis can be made only by using the microscojie^
the disease lias probably of\en been overlooked, and the cause of dtetith
ascribed im the one hand to inanition and on tlie other to siieh esjKX'ial forms
o( hemorrhage in the new-born as omphalorrhagia and meheoa. If the
numerous causes of hemorrhage from the cord had been more carefully
jexaminfd anatomically, the dLse-ase wotdd probably not have remained so
long unknown.
Sy'mptoms. — ^The infants who are affected by this disease are usually
born in a condition of extreme asphyxia without any appaiTut cause for it*
Attempts at resuscitation are, as a rule, only partially successful, aud at tiroes
jiot at all so, many of the cases dying at once. Diarrhoea is c?ommouly
present, and is often a*"e4jmpanie<l by bl^nxl from the rectum. There is
sometimes vomiting of blood. Oi'ten, after the cord has separated, there
may be a parenchymatous hemorrhage, which, although small in amount, is
at times sufficient to cau^' ileath. There is usually a bluish color of the
skin, which changes gradually to yellow or a mixture of yellow and blue.
Hemorrhages occitr frequently in the skin, the c<^)njunctivaB, the muw>us
membranes of the mouth and nose, aud sometimes the outer ear* Icterus
may be present in these cases, and at times may lx?come intense. Sometimes
cedcma oceui's, and without any noticeable rise of temperature there may lie
a rapid collapse, followed by deatli, commonly within the first fourteen days
of life. These symptoms are not always so well marked as I have just
described them. The external hemorrhages may not occur, and the cyanosis,
slight at first, may rapidly increase and be followed by sudden death. This
sometimes liapi>ens so quick ly that we are reminded of the conditions which
are met with in casc»s of death by violent^e,
DiAGxasis. — A definite diagnosis t*annot be made without a careful
micrr>sc^pic examinatiim. The disetLse must not Ix* c^imfounded with phos-
pbfirus or ai-senic pt>is<uiing, when* the organs undergo similar pathological
ehangt^s. The history of the vot^ and a chemical examination of tlie organs
will enable you to eliminate these other causes of fatty d^eneration. The
differential diagnosis iR^twccu this disease and cases of sepsis in which
hemorrhages and panTichymatous changes occur is verj' difficult. Where
the vessels of the cord are affected, we must in most cases consider the cause
to be septic ; where the ctLscs occur in groups, as Ls seen at times in hospitals
or other places where a number of infants are gathered together, this same
cause must be susj>ccted ; also where putrefactive changes have progressed
rapidly in the <:*adaver we shfHiId lie ineliiii^d to regard the c*ase as one of
septic poisoning, as these changes, according t«j Hecker, do not (X?cur in the
specific disease calleil fatty degeneration.
Fatty degeneration at times simulates so closely the apj>earances caused
r:b«s in wliidi the syraptoni8 are pronounced die. It is pogsibJ
milder ioniLs of the dirtoa^e ean recover, but as yet we do not kn
alniut this (*I&ss of caM?s to state what proportion of them lives.
Etioloov. — The etiology of acute fatty d^eneration of ihe
is very oI)s<!urc. The disease occurs in animals as well as in hun
but the invi^stigntions made by different observers both on anin
iniants an> so varieil in their results that we cannot at present ooi
we know much alxjut the cause of the disease. It is significani
that Buhl in his classics description of the disease states emphal
the vessels of the mrd are not affected, so that if it is due to sepsis
must have (K'(*urreil in intra-uterine life through the mouth, the
canal, or the umbilicus, but without producing any change in the
vess<'ls. This can scarcely be considered probable. We kno
^'oncemin^ the etiology of this disease, not even whether it is o
extra-uttTine origin.
Path<)L(K>y.— The pathological conditions which represent
consist of a ])arenchymatous inflammation, followed hy a fatty de
of the tissues of the heart, liver, and kidneys, and hemorrhaf
various organs. The j)ost-mortem examination of infants dyii
<liseas<% as a rule, shows the following changes. The cadaver is
usually ict<Ti(*. Hemorrhages and eedema are often found in the s
umbilicus and the tissues surrounding it are at times stained with I
a«i a rule, are otherwise normal. The umbilical vessels are in i
normal. T1hs<* h(*niorrhages are es|xx;ially found in the dura and
in the pltMira and jxTiciinlium, and in die connective tissue of -
astiuuni : they also occnir in the thymus gland, in the peritonei
nuiscl(»s, and iu most of the mucous membranes.
Tl)(> ftrfiiii is found to lie sof^. usuallv full of hlrwwl awwl U
DIHEA6ES OF THE NEW-BOEN.
443
■'The «p2fm k asually found to be enlarged, and its jmrenchyma is soft
fand a I most fluid.
Ht»m(JiTha^t»s may be fotind in the walls of the danmch and intestine^
ad their c-avitit'S are often found to be filled with blixid.
Multiple hemorrhages are found in tlie |mrenchyma of the htdney. The
[cortex is swollen in the eaj*ly stages, in filled with blfxid, and is pale and
[yellowish. The epithelium of the oftn vol utwi tubuk^ showt^ marked fatty
[degeneration, and the canals ai'e often fillt^ with fatty degi?nerated niateriab
The process of fatty degeneration d<jes not in all cai^ies affec^t all the
r organs. In &oiue the changes may be ab*ient or a parenchymatous condition
may be present.
Treatment.^ — From what I have said coTicerning this dL^ase you will
readily undei^tand that the treatment is usually unsuoeessfuL Stimulants
fihuuld be used and the food carefully regidutetl.
Literature. — You may perhaps like to know the sources (Table 90)
from wlii<'h liuoge has c obtained his facts in describing the acute fatty
d^eneration of the new^-bjrn.
TABLE 90.
L Heckkr, V,, n. Bxthl, Klinik d. Gelmrt«kumle, 1801, Bd. i. R. 2M.
2. Ukcker, v., MonaUJ*t"hrift f. GeburUkuude, lid. xxix. S. 321 j Bd. xixi. S. 197|
Bd. xxxii. S. 197.
8, Heckkr, V,, Att^h, r Gyniik,, 1870, Bd. x, 8, 537.
4, MCller, P.^ Dk aoute Fet ten tart uns^ dcr Nongebornen, HiJidb. dor Kinderu
krankheiten, von Gerhurdt, 1877| Bd. ii. S. 18(1.
6. CottXHEiMf VoHf«ungen ubcT allgem. Pathcjkina^ie, 2. Aafl.» Bd. L S. 661.
6, Herz, Oesterr. JahrK f. Padmtrik, 8. Jahrg., 1877, S. 139.
7. RtTNOE, Max, Chante-Annalen, 7. Juhrcr., 188*2, S. 720 n. 727.
a FrRSTENHEBtt, Vircbow'« Arch , 1SG4. Bd. xxix. S. 152.
9 RoLOFF, Virt'how's Arch., 1806^ Bd, xxxiii. S, 653.
10. RoLOFF, Virehnw's Arch., 1868, Bd. xliii. 8. 367.
IK fioLLiNOKRi Virchuw'f An:h,, 1878, Bd. Iviii S. 329.
12, BiRCH-HiR«iCHPELi>| Eandb. der Kinderkrankheiten, von Gerhardt, Bd. iv., 2,
S. 707.
la. Friedberoeb, Fraxz, u. Fr5ukkr, Euokn, L^hrbuch d. spec. Pathologie u.
Therapie d. UauBthier^, III. Aiiflajfe, 1892, Bd. ih S. 16 ff.
INFECTIOUS HiEMOGLOBIN.ffiMIA OP THE NEW-BORN
(WinckePs Dis+^ase), — Infectious hieniftjrlobinfemia is an affection which is
mt't v^nth in new-Ficirn infants uhuuIIv in thi* early days of lite, and, an a
rule, aris*?s as an endemic disease in hospitals. The sjjecific microorganism
which produces it Uns not yet Ikx^u distmvertKl, yet the fa<t of iti^ endemic
character and the changes which arc pnxlueed in the bliMx] warrant us in
8UpiK)e^ing that it is an infectious disease. Although it had been described
at an earlier date, yet tlie most systematic description of it which had
appeared np to the year 1879 was that by AMnekel, who in that year
reported twenty-three ca.ses of an endemic affection oliser\'ed by him at the
Dre^en Lying-in Hospital, The disease waa characterized by ejctreme
444 PEDIATRICS.
cyaii(»sis, ii'torus, hsE^moglobiiiuria, somnolence, rapid collapse^ and the i\
M'Uiv of lever.
Although in many resix»cts it resembled closely the acute fattv degeDer.-
tion wliii'h I Imve jnst descTil)od to you, yet it had such cLaraLttrrk
symptom-s and conditions of its own that it cannot, until further light -12
liav(» iKvn thrown on the subject, Ixj separated from tliat disease.
I am indebted to Uunge for a description of this disease. An analv^
of Winekers eases shows that it usually begins on the fourth day of life,
and that it may attack stn)ng, well-deveIoi)ed infants. The course oi' la
affection is very rapid, its average duration being about thirty-twu houR.
Twenty-live and a hall' jkt wnt. of all tlie children bom at tLe rinr
when this epidemic occurrt^tl had the disease, and of these nineteen per can
died.
8vMi>T<)Ms. — The first symptoms were generally restlessness and cyano-
sis, not only of tlio face but also of the body and extremities, and espxially
the back. The color increased progressively until it became a deep Hit
To this wari added an icteric color, which when death did not occur within
twenty-four hours l)ecame very marked. The respiration was rapid ;tfc
j)nlse was not esiK^cially incn»ased in rate. The rectal temperature never p«
hijrlicr than :i8.1° C. (100.6° F.). The skin generally felt cool. Vomitii«
and diarrha?a occurRnl in some cases. The most striking symptom wasiibe
apjK'aran(^» of the urine. It had a pale-brownish color, and was passed ^
(piently, and often with considerable straining. An examination showed
that the color was due not to bile, but to haemoglobin. In the sediment
were found numerous ej>ithelial wlls from the walls of the kidney, graDukr
casts with bI(MKl-corpus<'les adherent to them, micnxxKX?i, masses of detrina
and urate of aniuiouia. A small (piantity of albumin was present. LattT
in the <lisease (.H)nvulsions (►ccurred, followed rapidly by death. It ws?
notice*! that if the skin where the cyanosis was most marked vras scratiW
:ui(l tiieu pressed hard, a tenacious, almost black-brown fluid exuded. An
examination of the 1)1o<k1 sIiowchI a marked increase of leucocvtes and
numerous trranules.
In otlier cases U'sides those of Winekers where the blood was examined
the condition was found t<> l>e one of iKcmo^lobinsemia. The percentage oi
luemoLdol)in was iii^h, and free hwmojjlobin was found in the blood-senun
while tile erytlirocytcs were jrreatly reduced in number, at times amouDtinj
to only 1,7(K),()0U or even less.
i*ATn()i.()f;v. — A <'areful jM)st-mortem examination of Winckefs ca«*
showed that there was cyanosis of the external and internal organs. Exw-p
in one instance, no j)atholo^ical condition of the vessels of the cord ^"a?
descrilK'd.
Tile cortex of tlu^ kidiuji was found to \w wider than normal to be of a
brownisli color, and to present numerous minute hemorrhages. In plactf
the pyramids were <Mitirely black-rnl in color, and in other places nmueroos
bla<k streaks were found which converged to the papillae. This color w»
DISEASES OF THE NEW-BORN,
445
kauj^ by the filling of the straight tubules with gitmules of haemoglobin,
Dntact erythrocytes were never found,
I The bladder was icnuid Uy e<*ntain greenish -brown urine.
I The spkai was striidngly enlarged and hard. Its length was about 7.5
km. (3 inches), and its weight 25 grammes (| ounce). It wa,*^ black-red in
■DoIor, and on section tlie surface was siiiwjth. Mierosi**>pic exaniiuatiou
khowed a considerable accumnlation of bmwnii^h coloring matter, partly
lfn^» aud partly in the pulp-eel 1^.
I In addition to these appearances in sp€»cial organs, minute hemorrhages
'were found in uearly all the orerans, but e8jM?cially in the pleura, perictinlium,
endocardium, muttons membranes of the .stomach and .small intestine, and
idney : they were also found in the dura and jua mater aud under the
Apeule of tlie liver. The lymph-folljcles were swollen, especially Peyer's
atcliCB aud the mesenteric lympli-glands.
A niici*0!*eopie examination showal fatty degeneration of many impor-
\timi ^irgaus, esjxMinally tlie liver, aud at times of the mnst^es of the hexirt»
The bacteriological examinations were, as a rule, negative, esj^ecially as
ll^^gaitls the tissues of the intestine. Clumjis of bacteria were found only
lonee in the liver and once in the kidney.
Etk>L(kjy. — The etitilogy of this dit^ase is olist^ure, Winckel had
Icareful exami nations made of the organs chemically for jxasons, such as
iphos|)horu8, arsenic, and chlorate of potash, but -with negative results.
lExaminatirtus in i-egaixi to carlx^lie acid poisoning have also been made in
|these cus<*s, witli negati%*e results.
The resemblant'C of this disease to acute fatty degeneration of the new-
'}Tii IS very striking. Most of the symptoms arc cf»iuninu to lx>th dis4_»a8es.
er hemorrhages art^ also not uni'ommou in this disc^ase, but are not so
rked as in acute fatty degeneration. The striking jxiints of diflerence
are the presence of hjemogl«)l>iuurin, and that large mun tiers of cases are
^aflectcd at the same time in iniU^tions lut'inuglnliinteniia, while these condi-
^ffions have not Wn foinid t*> owwv in acute fatty deg*.^neratiou. In studying
' the literature of this disease we find a numlier of observations by difierent
™ antlim's. Dr. W. S. Bigelow dcsTilK's an epidemic at the Boston Lying-in
BHuspital in which the cliief symjitonjs were a dark txdor oi' the skin resem-
^M)ling sf>niewhat that producixl by the administration of nitrate of silver,
^flijemoglobiuuria, diphtheritic* deposits on cvrtaiu of tlie mue<His membranes,
Hfmtl dark bitjwn faval dejtH^'tions. I u this epidemic ten infants were attackKl
Hand eight died, the average duration of the disea^ l>eing five days. In one
Htof these ea^es phlel)iti^ unibilicalis occurnxl. Similar cas^/s have U'cn
Hreported by Parrot and Hcrz in which the urine was bn)wn and strr^ngly
Htinged with blix)d and the kidneys and liver showed the condition of fatty
Hdegeneration.
H Epstein, of Prague, mentions similar ca^^es where prominent features
Hvreri* the thickening of tlie hl(M)d. which made it im]>ossible to get a drop to
Hexaminc, and the dark brown-red color of the urine. Epstein thinks that
1
446 PEDIATRICS.
tlii.s dLseiiso is a poptic process which probably starts in the ga«tro-enw
tract. He Ix'licvc^ that he can controvert the apparent absence of I'everU
the ilict that in the (liseas<^s of uew-lx>rn infants great and sudden variaiii>
of teiuiKTature <»crur, and in cou6e<iUence the temperature, for its rc-cordij
lx» of vahie, shnnid U* taken very ollen.
Whether this is so or not, the dis<»asc has certain peculiarities, poiutiiigii:
some ea-^es to an apparent ri'lation with sepsis, and in others to acutpfetn
de^rencration.
The ohseurity as to the etiology of the disease has been rendered ftill
greater by the in<*oniplete examinations which have bc^n made of ihkciSs
of cases, with the extt'ption of those by Winckel and Birch-HirschfelA
TuKATMENT. — The tn^atnient should be the administration of oxysm
and stinndants, and forceil imling by means of a dropper where theini'aa
is t(K) wcjik to suck.
LiTEUATruE. — I have pla(xd in this table (Table 91) the literanit
which Runge hiis made use of in his description of this disease.
TABLE 91.
1. WiNCKKL, lKut<<lie MkI. WrK'honschrift, 1879, Nr. 24, 26, 88, 84, 85.
2. Biurn-HiKsciiFELD, I)fUl>c]H' M<h1. WiK'hensohrift, 1879, Nr. 86.
8. BiR('H-lIiKs('iiFELi>, Haiullnich dor Kinderkrankheitcn, von Gerhardt, 1860, Bi
iv., 2. S. 702.
4. ErsTKiN, Pmi^or M.-d. Wnchenschr., 1879, S. 848.
5. Sani.nkr, Miiucli. Med. \V«>c'beiisehr., 1886, Nr. 24.
6. Stkklitz, Anliiv t*. Kiii(k'rln'ilkiinde, 1800, Bd. xi. 8. 11, and Baoixset, fei.
Klin. Wcrhi'u^clir., ISH!*, Xr. 8, sanu' cuse.
7. BAniNsKY, Lt.'hrbuch der KindiTkmnkheitcn, IV. Auflage, 1892, S. 59.
HEMORRHAGE IN EARLY LIFE. — Spontaneous hemorrbag? o
currnijr at snnic iktIckI (hn*in«i: the early years of life is not uncomm(^
Thrsc h('niorrha*r<'s may occur cither in tlie skin or fix>ni some xii&n:
tramnatic lesion, or th(y may take place in various internal oi^n;:, aai
c.sjM'cially from the mucous mcml)rano of the mouth and the gastro-enterie
tract. A definite division of this class of cases has never I)een thomughlj
mad*', so that the subject has always lxH?n somewhat involved in obscurity.
Tlie prol)a])ility is that these s|)ontaneons hemorrhages are simplv fviap-
tomatic of ditlerent specific disca^^, and that as our knowledge of the*
diseases increases we sliall iind it nccc^sar}'' to make a clear distinorins
iHtwe^'u ca-es which now are s})oken of under one head. The proprieivof
H'j)aratiuir cases of spontaneous hemorrhage which occur in the earlv days
and wei'ks of liie from tliosi* which arise later has been shown by Dr. Tovb-
send. ]!<• lias hy a series of (fhservations corrolwrated.the now generallvai^
ce|»te<l o|Hni(»n that the hemorrhajrcs which occur in the new-bom sliouU
Ix' se|>arate<l from tliose met with in connection with the hsmophillAof
a later perI(Ml f>f cliiIdho<Hl and of adults. He has called this disease ik
hriiwrrh(i(/w dimttiv of the nnr-horn. The hemorrhages which occur in
n(Jw-l)orn infants anj so general in their distribution, and yet so imifonnin
■ DISEASES OP THE NEW-BORN, 447
Kheir geoeral symptoms^ that they can well be claasetl under this one heading.
These hemorrhages occurring in the early weeks of liie run a definite course,
ad end ifi death or in complete re<:^)very. The self-limited oaturc of tliis
tion corresixinds to what is seen in the acute infectious diseajses, and
a relationship to them. The hemorrhage may arise from the
stro-enteric ti"act, from the mouth, the nase, or the umbilicus, also from
be skin, and in the latter case may show it;!?elf in the form of ecchynioses.
Lgain, it may oci^ur in the form of liemorrhages in the alxlomioal cavity,
be meninges of the brain, the pleura, the lung, and the thymus gland.
Dr. Town?5iend has wjllected fifty ceases of thii* disease, and ha^* tabulated
lie sources of the hemorrhage, ha follows (Table 92) :
TA.BLE 92. (Townsend.)
Locality. CaiM.
Intestines *.*.... 20
Stt)maoh ...... 14
Mouth . , . . .14
Ntise 12
Umbilicua , . . 18
SeohymoBis in ftkln ...»..,... 21
Bcmteh of Mn 1
Ce^pbalba^miiiomtv S
Meninges 4
Abdominiil cavity^ , . • • 2
Pleurttl cavity * . . 1
Lung 1
Thymus gland . . . , , 1
From the ga^tni-enteiio tract » noae^ and umbilicus^ acoompanied by eccby-
1I106LB in the skin 8
From the gnstrtM?nterif tract alone . . , . 10
Fiviin the umbilicus alune ,..,., 8
From fccbymoBis in the skin alone 0
The oiortidity in tlw^se eases was 62 per cent. The bltx^diiig first showed
elf in all but three* within the fir^t seven days of Hie, the exwptions l)eing
[)n the ei|^hth, ninth, and fonrtin^uth days. The hemorrhage in the majority
:>f tliese eases began on tlie seotind or third day, thirteen starting on the
Iseoond and sixteen on the thii*d day, while only eight lw>gan on the fiiurth
nd two *m the fii'st day. One- half of the fatal eases laste*! one day or !e?is,
Und all the others died within a week, exeept one ease, in w^hich death took
slaee frtini the efleets of the bemorrlmge on the eighth day and several days
[after the bleeding Iiad ctused. The cases that lived recoveretl within nine
lys, and two-thinls of them within five days.
The eases of |iseudo-menstniation wliit-h oeeur not uneommonly in the
rly days of life should not lie inehid*>tl in the <-ases which are elusst'd under
be heading of hemorrhagi(^ disease. The hemorrlia/;ic dweaj*r is apparently
[ general and not a loeid one, and is loon<I more fn^j nently in hospitals than
lin private praetice. This fart is well exemplifuxl by comparing the per-
entage of hemorrliagic cases which otvuri'eel among 7225 infiint^ ol^sen-ed
in tlie Boston Lying-in Hospital ^id its out^jiatient department. The per*
1
448 PEDIATRICS.
conta^r of the (Hsc*asc* in the hospital itself was represented bv .o7,whik.l
n'pivseiits the i»rojxn'ti()n out'^ide of the hospital. In Towufsend-j? fifty ttt^
the proi)()rtioii of lemales to male??* was as 20 to 30. In four of To\*iw-oi-
<*ases the iieinorrha^e took platv in several places as well as at the ba^c-f
the cord, hut the patients rei^)vered and the cord sc]>arated, in (>De itir
in two days and in the otlier three in fonr days after the cessatiou of tk
diseasi*, witliout a iVesh hemorrhaj^ ocxHirring.
In ionrt<M'n of these fifty (u<(Vi the temjx?ratiire was carefully oWrvi-d.
and in all hut two wtu^ lonnd to Ix^ elevatixl at first from 38.3° C. (lOl* F.
to ;59.r)° C. (10;5.1° F.), and in one ease* to 40.1° C. (106° F.). After tljp
cessation of the lieinorrha^^s the temjK'rature was normal, and often !*ul»-
normal.
To recapitulate: it would s(»t»in that we are warranted in considering dr
disease as one of a p'neral nature*, and infec»tious, for the following T«isi^.
(1) It <K'<'urs usually in hospitals. (2) It is self-limited in its ciwiiv.
and, although a danjrerous diseitst*, may be recovered from in one or twi.
weeks (•()niplet<'ly and never n»turn. (3) The tem|>erature is raised duriof
the continuation of the chief synii)toms, and becomes normal or subn«)nijal
when tlie hcnioiTlia«j:c has (vasc»il.
Hitter at t\\v Pi*ji^ue Fonndlingr Hospital has also noticed a pm
preponderant-e of casis occurring in hosjutal deliveries over those vhia
were met with outside of the hospitals.
In connection with the hemorrhage which occurs in the gastrcK-ntfrK'
tr.ict, the tar-color of tlie intestinal dejections, arising from the hemorrkc'^
takiriii- phuM' lii«rli up in tlie intestine, is noticeable. The resemblance of u-
color of the deje<'tit»ns to that of meconium may (^usc the dt^ease toljeovrr-
looked. A -lijrhtly pink tin^e on the napkin annmd the dejection is oiut.
Jiowever, seen, nn<l where there is a doubt as to whether the stain k fr'D
l)l<M»d or not, it can usually Ih^ determined by means of the raien>sa»i«:.
When* the corpuscles have U'come disintegrated, as at times oceiiK, ik
Jueniin crvst;il- may Ik* recognize<I by means of a simple test which I sbll
>pe:ik of latci-. Tlie post-mortem examination which was made in ninei'l'
the-r (iiHX throws ii(» additional light u\Hm the nature of the affection. TIk
HMMvrnf the lieiiiorrlingc was found, but in no case were there anv ppt^
le>ii»iw of the inucou> membrane or the bhxKl-vessels. In all these (*■>
the iiiliiuts looked very aiuemic. In one cuse cultures were made hv Pp.'-
fe>^or ( '..imciliiiiin I'nnn the blood, with negative results. We do not kiP.'V
whjii the caiisr <.f thi^ disease is, but it is probable that in the great niajorit}-
<)f ej»-i< it ini- Mu infectious oriiiin.
I will now sh<.w yon a ease (( asc IHo) which is especially interesting, as
it slu)\vs ail unusual result (►f the 1)1o(k1 examination.
Til." ii.tMiit i^ tlnv(M.I:,\. oKl. :iim1 pn-s.Mt^ :i Mancheil appearance of the skin, withrtiis
oil til.- lijij.lviii .Mmuiid tin- iMt.-tin;il .liM-liar-rs. Thoso stains have been examined in it*
f..ll..\vini; \v:iy. A .lr..]i ..f tlh- x-iiii-li.iui.l (U-j.-ction was mixed with a little glacial vrV/i
««i<l aii.l ;i W'w <-n ^tals of .•uunnuii >ali on n ^rja^s slide and heated to boiling. On diriEj
DISEASES OF THE NEW-BORN,
449
the prepamtion and examining it under the microscope, the dark rhombic crystak of
liKmin were as^Wy pecojrnizfdT shuwiii^ us that we are dealing with a case of hemorrhage
I taking place probably high up in the intestine. Dr. Wentworth's blood examination
gives the following results :
BLOOD EXAMINATION 87. (Wentworth.)
Erythrocytes , . . . 6»245>000
Hemoglobin 125 per cent.
The blood spread out very thickly and stained poorly, but the polynuclear leucocyte*
greatly in excess of the other forms.
I "
■ The
W^ The cases which are commonly designated m mehena nrnnatonmi should
■ be classed imder this heading of* the hemorrhagic disease of the new-!x^nj,
and are represented by this case (Case 185), in which the bhNxl examination
was made by Dr. Wentworth, The child died in a few days.
An interer^ttng case (Case 186) of this dit^ease was seen by Dn Townsead
and mystJf in a>nsultation with Dr. Bnsb.
A male infant apparently healthy at birth developed on the third day of its life ecchy-
moses on it* bead, grtnng, and one foot. Tbere waa abso hemorrhage from the upper port of
the intejitine on the fifth and sixth day, the dejections being tar-colored from altered bir>od
which simulated meconium. On the fifth day the child devehjj>ed a marked parulypis of
the left side of the fut^e, and to a lees degree of the left arm and leg^ presumably from a
meningeal hemL(rrhage. On the seventh day of the di^iease the hemorrhage had appan3ntly
ceased, as the purnlysiii was beginning to disappear. On the twelfth day the paralysis of
the left ann and l^g had improved : there was, however, still some paralysis on the leftside
0f the face, but tbii* did not continue to any great extt?ntj and in the third and fourth weeks
decided imprr>vement took place in the child's condition, and there were no longer any evi-
doDcee of hemorrhage nor any paralysia.
ThiH infant improved rapidly during its first year, and is now living, healthy and strong.
It learn(^ to walk and talk rather later than usual, but now at four years of age is in a
normal condition both mentally and physically.
I have met with a nnmber of cases in which tliese hemorrhages oc-
curred and in which they varieil greatly as to extent and |>crsistence. The
cases in which umbilical hemorrhage was present showtxl this same ten-
dency to self-limitation, and eould he distingnished fn^m thase which are
classed under hsemophilia. In fact, it is probable tl^at most coses of umbil-
ical hemorrhage are caused by infection and are not especially connected
with haemophilia.
\
I have here to report to you a case (Case 187) of umbilical hemorrhage in a male which
illufitrate? what I have just said concerning the de.sirability of separating the hemorrhages
taking place in the early days and weeks of infancy from those which occur later and in
childhood.
The parents of the infant were well and strcmg, and were Russian Poles. They had
another child, eighteen months old, which was healthy. The mother had never had any
tnisearriages, and stated that her parents were healthy, as were also th^jse of the father.
The Iftbor was a normal one, the child presenting in the flret position, and nothing
nbnormal was noticed, except that the placental end of the cord continued to bleed quite
i|p»e1y notwithstanding the applicalion of two ligatun^s. On the day follc*wing the deliveiy
the mother and intknt were both doing well ; the latter showed slight signs of icterus, but
29
450 PEDIATRICS.
miM'tl wfll, and the foniuT hud plenty of good breast-milk. The infant c*jr.i:n'j-c s
thrive, txrept that thi-n' was a slij^ht hemorrhage around the insertion of the cuni. %lv^
fell ntf (III the eiLchth day. After the separation of the ct>rd a slight hemorrhage fr-^i-j.*
uiiibiiieiis cfiiititiut'd. On the thirteenth day the hemorrhage increased and W-&t::c •:•
extiri-ive that I was .-ent f«)r to see the infant. It was then found to be decidtd'.j jiUB-
di(«Ml. thniiirh nt»t d«M'pIy mi. It was nursing well, but looked thin and puny, y.uirj
alMmrnial wu.s found on making a phy>ical examination. Pale watery-looking M»i-»u
oozing from tin* uniliili<'u^, and quite a large cloth had been soaked with the Mi-drr-L
th<' unihiliru>, i^iving evidener of a o«»nsideruble hemorrhage. The umbilicus waspl'ir:^!
with .-ntall }>ie(r< nf lint M>akcd in pi'rchhtrido of iron, firmly compressed by a band^r^,u'jd
alt«Tnati- drop dn>.s ^A' fluid t.vtract of ergot and tincture of chloride of iron were«inis:wi
tt» Im- irivrn thn'«« iirne> a day.
On thf tlf'trrnth day the hemorrhage had somewhat abated, but it was not thixc'r.
advi>al»lc to n-niove the bandage; the ergot was omitted, on account of nausta kii
v«)miting.
On the >ixt»enih day thi* infant was reported to have vomited and cried agreuid^
and th<' pluirs (if lint had lM*en fonM>iI out of the umbilicus, leaving a bleeding surfaov; ±>
uniliilicu.s wa-i then tainponrd with Monsel's solution of subsulphate of iron; the tirA-i irr
of eliloridi' of iron wa> omitted, as it caused vomiting. The hemorrhage then lesscucc jDC
at times i-raM*d.
On thi- -rvi-ntfenth day the older child pricked the infant's lip with a pin, an-if-nib*
eightri'nth day tin- lip was found to be still bleeding. The point of hemorrbntrt ti
eaut<Ti/.«"d with a .-tiek «»f nitrate of silver. Thi.^ controlled the hemorrhage foraK-Jti»>
h<iurs. wlnn it ntunnd and mntinutKl. Compression of the lip finally stopped the ben.:-
rhag«* oil thr twenty-fourth <lay.
On tbr nin»'tiM-nth day the hemorrhage had ceased at the umbilicus, and the child u'>
tinned to inns«* w<'ll.
On tlir tw«nty-ninth day the bandage and lint were removed from the umbilifu?, ji
the abdonuMi wa> wa^lu-d. There was no hemorrhage; the child looked better, acd iiry.
was not !-o much ieti-rus.
On tli«' tliirtii'tli day th«' infant was reported to be perfectly well. It coniinu-fll:'
thrivi- ffiMii tlii^ tinn'. with no n^curn-ner of the ht-morrhagc.
On tin- >i\iii'th day. altljout^h I advised that the nperatif>n should not N» perfon;:-:.
tin- infant, in a( iil:nn'r with tin* dj'wi>h custom, was circumcised. I was pr^ent a: '.i:^
eircunici-iiiii. to «.«■(• if tin- hcnmrrhage would be eai^ily arrested. The circumcision wa- {■:••
fnrin»d witlmut arcidi-nt. and tin' hrniorrhage was immediately arrested by a weak fi-lJi/-:
of inm. From thi< time tlnre was no hemorrhage, and the child continued to be str n;
and w«ll.
Tills ca-e is an in-tance <if the self-limitation of the hemorrhagic disease of theit*-
born. >ii , altli.iUi^li it was a pron«iunced ease of umbilical and general hemoirhist
at tin- iH-LMiiMinir of tln" infant's life, this tendency had ceased by the end of thest^v^:
montli. ji> wM-i »vid«Mcod by tin* ready oontn»l <»f the hemorrhage afVor the ciroumci«ieTi.
In aiiMtlnr vu-o ((Vr 18H) wliii'h eamc under my notice the hemorrha^ took pUt
from tlM- uml.iliru- in tin- <'arly days of lif«. at the time of the separation of the ixml. asd
was r.iinpl.tcly uncniit rollrd vvvu by liiratun's pas.s(*d anmnd netnlles intnxluced thr.ttrb
tb<' -kin of tin- alMlnmrn on «-itln'r side of the umbilicus. This case eventually i*-
ruvi-n-il.
In n'TH- I'f tlii««' ea'-ts ha> a tendency to bl«»».Hling developed in later life.
At times w(* nuH't with what aix? apparently very mild cases of this
fliscasr. I have hrrc the record of a ca.^i' which occurred in the practiceof
Dr. (i(or^r(. Haven, with wh(U!i I saw it in consultation.
Tin- infant iCa^.- Isjn. a unrl. wt-ll deveb)pod, and weighing 8858 gimmmes (aboot ?
pound- «; oui.r.«,, wa- born at \'2.Ar> a.m. Nothing abnormal was found on examiniDSi^
DISEABES OF THE NEW-BORN.
451
P
And tt was perfectly quiet until fourteen houre after its birth ^ when it began to be very restlejia.
Thi« reatloBsnett oontinued^ and the tempenitupe, which tit birlh was 88.6* C. (10L5'* F.) in
the reL'tuio, began to rise, until at the end of twenty-four houre it had reached 39.4^ C.
(108** F ), When it was thirty-six hours old, minute h*»morrhagie macul© were noticed,
fttBt on the back of its right hand and arm and then on the Hg^bt side of its back. A few
hours later a number of the&e iiiaeuke also appeared on the right side of the chest* near the
ann. It nursed vigoroUiily^ and did not show any signs of weakness^ but its reiipi rations were
at tinieg quite irregular. From this time no new leaionis of the skin appeared, and no
hemorrhftgea from any other bx^alityr the mactil^B gmdimlly fading away in ten days. After
the first duy the temperature fell gradually^ and on the flflh day was again normiil. Whether
there wa.s any loii^s of weight during the irst ten dayg of life was not knowni as it waa con-
sidered unwise in the infant's precarious condition to weigh it.
Here is the temperature chart (Chart 9), which illustmtea what 1 have already told you
in describing the diaea*e, — namely, the ri^e of temperature, and in favorable cases the return
to the normal degree in a few daye.
CHART 9.
^
I>^s afj^is&aae
F
m-^ —
I07«*
m^
105»,
i04*
103^
102"
I0l«
I00<»
1 99c
970
%»
95^
1
2
H 1
3
4
5
6
7
c
41.^
4 LP
40.5'»
40.0*
39.4* 1
3a,e«
3770
37 2°
37 0^1
36 6°
36. P
35.5''
35 0=1^
■1 ■
M I
,M B
H 1
H E
1/
1
i
J
—
f
V
^
U.
BemoTTba^c dbeaae of the new -horn. Female. 24 botus old.
The cord separated on the tenth day without hemorrhage^ and gtibsequently no
labnormal ayraptomii arose, and the infant continued to thrive during the whole period
of its lactation.
H^MOPhiIjIA. — In contradistinction to the bemorrhages of infec-
[tioiiB origin which otx'ur in the early weeks of life is that cla^ss of hemor-
rhages which, as I have already said, can be elapsed under the terra
luemophilia.
Htenidphilia simply means a rarvrhid wndition characterized by a ten-
^deney to bleed sj^vontaneously or from any insignificant wound. Individuals
who are liable to bleed in this way are desit^nated as having a hemorrhagic
' diathesis. The disease is not c^jieeially common in the early weeks of life,
and usually occurs at a later j>erif»d of development. It begins to he moit*
frequent towards the end of the first year, and is apparently well established
I
452 PEDIATRICS.
in the second year and later in childhood. It does not have a self-limiw
course, as is the cuse with the other form of hemorrhage. It Ls not infeN
tioiis, and is not mxromiianiiKl by fever. It may be for many years macti
and then may arise from some trivial cause, such as the extraction of a t«»tL
It is a dangen)us disease, and death is very liable to occur from inability Vy
contH)! th(» homorrhajre. Thedis(»ase is hereditary, being transmitted thixMuL
tht» leniah's to the males, hut st4dom occurring in the females, the prc-pi-
tion iK'injj: one ta eh'ven or thirteen (Osier).
Tliert* is no treatment which has been found successful in the^e ca*
Inyond the active hx'al employment of styptics and compression.
TETANUS NEONATORUM.— AWiough the group of syiii|.iom5
ivpnsentin^ the diseiu^? usually known as tetanus neonatorum^ or tri^vt
7t(ii<(u'iifitim, is essentially of a nervous character, yet, as it occurs iii\*ari-
ably in the early weeks of life, I have thought it best to speak of it intht
(Nuuiection.
The whole c^)urse of the disease, its self-limitation, and the highi«n-
|)erature at the time of its invasion, would naturally lead us to clas*ityii
amon^ the other diseases of infectious origin which I have just described i:-
yon. Th(^ disease usually occurs in infants from the third to the tweltth daj
of lile, and is almost always fatal in two or three weeks.
Kti()I.()<; Y. — The (»ause of the disease is supposed to be the same as ibit
of t("tamis in the adult ; that is, the bacillus of tetanus.
Symptoms. — Alter (considerable restlessness and muscular twitdiing
lastiiitr ior some iKuirs, the infant a^^sumes a verj' characteristic apjiearan-^.
There is extreuK; rigidity of the h»gs and body. This rigiditv soraetHl:^r«
takes the iorm of opisthotonos and trismus. The eyes are almost clu^J.
but the infant is sleepless. The trunk and limits are so stiff that the infani
nMimins in whatever i)osition it is plaecnl in. It is unable to nurse, and ii3?
a hijih temperature, oecusionally ri^ehing 40° C. (104° F.), and a pul><^"r
lo<) or !<)<). At times it will have slijrht convulsive attacks.
Thi> (liseasr is epidemic in tropical climates, but as we sec it Ls iwully
of a sj)ora<lic nature. It is extremely fatal. When recoverv takes pb*
the improvement is very gradual, the tem|x?rature and pulse decreasinir and
the ritri<Iity of the ninseles passinjr away very slowly, with at times a recur-
ren("e of the synipt(nns.
TitKAr>ri:NT. — Tiie treatment of this disease has thus far been ver
un^atisl-Ktorv. Tlie possil>ility of successfully treating these cases viti
the antitoxine of tt^tanus mnst be considered.
Thr form of treatment which ai)i)ears to me most rational is to plawtbe
child dnrinu the eontinnati(>n of the tonie si)asm in a warm bath and top^v
it .(M) liTamme (1 ^rain) of hydrate of chloral every hour until theeflWtp
of the dru<:; are shown l)y the lessening of the muscular rigidity and bv a
<lis|)osition to sleep. Jn addition to this treatment, small quantities of miU^-
1 ■) r.e. (ahnnt .] oniicr), should l)e ^/ivtm to the infant by means of a dropper
every hour, and t*) each feeiling thrcye drops of brandy or some scimaliint
DISEASES OF THE KEW-BORS.
453
I
should be added. Under this treatment a certain number of ajises have been
known to live.
I have here a case (CVse 190) whieh was first brought to the hospital
two days ago with the follo^^^g hLstor}^ :
A male, eaid to have been healthy at birth and to have nursed without difficulty during
th€ fli»t week of \U life. It then refbaed U) imrtjt*, apparently from inability to open its ju ws.
Xiftometamei^ i;ried| but feebly. There were no coQvubbos^ no Tomiting, and no rigidity in
, any other part of the body. The temperature was not taken. On physical eatamiriation it
nna found tbut, although the infant could swallow^ the jaw could not be opened wider than
|I,!Scm« (J inch). On forcing the finger between the jaws, nothing abnormal wai discovered
In the mouth or pharynx. The respiration vfoji regular, but rtither shallow, and there wad
no evidence of injury. Nothing else abnormal was discovered ab<^jut the infant.
The infant was given .06 gramme (1 grain) of hydrate of chloral three or four times
in the twenty-four hours, and tCMiay shows marked improvement, and, with the exception
of still Imng unable tu open the jaws widely, nothing else abnormal km been discovered.
The rectal temperature is to-day normal.
The infant tia,^ probably passed through the active part of the disease in safety ^ and it
teems likely that it will n^iover.
This, of coursei U nc.>t a typical case of tetanus neonatorumi but is one of the milder
forma of- trismus.
SCLEREMA NEONATORUM,— .Sefrmna 7ieonoionim k a disease
whi(*h (K'fiirs in the early tiays of life, and usually amoug those who are
born in the inidsit of exceedingly jXM>r hygienic wuiTOundings and in (?old
weather. It is charat*terized by a hai'dening of the skin and the subcu-
taneous cellular tiasue and by a ^reat rtduction in the tem|XTatiire. The
tissues eijntiijue to grow eooler and harder until death, whieh (K'eurs usually
about tlie ninth day. It is a rare and exceedingly fatal disease.
It sluitdd not be looked upcm as a lix^al disease of the akin, but as some
obscure constitutional atleetit^n of the respiratory and cireiilatory systems,
as shown by the sliallow respirations and the diniinislied ^it'tivity of the
circulation.
8YMPTf>MS. — ^Soon after birth^ spits of cireumscrilied hardness apjiear on
the skin. These* spots soon beeome diBiist*, and the diseiL^% stortitig, as it
usually does, in the feet or the calves of the legs, passes up the thiglis to the
trunk. It may, however, first ap|>ear upm the face and upjier extremities^
tJiongli not commonly. The skin ha^ a waxy and glistening hmk, anil is
hard and cold ; the limbs become thick, stiff, and misshapen. The infant
eooD grows weak and s«>mno]cnt, and refuses to take its fiMxl ; the breathing
beoomes rapid and superficial, the voice is weak and whimi>ering, and the
pulse small and retarded. Towards the end of life a discharge of bloody
serum from the mouth and nose of\eu occurs, and death takes place seem-
ingly imm inanition.
Treatment.— There is no treatment which has been especially suo-
oessful in this disease, but the aftkliou should lie recognij^ at once, and
energetii^lly treattxl with inunctions of hot oil and by manage and stimu-
lanti^.
A number of cases of this disease have been reported in Europe, and
454 PEDIATRICS.
several in this wimtrj', notably by Osier. Some investigators think tk:
they have toimd eharaeterLstic changes in the skin. The oliservatioos k
Northriip, however, who piibli-shcd the first report of a ty|>ical cascui't
kind in America, seem to show that there is no definite lesion of tho likii
Nortlirui) made a eareful study of his case, and has plainly i&hown liv--
tions ol'the skin comiMireil \Vith normal control s{)eciineus that the Li-tiJfiy
of the disease doi.*s not revival any cliange which can be regarded as charar-
teristie. Dr. Northrup's case emlxKlied every feature of the typical ?(lertiL3
ol* th(» new-lx)rn. The infant was a foundling, born in a wretched, damp
habitation, and was the weaker of twins. On the fifth clay of its lite ik
feet were found to Ik* swollen, and soon began to give on )>alpati<.»u a Ml;
of hartlness like that of a lx>ai'd. This condition soon spread upward t.
the legs, thighs, hips, shoulders, arms, face, and scalp. The whole bJj
ftdt as though it were half frozen. The tcmi)crature in the rei'tumwt
under ;55° C. (95° F.). The infant died on the nmth day.
N-ffiVUS. — Tlu»r(» are two forms of pathological disturbance in rt^uEt^
tion with th(» blood-vessels of the skin which, api)eariug at birth, ci)D>titi:ti:
a disease called naruK Both these forms can appear on the skin ot' any
part of the infant, but ha occurrence is esi)ecially unfortunate when it >
loeateil on t\\v face.
The iii-st form is very sui)erfieial in its distribution, and is the onewhit-L
is usually called " iM)rt-wine mark." This form can in a numl)er of ca**
l>e destroyixl by the use of electri(*ity. The second form, which is dwp in
its (listribnti(>n, as a rule needs to be treated by the knife or tlie Paquelin
cautery. C'as<'s of the suiicrficial form of nsevus are quite commuii and
vary greatly in degret\ A fre<[uent locality is l)etween the eyes at ik
bridge of the nose, and another is on one of the eyelids. Often in tliK
eases the disturbance disapjx^ars of itself after a few weeks or months aix;
dms not return. In other eases the lesion remains, often increases, ami
continues, unless treate<l, through life. In the second form much can k
done by oi>erative interferenci*. This form also varies greatly in size aal
in the degre<* ol' the telangieetasis. In operating on these cases it ?b:mlJ
Ix* reniemlHTed that at times the hemorrhage is great, and that the mfiuit
are liable to die from exhaustit>n. The following case (Case 191) ^-as am
by nie with I>r. Lovett :
An iiitMiit i..ur iiK.nihs old was }K>rn with a ^uporficial nsevus on the foi^head. Tls
iiuviiv iiicn-a.-u'd in si/t-. and at four months showed a deep discolored protrusion thetiw-'"
a liali-dollar on the l.-ft sid<' of tht? fondn-ad. Dr. Lovett removed the growth by inoUixj
< \t«Midiiiij: into rh.' M.und lissui's. Thm? was much hemorrhage at the time of the open-
ti.in. and afuT tin* njHTatiorj ixn.>at pro>tnUion, appan?ntly from loss of blood. Theinfiai
was tivalrd with .<tiniulant> and th<' appliration of heat; it was fed on a careAilly amnff^i
Mil.-tiiuto foo<l f.T a nunihor ..f (hiys, and finally n^covered. At the end of a year all ih»s
rvniaint/d tif tin* original lesion was a very slight soar on the forehead.
DIVISION IX
DISEASES OF THE SKIN.
LECTURE XXI,
In a previous lecture (Lecture XIII., page 320) I referred to tlie
importance of inspection as a means to be employed in making a di^nmis
of dbeaaes in children* The nile that the child should k> ins|iected in
every part is especially applicable to the class of cases which I am now
about to describe to you.
The lesions of the skin in children differ somewhat fmm those which
occur in iidnlts, and these variatioas, hoth in dogree and in kind, otlen
make a diffcn^ntial diagnosis more difficult than in adults. Every pmc-
titioner has doubtless been struck by the similarity which at times is sec*n
in the cutaneous lesions of the various forms of erythema to those of
such discuses as syphilis, scarlet fever, and erysif>elas, 1 Imve seen in
eonsultation the delicate pink of an alxlominal erysipelas in a young infant
mistaken sc? tximpletely tor scarlet fever that the precaution of removing the
carjH't in tlie nxmi hatl already tieen taken. In like manner I have knnwu
a slight grade of the efflorescence of scarlet fever to be mistaken tor that
of crj^tliema neonatorum. I liave also set^n a harndess |>apular erythema
closely simulating and mistaken for one of the papular efflorescenees of
syphilis.
Another rule, and one of equal imix>rtance, is that no single dermal
lesion, whether it be a macule, a jmpulc, a vesicle, or a pustule, makes it
jiLstifiable for us to decide that an t*special disease is present. We must
rememlier that tlie same cutaneoiLS lesion may appear in almost any disease,
and that it Is the combination of dermal l<^ions and general symptoms
wliieh makes up the entire picture of the disease and justifies us in making
a diagnosis.
I shall not attempt Ut sjx'ak at length concerning the Iik^I disea^^es
of the skin. These diseases c<mR' ratlier within the provintx* of the der-
matologist. I wisli, however, to show you a few ilhistrative cases of
the more common cutaneous affections which you will meet with in your
456
456
PEDIATRICS^
prat'tioe and will be obliged at least to differentiate from the con
diseofiGS with dermal lehionn whith you will have to titiat.
The firat ca^e (Ca^^ H>2) tliat I have tt> gh<»w you Ls one which
the purest tyi>e of a priuiary di-^t^ase of the skin. It ii* caused by i
parasite of the skin, tlie Acarus scabieL
SCABIES.— ThiA child, Iwo and a half y^ttan old, in health j and well dcreltiped
For the liiiit two weeks it ha* been vt^ry irriUible^ and it» mother has brouiflitillolli
bcMpital to inquire about an efflorescence which haa appeared on ib« skin.
Un inve.Hti^Aiini;; tbi^ ledotift W6 find a number of Mnall puptite^ and a fp«^)«Me«
«cattej%d irregulurjj over the antu and che«t, and one or two small pustules on thf ^r*>/
Cask 192
Female. 2>% yeaf> oM. with Ietiv'n> ij tJit sliiu causeil b> tbt Acarus
the feet The fingers are not especially affected, but in one or two places at tbcbiat'^
the fingers the efflumscence may be plainly seen. In addition to the jiapule^ ^nd pu^«il«
there ure jiujo^^tous lesiuni^ of the skin cautiK! by scratching. Here on the delicaU' ^kin-^
the alxJomen h a oihiute blnck line with u vt'siele at one end of it. On removing aiMf
with a needle a little of the fluid in this veside and plating it under the tnicrtiicuM, finidl
see the parasite, which evidently had its hnbitat in the vesicle, Thia organism/wliki I
ihitU not describe more fiilly, as it is best illustrated in your course on diaeaa^t ^ ihttla.
i* called the Acant« smHei, and is the cau^e t.f this special dermal lesion. Thel>lackl&il
rupresenta the bumow by which it enters and tlmmgh w^hich it trave^ls as far as thaf^eii.
wher.^ it b>dges and pnxlucea irritation, causing first a minute papule^ and ihfn • pH^
vesicle. Finally" th** vt'sicle may become pnsluiar*
In contradistinction to the effects of the Amru9 aeMei on the skin of adulu m (Wtl
DISEASES OF THE SKIN.
457
I
I
infants and younf; children that tlie parasite may attack the soft skin of the ftolca of the feel,
whilt? in the adult we da not find the lesions on the soles, as in walking the ekin hwj* become
toughened in that locality. In adults efflorescences on the aoles of the feet and the palms
of the hands are, as you know, rather unusual unleai they are connected with syphilis ur
artificial eczema.
Infants and young children are usually infected by the Acarus seabiei from sleeping in
the bed with gome adult who has scabies. In this case you see that the child ^s mother shows
the lesions of scabies between her fingers.
Treatment. — Tn the te*atment uf this dLseaae it h of oourse very
(miix)rtaut to treat it in the motlier as well a^^ in the child. The clotJies
of the bed, of tlie mother, and of the inliint should first be thoroughly
steamcHl, in order tn kill the parasite, and it should l>e impressed yi>on the
mother that the treatment miLst l>e carried out very earcfiiUy, and tiiat all
the clothes which have come in contact with the skin must be thoroughly
cleansed.
The treatment of scabies in the child should diifer somewhat from that
'which 18 cmploytHl when the discu.se occurs in tlie adult, l^ecause the skiti
of the former is much more sensitive tlian that of the latter. The severe
xemf<lii?s which can pro[>erly he used in treating tlie adult should not be
^niployed in the tre^itnient of intants and young children.
P In this case I shall adopt the method which I have beexi in the habit of
'employing, atul which was recommended to me by Dr. Bowen as suecessliilly
tiiscd by him in liii^ practice.
This treatment consists in an application to the skin of this ointment
(Presfjription 47) :
»PRI»CRlPTIOIf 47,
Metritis Apothecary.
Oramma.
I ^
. . . AA 60
I
B
Balaami Peruviant,
Fetrolati . . * . .
M.
Balfiami Feruviani,
Fetrolati . ft& 511.
M.
For an infant m old as this^ and for older children, an ointment contain-
ing some sulphur could be employed without much danger of irritating the
skin (Prescription 4H) :
Metrit.
FmscmiFTioir 48.
Gn
Apothecary,
'B Sulphiim snblimati
3HUanii Prrnvinni,
Petroka .....
M.
, 7
6 R 5^iilphiiri.* ^fiiWiTnati .... * 311 ;
Hal^iimi Peruviani,
0 Fetrolati , Wk 51.
In the use of either of these ointments the followiog technique should
be employ€<d. The cliild is to l>e first thoroughly washed with warm water
and soap. The skin is then dried, and tlie ointmeut is applied over the
whole bcxly, avoiding the head, which is seldom attac:^ked by the parasite.
458 PEDIATRICS.
Tlu' face especially might be irritated by the ointment. The ointmeoi b
allowcnl to reiuaiu on the child during the night, and in the momineb
washed off with warm water and soap. The skin is then thoroughly pciT-
dcTcd with the zinc and starch jMnvder which I have already mentiniri
(Prescription 2, jmge 130). This treatment is continued for three or fe
days, and then, if the disease is not entirely cured, it can be repeated k i
few days nioix'.
A (X'rtain amount of ec'zxima usually follows the treatment, owing to the
irritation pnKluced by scratching, which is very difficult to prevent Tik
iH'zcnia should Ix? trc^ated by soothing applications.
PEDICULOSIS. — A j>aiu'^itc whose nidus is on the head appears quife
fn^qucntly in children as well as in adults. It is especially met with amf?ng
tiic iMMtr and ill cared-for. This parasite, the pediculiis oapitU^ cause
cxtrrnic irritation of the skin, which oflon results in eczema and in tfr
i:ir;r<*<l jr'ands. Althoujrh the iK<liculu8 itself is in the hair, yet by ir-
IrritatinLT action on the scalp of the child it frequently gives rise by reS^i
inllncnw to [)atch(*s of eczt^ma grouped about the nose and ears.
TuEATMENT. — In treating these cases the hair and scalp should fim^r
siitiiratcd with |H?troleum. This application is allowed to remain on iIk
head lor several hours, and later is thoroughly washed off with soap and
water. Th(* nits should then 1k» carefully removed by nriftf^nj^ of a fine ft^mb
wet with vinejrar. It is usually necessary to repeat the treatment for two
or thiXH* days.
IMPETIGO CONTAGIOSA.— I have here two children (Cases Wi
liM) who iiavc a parasitic disi^a*^* of the skin called impetigo Gonta^l^^.
It is a disease which usually occurs in children, but it mav be found in
adults. It sometimes ai)i>ears as an epidemic, and in these cases, in all
prohahility, is caused by the same micro-organism as in the isolated cas*.
It is usually met with among the p(K)rly cared-for, but it mav attack tie
healthy as well as the siek and weak.
The form of the efflorescx^ncc is variable. Beginning as small vesicfe.
the lesions soon spread over a larger area, coalesce, usually form piistnlt?.
and later heeoine rai)idly eovcn^d with a thick yellowish crust. The 1(S>.«
nitiy oceiir on any ])art oi' the l)ody, but is esi)ecially common on the face and
hands. The it<'hin^ is very slight in these cases, and there is no constitu-
tional disturbanee caused dinn'tly by the parasite. In accordance with the
idea that it is oi* para-itie origin, the prognosis is favorable, and the disease
ran usually he enrc^l in a week <»r ten days.
Th«H- ln.ys livo in n rlani]) dwoUini;. T\wy both have lesions on their skin which mdic^
hi' fXpluiiH'd a.s thox* cf any of i\\v diseases of which I have previously spoken to yc^^'T
wliifli 1 am ahnnt to >how you.
The rti>t rase (Caso lO.'i) i*. nine yoars old. II(j has lesions on the arms and on thelwe
(A' til" nox'. TIk'V an- «?hanic*t<'rizfd \)\ some yellowish crusts.
The MthiT liny iCasr 104) is eleven years old, and was apparently infected by tlie
former. He pn-sents h-.-^ions of the same character as in the first case on theendofbii
nt»se ai.<l on th»' cnrnor of his mouth.
BISEASES OF THE 8KIN.
459
Treatment. — The treatment of im|ietigo contagiosa is very simple, and
I consists in cleanliness, exposure to sunlight^ and the application of an oint-
Iment such as this one (Prescription 49) :
pRESCRIPTIOir 49.
Meirie.
Qnmnuk.
I B Acldi borici 3 I 76 B Acidi borici
Adipi^ 80 1 00 Adipis . .
M. M.
Apothecary,
FURUNCUXjOBIS* — Closely connected with impetigo contagiosa is
Ifuntnculmiiij which h gnpposed to be caused by the same micro-organisms
[that give rise to impetigo contagiosa* but which affects a different part of the
fwkixif such as the deeper portions of the hair-ibllicle, in oontradl^tinction to
the upper layers of the skin, tlie part atJected by imi>etigo contagiosa.
These microorganLsm.s are those which are called the ** pus organisms/* and
are usually represented by the staphyl(«5<3ccus pyogenes aureus.
Treatment. — The treatment slioidd Ix^ with an anti-parasitical ointment
\ or solution preferably eontaining boraeic acid. In many t^se^ in addition to
[this local treatment some form of constitutional treiitment should be em-
ployed, a^ the children are usually in an almormal condition. The lesions
'should he batiicd every day with this solution (Prescrijttion 50):
Prescription 60.
Metric,
Gfai
Apothecary,
% Acidi borici 15 1
Aq. destil.. 24ol
B Acidi borici Jas ;
Aq, dentil Jviii.
M.
After the parts have been tJioroughly bathed with this solution an oint-
ment should l»e spread on linen aimpi^esses and applif*d to the lesions. This
ointment should be made in the ibllowing way (Prescription 51) :
pRKSCBIFTIOir 51.
Metric, Apothecary,
GramioA.
B Addi bt?rici 3 175 B Acidi borici , . . , ^ ;
Petrolati , . Sojoo Petrukli , Jt
MOLLUSCUM CONTAGIOSUM. — Another probably parasitic dis-
ease which is rare, but which is more frequent in children than in adults, is
mollusc^uin contagiosnm. It occurs most commonly on the face, though it
) may be found on other parts of the body. The lesions consist of small, firm
' nodules of a wiiitish color, with a central depression from w^hich matter of
a sebaceous consistency may be pressed. The diagnosis is not difficult for
one who has once seen the efflorescence, the only condition with w4iich it
might possibly be confused being verruca, which, however, does not ckvuv
430
PEDIATRICS.
commonly on the face, has no eeutral depression, and does not C50]
BtibstBiice which ma}' be squeezed out.
Treatment, — The treatment of the*^ lesions is to pmicmi^ \hx
equeesse out tlieir ctrnteuts, and dress them with the follomng aai
ointment (Prescription 52) :
PRK8CRlPT10Br 63.
Metric, Apothecmy,
QrnmuuL
B Acidi boricl ..,..,,.. S 76 fi Acid! boHcl -
Adipis . 80|00 Adipi* .,.,.. '-
M M.
TINEA TEICOPHYTINA (Ilin^nrra). — The disease called f^
triec^i^hi/tina occurs clinically in two forms. The first form affe*1s tic
scalp, and is called tinea totwurang. The other form attacks the noo-^
portions of the body, and is called tinea eircinata,
Thh little boy (Cose 195) has, as you see, two bdd spots on the bttck nf kii M
Thii huit uver ibe reet of hb head it thick, and there u« no appeanuioii of Um<)tim
Case 195-
Ttoea toiMuraDs, Male, 8 yettf» old,
ftojwhere else on his seal p. The areas of scalp attacked by this diseaae twt in
thia fpedal case, however, tho spotii tire about 2.6 em. {1 inch) in diameter. As a mle.t^*
have a fairly reg^ular cireuTnfenfnre. On L'xumming the sp^is you will 8e« lliat tb<9« ti>
little short hainB on their ^urfjict*, wliich evidently have brtiken off from lack of nutril
On the edges of the spots thia is e^peciiilly iioticenble. If you place one of the haii*
the microacope, you will find a i^pet^iflo organism which has l>een determined lo W (b«
of this disease. It h of vegetable orisrin, iind consists of maasea of spot^ oomoOKmrn
threadfl of mycelium, some long and somp «hort, which are divided into numercme wtemf^
The ffkranp itself is called ilma triropki/tina, and the parasite v1]|H{
causes it is callctl thc^ Ttimpln/fon loimuranJi. ^^
Tinea tricophvtina has the y>ecnliarit\" of not appearing on the &alf
except in children^ but is the same disease that occurs in adults in vmM
LJiattb<9t0i
of nutritk^^
coiDpdM4^H
DISEASES OF THE SKIN.
461
localities, m on the face in men, destroying partes of the beard. It may
Im occur on any part of the body both in children and in adults. Its cause
usually be traced to the same parasitic affection in some other person
Por some animal.
Treatment. — The treatment of this disca.se should be active, and it is
usually necessary to continue it tor a long time, esjiccially in causes where the
parasite has attacked the heail. This ointment (Prescription 53) is a good
one to begin the treatmeut with :
Prescription 68.
Metric.
Gr&mmiL.
Apotheearjf,
Acidi anUcylici,
Lanoliiii ...
M.
80
76
B Acidi salicjlici,
8u]phuni ^^l
Lanolini JL
It .should be applied twice daily, and should be thoroughly nibbed into
tie bald spot^, the skiu first having Ix^n washtM:] with soap and water.
Where the ea.s<' proves to be somewhat intractable, still stronger appli-
ations can be used, and, if necessary, a certain amount of carlx)]ic acid can
mixed %vith the ointment, from one-half to one dmehm to the ounce
>f ointment.
The second form of tinea triet^ph)^iiia5 tint^ eircinata, may at times
Fapi^ear as uumeroiis midtiple k^ions in different parts of the body, and is
isily iitfcctcd by ant i -parasitic applications.
TDSTEA FAVOSA. — The next case (Case 196) represents a parasitic
lisease calltHl /«iw^. Its favorite* scat is the scalp, thniigh it may attack any
: of the l)ody. It appears in the form of small, bright yellow, cup-sha{>cd
fits, whi(*h upon their remiivul leave a permanent l>ut suj^Tficial cicatrix,
bese yellow crust** |jenetnite the hair-iVdlide and destn>y the growlli of the
dr. When plm'cd under the microsctJix' they mv lT)und to t^onsist almost
atirely of myoelinm and s{>ort>i of the form called Acfif>rion schoenleinii,
crusts otten become cf>nfluent, fi}rming a large thick covering over an
extensive area.
Treatment, — The treatment is the application of an ointment to
I soften and remove the ^crusts, epilation^ and anti-pai'asitic ointments such as
|I have already mentioned (Prt^^ription 53).
ALOPECIA AREATA.— On wmparing the bald spots on this little
oy*s head with these on the head of thi^^ little girl (Case 197, page 462)
fon will notice certain diffcmuces.
You see on drawing ftiide her long hair that nn irregular surface of the scalp is entirely
! fn:>rn huir up to where the long hair be^iii» io grtiw on its edges. The appearance of
be akin over thb 6p<jt is normal.
The nature of the disease has not yet been determined. It must be
ifferentiated from this csafle (Case 195) of tinea tricophytina which 1 have
462 PEDIATRICS.
just shown you, and, as you see, it has an entirely different appearaiHie, ilt
skin l(M)king sound and healthy, while in the case of tinea there are noiotf-
ous short hairs, which, as I have already explained to you, are brokoi d
throuj^h the action of the parasite.
Aloixx'ia areata is somewhat intractable to treatment and runs a ruber
long cx^urse, but, as a rule, in children can be cured.
Case 197.
Alopecia areata. Female, 5 yean old.
The diagnosis is made by finding a bald spot on the head having the
appcaraiuv which you ^h} here. The remaining part of the scalp is fouDd
to l)e in a healthy condition and well covered with hair.
TuEATMENT. — The treatment is the continual application of stimokiif
remedies, such as ointments of sulphur and tar (Prescriptionfl 54 55).
Mrfric.
PrEvScription 64.
^pothecarv,
(immma. ^
K Sulpliuris 3176 B Sulphuris xi;
»*«'tn.lati 30100 Petrolati tj
M. M. ^
Prescription 66.
Metric. Apothecary.
Gramma. ^
R Olei cadini 3 ■ 75 R Qlei cadini -i-
l^^trolati 30 00 Petrolati . 5/
•••••••••3
M. M.
These remedies should be used so as to produce a slight rabefiustioD tat
not inflammation.
PEMPHIGUS NEONATORUM.— In addition to the trae pemphigiK
of adults, the (^])idemic [K^mphigus infantilis, and the pemphigus which fc
DISEASES OF THE SKIN.
463
seondary to diseases of a debilitating nature, we at times meet with a form
f pemphigus which seems to be caused bv a para^iite of the skin. Bloin-
irg has re|x»rt*:<l cases of this kind ; one in a girl six dayj? old who had an
lorescenee ol* pumphigus begiuniiig on tJie lower legs and quiekly ^pivatl-
g to the thigks, the abdomen, and the fr«3nt of the thorax. Later tlie
irearra and head were attacked, but only a few bullte appeared on the
k. The lesiions developed quickly on a previously normal skin, and
isappeared after a few days, leaving a moist, reddene<l ec^rium. One of the
Ihe on the head was 1,2 cm. (J inch) io diameter. On tlie rii;ht foot one
tdla ciivered al I the toes and the sole of tlie foot. The sole of tlie left fo+it
covert^d by three bulla?. Entire recovery took place. No evidence of
epidemic was found to aoetRint for this case. Three ser\"ant-girls in the
ily who took care* of the child and who washed its clothes were ai!k*ted
fnim thi*ee to six days with the same efllort^xmce on their hmids and
ms. Another child and the mother had a fe\v bull© develop on them.
llomlxTg inoculated himself on the forearm with fluid from the bullte, and
the following day he was affected with a similar effloresi-ence, which
isappeared in three days.
This class of cases has not yet Wn fidly accepted by dermatologists,
id we must remember that on the delicate skin of infants and young
ildren impetigi> c*ontagiosa may cause the lesion of jDemplngus through the
Ctivity of the parasite and the great vnlnenil»ility of the skin.
PEMPHIGUS. — Pemphigus is a dist^ase of a constitntinnal cbarat^er^
d is represented by large blebs and bnllfe. It occurs at times in infants
d child ivn a.s it does in adults. It is very rare, and I shall not describe
io detail. There is a form of pemphigus, however, which I have met
ith in mfants and children in which bullie of various sizc^^ apj>ear u[K>n
e luubs and trunk, and which is not connected witli syphilis. It usually
cjcurs in pjorly-nonrishKl chihlren, and can come not only as a disease of
If, but also as one of the sapielse oi' debilitating diseases, such as pneu-
lonia, rheumatism, and others. Where it is sect*udarv to other diseai^^es it
Bpresenfcs^ a condition of malnutrition, and in all pnibability is not con-
leeted witli the real disease |x*mphigns. In my exjierience tliis class of
is not esijec*ially serious, but merely represents a greater or less degi'ee
lack of vitality of the skin.
Treatment, — There is no esjx'cial ltx*al trt-atment which apj>ears to
nefit this condition of the skin, l>ut it soon disappears when the general
iUtrition of tlie child has again beccmie normal.
This form of pemphigus, in which the efflorese<?nce is secondary to other
iseases, is not usually st*en uptvn tlie soles of the feet or tlie [lalms of the
imds, and this is of considerable aid in distinguishing the disease from the
wllous form of syj)hills.
Where |)empliigus oec^urs as an epidemic among infants in foundling
pitfils it is of a more serious nature, and is aceompanied by constitn-
nal symptoms, represented by fever, sometimes lasting i'mm three to six
464 PEDIATRICS.
wwks. Ill these* cases it is usually acute, but it may become chmnicnl
lust, with int«*i-\'als of recurrence*, for many weeks or months, li^.
<iisi*s are more apt to Iw fatal than the other forms. Tlie true epidoLK
iorin i}f jtuniUmt pcmphigm^ as it has been called, is almost always lata!. aai
ill casiv^ whei-e it is not sei-ondary to any other disease has a grave pruptek
Many of the rt^jHirteil cases of this epidemic form, as well as of the«4T
ioriiis of j)eiii|>higus, may really be only manifestations of the staphvlocuxis
invasion.
DERMATITIS EXFOLIATIVA NEONATORUM (Ritters D««i
— Ill the year 1878 Ritter gave the first complete description of thedisK
(fcnudtitis (wfoiiativa neonatorum. Previous to this date ceases of thisaffR-
tion iiad In^en n'iM)rted, but many of them were regarded as some rare or
unusual man i flotation of ()emphigus. Ritter studied and reported the c»«
which he saw at the Foundling Asylum in Prague from 1868 to 1878. A
<-areful n>view of Hitter's original observations of these cases has been mai
by pniiot, to whom I am indebted for what I have to tell you ooDoernia;
this rare disease. The majority of cases were in male infants^ and the mor-
tality was ibund to \)o 48.82 j>er cent.
The <Hs(*ase oe(»urred rar(»ly before the end of the first week, and uaiaD;
appeare<l Ix'tween tiie se(M>nd and the fifth week, of life. It was iysi
to vary greatly in the intensity of its symptoms. In some cages a diy
s<iily condition of the skin preceded the subsequent lesions, which had a>
j)areiitly last<Kl ixi\er the physiological desquamation of the epidemu? hii
taken phice.
SvMiTOMs. — The first symptom noticeable in these cases was a di^in
rc(hicss, usually over the lower iialf of the face about tlie mouth, sometiotf
however, iK'ginning in some otluT iK>rtion of the body, and at timesilMK
iinivci-siil Iroin the Ix^giniiing. This hytiersemia of the skin spread rapidly
mid in a few <lays Ix'canie uuiversal, the extremities, as a rule, being the 1*
jmrts atlectfHl. The mucous membrane of the mouth and nose wasattiiK
a11"cct(Ml, and the conjunctivje usually participated in the hyperemia. Ti
i-olor of the clHorcsc<'n(v vari(Hl from a light to a dark purple-red. Astk
hy|MM'jciiiia cxtciuhxl to new surtiu^es, those which were first afieeted began ti
<lcs<inaniatc. This (h^scpiamation at times gave no evidence of exiidati'3
the c|)i(lcriiiis Ining simply thickened, and the loosened epithelium separaiin!
easily. At times other lesions apjx'ared, such as milia, and sometim&dk
hniiiy layer of the skin was raisf»d alx^ve an intensely reddened base^flD
lar^c. irreirnlarly-shajHil bnlhe filled with fluid were formed. After th
(les<|namatioii had taken j)lace the skin nxiovered its normal conditk*
sometinus very rapidly, but it rcmaiiUHl for some time rough and irritahl
In the eases where there was no (^xudation a longer time was neccssarrfv
the separation and rcixeneration of the ejuthelium.
r Usually the disease was found to run its course in from seven to ti
<lays. Relapses wen- sometimes observed ten or twelve days after li
firr^t attack, but were always mild.
DISEASES OP THE 8KIK*
465
I lo typical cases the process wa.s iinaccompaiiictl by any fever or systemic
WLstnrbsinet^ unless some complication existed. The functions were normal,
and the weight of the infant remained stationary or was even at times
increased. The fatal caiscs resultetl cither from the intensity of tlie attack
or from some intercurrent atfection or sequela, such as fiiruneidosls. The
dL^ease is usually recognized as a local septic infection of the skin, and it
would sc*f*m that it should lye distinguished from the pemphigus which
<Mrurs in the early weeks of life,
I I have myself seen but one cai^e in which it seemed that this diagnosis
of dermatitis exfoliativa could reasonably lie made.
I Thi« case (Ca«e 198), a nmlfi infant, at tlit* fourth or fifth day of jt« life presented
[a marked eutidHkin of cni'thema tieoimtoruin AlVr a fi^w days IhU erythema began to
I desquamate i?li^htly, but somewhat Inter a pronounced dermatitis appeared and ran it< course
for a week, Diirinj;!^ th** course of the di&eai^e there were lesions of variouii kinds represented
hy a few pustuleii and bulla?, but mc»»tly by an intense erythema. The lesions gradually
j grew leis» intense, a profuse d«*y^f|tminatiori took pUct*, and the skm then pn?i?ented a normal
* appearance. During the etiursc nf the diseuse thfe infant did not show any oinsititutinnal
8yni|>toTni<, lind gained somewhat in weight. The pMit^nt>i were healthy, strong people, with
gOL*d hygienic surroundings.
I 1 shall nmv speak of some of the more simple forms of dermal lesions
[whidi fn'fjueutly occur in iufaiits.
I ERYTHEMA. — Erythema plays an im|x>rtant part in the diseases of
infants and yoim^ ehildiTU. Altliou^h it is one of the most n)nimon and
. rt^adily diagnostieat4xl disc^asii's of the skin which oeeur in early life, yet at
|tlm(?s it is quite difficult to diffen'ntiate it from other disi»ases, owing to the
[variety of its forms. It may l>e dividctl into two broad classes: (1) the
ofingestive ftirm, or (ryfhema mmpfvx, whu-li is eaused by traumatism and by
various drugs, and is als*j symi>tomatie of t!ie a<:"ute exanttiemata ; (2) the
inflammatory form, (rtffhana midfijnnm\ which may affect any part of the
lx>dy and eithcT small or liu'ge sinince*^. It lias, however » a prtMlilBtion for
tlte hiM'k^ of tlie hands aufl of tiie ilt't. Its h^i*ms may lx» reprc8(iitwl by
macula*, or in the process of its evolution these maculie may develop into
macnIo-pa|»ulc?(, vesiavpapules, papult^, vcsit^lcs, and even bulhe. The
k*?iionrt vary in eize. The color varies from bright red to purplish n?d,
I and is sometimes very vivid. The delimte texture of the skin of young
Bubjects is more likely to show varhitious in the f^ilor and the form of ita
lesions than Is the fully deveIojM»tl and stronger skin of the adult
I Symptoms* — The symptoms of tlie c«Uige^tive form are varii-il, and they
[do not a**cfmipany each manifestation nf tJie disi'iise with any es|xx'ial regn*
I larity. The slightt^t h>ral irritaticm, wh<'tlicr from ]>arasites or trauma of
[any kind, changes in temjxvr.ituiT, ivflex irritation from the ch»se mnuection
I between the digestive organs and the skin, and many other reflex manifc^ta-
f tions, may pnxluce the disease.
I In erytliema nudtif^^rme there may be pains in the joints simulating
I rheumatism, malaise, slight fever, nauaeai ooeted tongue, los8 of appetite, and
I 80
46G PEDIATRICS.
a swollen, tcndor skin. These more marked symptoms are, however, .iiiru
absent, and the lesions of an erythema multiforme commonly apjiear on tii-f
skin of yonutr suhjwts without any esj^vial geueral symptoms acwmianjii:
them. It is U'thT in your nursery practice not to endeavor to cla.«?ity tii
protean disease under siK^cial names which have been handed du\ni tNi
tinu» iniuiemorial in the text-lxK)ks, and which have no particular -kaii-
ciuuv. These names have IxM^n use<l indefinitely by physician?. aiiJ ilr
same form of lesion is S4»metinus ealleil by one name and s?ometiin(< h?
another.
TuKATMENT. — The treatment of all forms of erythema is praiti-illj
the sam(\ It consists chiefly in the application of a simple powder iI'k-
scription 5<)) of oxide of zinc and starch, and of a lotion amskting of tiiLtr
lim<' water or ros<' water in which calamine and oxide of zinc are suspcftW
(Pn'scription 57).
Prescription 56.
Mr trie. Apothecary,
Gramma.
K Zinri <.xi(li 7 ' T) R Ziiici oxidi ;i :
Aiiivli tritici 60 0 Amyli tritici 5L
M. ' M.
S. — For ext«Tiial application.
Prescription 67.
Mrtric. Apothecary,
Gramma.
H Zii'.ci oxidi, H Zinci oxidi,
CaliiiMiiiji' pni'panita; .... mi 7 T) Calaniinif prscparatss .... 44 Ji:
A<}u:i- c:»l('i> 1^40 0 Aqua* calcis s^Ll
M. M.
S. — For external application.
KnvTH?:MA IxTERTRicjo. — The form of er^'thema which is called in-
tertrip) \ have already referreil to in my lecture on nursery hygiene
(Lectnn' V., pajre 112, Phite III., A), and I showed you a case (Cas? 4i
j)ao:(* 1:52) of this disease at the time that I was explaining the proper ^^^
t<> preserve tlie infant's skin from irritaticm. I shall, therefore, not speak
any nmn- in detail concerning this (^>ndition, but shall merely state that it
shonld he classified as helonofino; to the (H>n^estive form of ervthema.
In the more severe forms of this disea.«e, where the erythematous conli-
ti(ui has iM'conie ec/eniatons, and wheiv the skin in the folds of the gnuih.
of tlie neck, <»r of the axilla' shows fissures and the moist condition k-piv-
sented hy ec/ema niadi<lans, 1 have found an application of boiaeic *y
po\v<ler ([uite eilicacions.
Krvtiikma Xodost'm. — Another form of erythema, called fryttflW
luuhinuni, is a disease which is cl(»sely allitnl to erythema multiforme. Thf
general characteristics and syni|)t<>ms of erythema nodosum can be wll
learnHJ hy stndyin<r the case (►f this ehild who has been bioufffat to my
clinic for examination.
DISEASES OF THE SKIN.
467
She is a little girl (CaBe 199)^ five years old, and until two days ago was perfectly well
["At that time she began to have loss of appetite, fever, and malaise, followed by pain in br*th
her legs. Following these general tymptt^nns this effloroecence appeared in various places
ou her leg«. You will notice it above and below the knee, but mostly over the tibia and
extending down as far aa the ankle. These lesions vary from 1.2 to 2.5 cm. (J to 1 inch)
in diameter^ ancf are of a somewhat irregular elliptical outline. They are of an erytbetoatMUs
I type and have a delicate pink color. Tht' skin over these lesions is hot in oomparison with
I Ihe unaffected portions of the skin around tbtm. The lesitma are tender on pressure, and
I their tisauos are somewhat indurated, *o thtit the feeling k thut of a hard, raised Bwelling.
The disease i« self-limited, Imt U irregular in its eotuise. It usuHlly disappeapa in about
two weeka. Ita cauae 1b ttot known. The treatment \s simply palliative.
I
UETICAKTA (Nettle-Ri^h, Hives). — The term urficaria has beeQ
applied to ati efflorescence characterized, a? a rule, hy wheals, which appear
suddenly and disappear quickly. It is aca>mpanie<l l>v intense itching and
burning, and may show itself on any part of tlie skin, in lesions either small
or hirg«* in niimljcr.
It is commonly caused by irritation of the gastro-^nteric tract. The
diisease may end in two or three tlays, l>ut usoally lasts for some weeks, and
may become chronic ; it is essentially , however, an acute afltction.
If the lesion has betvn severe there may be slight de^jnamation, but this is
rare, Somt^timc^s there may he only one attJick ; again there may be relapses,
and in some forms and in certain skins it may occur from year to year.
When set*kiug for the cause of an outbreak of urticaria you must in-
vestigate carefully as to whether there hns been an error in diet. In chil-
dren some simple article of fotxl may cau.se an urticaria to appear, just iis
in some adults the disease occurs from an idiosyncrasy which prohibits
them from eating oysters, lolisters, strawberries, or certain other articles of
diet. Again J in some individuals certain drugs, such as chlnnil, bromide <if
potash, chlorate of {Kvtash, and belladonna^ may cause the dermal lesions
of urticaria. The wheals of urticaria fre<piently occur as a symptom in
the c<uu:"se of various diseases, such as scabies, or may be caused by the bites
of insects.
Treatment. — ^The treatment should be directed first to the removal
of tlic amse of the dermal irritation. When this cause has been remov(Hl
the dermal lesions will, as a rtile, disappejir, unless still ftulher irritation
has been prixlut^ by scratching the lesion or by its being too severely
treated by the pliysician.
The diet should be milk for a time, and exjieriments should be made
with different artick^ of focxl to see wliich one may mus*^ this es|K<'ial tbrm
of irritation. The liowels should he c-arefully regulated. The local appli-
ions *A)nsist in n^mwlics to relieve the itching and l>urniog, in the wexu"-
of unirritating clothing and .S4)ft linen next the skin, and in a jHfwderof
starch and zinc, miulc as I have already described to you (Prescription 67),
fpwpiently applirxl to the lesions at intervals during tlie day. Where the
itching is extreme, anti-pruritic lotions and ointments should be applied,
such as the following (PresfTiptions 58, 59, page 468) :
468 PEDIATRICS.
Prescription 68
Metric. Apothecary.
Gramma.
B Pulv. calaininw 7 5 B Pulv. calamine j^i;
Aq. culcis 240 jo Aq. calcis Jii;
Aciili curbolici 1 87 Acidi carbolici . jn
M. M.
Wiion this lotion is not sufficient to allay the irritation and when; tk
burning is extreme, this ointment (Prescription 59) can be used:
Prk£h:ription 59.
Metric. Apothecary.
Gramma.
H Mintliul 0,6 B Menthol p.x
A(Hi)is 80 jO Adipis JL
M. M.
I have luTu a little lx»y (Case 200), sixteen months old, who has been bri»uehtt:»ti
hospital tor advice coiic<Tning the^e lesions on his skin. The mother gives thefilloTi:
account of the case.
A woman who had been taking caro of him, and beside whom be had slept »t ni^
was attacked with facial erysi|>elas of a rather severe type. The mother was exccediDZ
worried at this occurrenct*, and consulted her physician as to the probability of hericfu]
huviiii; c<»ntnicted rry>ipclas. She was assured by the physician that it would be unlia
for int<'ction to take |>la(»»» under these cinuimstanocs.
Thi^ was two days atro, and to-day she says that early this momincr the infant wai^Ai
to liavc c.)n^i(l«Ta])lc frver, to Ik* vomiting, to feel dull, and U> seem quite ill. While li -I
intr tlic infant in licr lap >he noticed that there was a red appearance of the skin ci»v«i
its riiiht kne<', and another member of the household, who considered that shehadiSR
knowlcdi^e of dix'a-cs in cliil<lren, announced to the mother that the infant had pn>ii
l;i> : the moth«T at once .-up])os(Nl that it had contracted it from the woman who hadfr^
«M"v^ipela»<.
On «xaininini; tlie skin you will see that the knee and the upper part of the lower lee i
swollrn and of a vivid red color. On touching it we find that it is not painful, but ihsti
skin is hot, and that there is considerable swelling of the tissues. The infant's t«?mneT»:w
is 40° ('. (104° F.), its pulse loO, and it looks as though it were suiTering from some jb
constitutional disi-a-e. The coh.r of the effloreiJcence is identical with that which weatt.n
see in eases of ery>ipelas, and this t'act, in connection with the constitutional disturb
Would make th«> mother's sup}>osition that her infant had an attack of erysipelas a ivty
able on«'.
1 have already impn-ssed upon you the rule that we should examine the entin sli
betop' makini; a diai^nosis of any special disease connected with it. I shall thewf-
altli«»ui;h it^is InLchly probable that this is a case of erysipelas, investigate theci«fl
further.
Now that its e|otht'> an» removed you sec that there is no other dermal lesion ont
infant > front, but on looking at its back you will see a number of lesions, some papular. tHfa
].aj»nlo-v«'siciilar. and In re, jn-t below tlie right scapula, you see a whoal. The infant i
show- ('vid»*n(o ot' irritation from the way in which it endeavors to scratch. These le*:
on tiie Lack are nvich-ntlv not tbo>e of infantile erysipelas, and on looking against t
oriLriiial source of (li>tnrbanee you will notice that instead of the diffVise redness so cl(«
sinuilatinix erysipelas, whicli you saw a few minutes ago, there is now an efflorcscc!
gra<lually fadinir away an<l Ijceoniini^ liirbter in color.
Thi- ehaniice in lh»' ap))«'araru'e of the etlloresconce, in connection with the verv eviA
lesions of urticaria on tin* infant's back, lead-* me to defer making a diaenosis untillb
que>ition<'d tlie mother '^till further cone^Tnimr the infant.
She now tells mo that yesterday the infant had been taken care of by afHend, whoftlkn
DISEASES OF THE SKIN.
469
I it to eat tome unusual articles of ftHxl. We can, therefore, account far the vomithig, lo»»
I of appetite, malaise, and fever by a disturlmnoo of the digestive orguns,
I I can now readily make the CL»rreot diagnosis, which is very evideut, and which would
lliave heen impossible if we hud only seen the efflorescence ha it occurred i»n the knoti and lit
I the time when we first saw iu It is a typical case of one of the more severe fiL*rnis of
I urticaria.
I The next cuse (Case 201) is a hltle gir), six year* old. There is no history of ct^nstilu-
[ tional disease in either of her parents. The mother states that she has had no miscarritiges.
I The child is said to have been a hoaUhy infant, to have hail no disetises, and to have heen
1 well until six months ago. She tlien began to c<ttii plain of fri>iitiil headache and to be
slightly fovpri^sh ui nig-bt* Her appetite grew ptmr^ imd she lost in strength wnd weight.
She has had no cough. She is slightly atitt»mie iind decidedly nervous. She sleeps well, but
I Ibe bowels are conalipftted. Nothing unusual has been noticed alwtut the urine, i^he coni-
iplaiiis of pitlpitution and dyspnoea on eatertion. There have been no artjculwr or mutcular
[pttins. A few weeka ugtj an effl'>re«eence atUmded with nmch itching appeared tJrst on her
li*ga and tlien on her buck und face* The soles of her feet and the piilms of her hundis were
not allected. The effloreskience coniisted of macules, at times wheals, evaneaeent frimi duy
1 to diiy, and^ as you see, irregular in their distribution. At tlme^ the leaions have been
roaculo-jnipules in certain areris^ and al>o papule*.
All exttmlntition of the t*he?*t sbuws the Inngg to he normaL The cardiac area of dulnesa
18 noriual. Titer*-* tire no eontinu<»us euniiac rnurmur^. There i?» slight irregularity of the
I cardiac rhythm, iind a abarp ring tu the eanliac sound^^t egpecinlly the second pnlmonic
I iound. At times altk.* there \a a sotlt evanescent murmur heard over the base of the heart.
On cbjfrer exami nation of the efflor^&cehce we Iind on drawing the finger getitly over it
f that the pink eulur disappears, shnwitig that the maoulei$ are caui^ed by a congestion of the
' hloc»d-ve>Ai'b supplying these area^ of the sktn. We therefore are not dealing with a
^ eonstilutionnl condition such a* purpura, which would have resulted in a rupture of th^e
' vessels, and wliieh also would have l>een free from itehing »nd darker in color.
[ The muthtM- niitumlly »&k^, what h this disease which so dii-fignrea her child's appear-
I ance. What shall we tell her? In the first place, I have inquire<l alwtui the child^s diet,
and have f(»und that it hits not been a nutritious one. What, however, especially struck
me was that the child hai* had fttr the past year a diet consisting largely of tea. We cfin
at once, then, account for her general condition nri the supposition that she is an inveterate
I little tea-clrinker. Her failure in genernl health, her headache, nervousne^^, and fjccasional
cardiac murmurs, all correspond to the hi>tory rif tea-poisoning.
We can now with thene facts obtained fn«m the general hist<?ty of the case diagnosti-
cate the efflorescence which play^ so great a r6ie ir» the child's ca.*e, iirr \i is the rash for
which the mother has bn^utrht her for treatment. The genenil lippeanince and description
of the t^ase pennit us to elinunate in our diagntfc^is the various eflioreM ences occurring in
r the course of scarlet fever, measles, and varicella. The ub-aence of hemorrhage, as I have
I already stated, precludes purpura. Th*^ absence of heat, of pain^ of swelling, and of indu-
THtion of the subcutaneous tissue* aUows us to eliminalw erythema nodosum. The eva-
[ Tiesoenoe of the macules and the great irritation enable us to state that we have not a
[ sypliililic erytheaia to deal with, for, as a nile, the macules of syphilis do nt^t itch. The
I appearance and deseriptir^n of the lesions are not those of eczema. In a word, you have
I befoi^e you a ctise of urticaria.
I As to the cause of the urticaria, we mt»8t remember that certain dnjgs, which I have
already referred tx*, may pn>dyee appearances of this kind on the fkin, and tlie clwe reflex
' connection between the delicate tenninal filaments of the nerve»» of the st^imach and the .^kin
I may caiij*e a great many disturbances, aniong which are irritation of the gastric membrane
• And a resulting indigestion.
In addition to tea and impntper ft>od, I find that the child has had quite large d'^ses of
tincture of chloride of iron L'iven to her This pre|pamiion of iron is a valuable one, and
was given for the child's amemiai but in young children it often is of itself a cause of
gastric irritation iuch as is reprf^ented in thi^ child. It was, thei^efore, especially as the
[eihild was constipated, not indicated in her case.
"f^mM'^m
P's^rri
470
PEDIATRICS*
In thit cliiss of cuet I think ibot it fs beet not to ^ve iron %t llivt, bQll#itQi>f^
ftU^mach to r«*cover lUelf by rejfulalinfij the dirt. I fehall treiit the child with i oKk
tlightlj alkaline with lime water, ami with thin soupd and bread onr iUt old 1 «lri
exclude from her diet tea, p«*try, und fnvd foods uf mU kinds. Lttt^r T tludl liWvk
to have a more laxative and leM irritating form of iron, &uoh aa this ( Prc«cnptioo H ^
a91).
Under this treatment, ctimbincd with IVeedom fham exciteiDetit, bathf, and pisif ^
fhssh air, I can, from my previou* experience with auch Giiaea, amfely promlie 1^
thtit thf* child will improvci become strong and ro6>% and foon be reiiered f^om bcri
able f-ymptomft,
ECZEMA. — Eczema is a disease of the akin which plays a mudi pm
r6k in infancy and early cliildlxotd than id any other period of life, b
one of the k^ion8 of the ^km whk^h should be placed in the hsndiaf
dernmtologiiit. It is m diffieult to eiire that it luiist always be look
upon as a grave dist^ase. You should, therefore, even in the slight
insif^nitirant forms of tvzema, lie careful not to give a favorable progpfl
imtil you have treated the disease tor some weeks, for at anv time it
extend to new areas of the skin. I dmll not attempt to g^iv^e morp das
very brief description of it.
It irf es.sentially a form of dermatitis, and we may find the saine
apjM'urin^ in cases whieh have been exposed to certain vegetable poisoB
such as the rhus toxicodendron, t<j variotis aitificial irritants, or to extna
of tem|ierature.
Bi^fore spakiug of the general treatment of these case? whieli uredj
in the hospital, I shall show you a few of the oases tliat have oome
care.
OA0K 202.
Here ia an infant {iln^v 202) in wb^^m the lotion s on the fikio are conEnsd iM
and face.
These lesions eonsjftt of papule*, pu^tules^ crusts, some excoriated DAtch«
scratching^ and a thick rather cedematoim condition of the »kvri, esp^K^iallv aimtiidl
noee^ and eyes. The hair has been cut off, and yoa see Yarious leaiona on th« acaln* \
DISEASES OF THE 8KIK.
471
in parts of the ec&lp you will notice a reddened moiet condition » which representB what is
tiled eoKemi* mbrum. Thi* u the aumu case as the one (Cnfie 48) that I showed you
I ft previous lecture (Lecture V.^ page 143) h& representing how-legs. He has returned to
le hospital with a recurrent eczemii of the fjace and head.
The treatment of this case is aa foUowa. The crusts aod the thickened tissue of the face
tld sscalp will first be softened by means of « pttultice. After the larger crusts huva been
^moved, the mask, which I have already shown you (page 148), will Ije applied to the fac©
bd scalp. The inner surface of this mask is thickly spread with ihU ointment (Prescript
bn GO) :
Prescription 60.
Metric Apoiheeofy.
Gmmma.
Ungjuenti zind oxidi, | B Uni^enti zinci o%idi,
Lanolini M 30 , 00 Lannlini . && gi^
M- M.
Eczema Unr^ersale*^ — The next case (Case 203) which I have to
Cask 208.
i universale. FV«iit]|]e, 5 ycnn old.
L Before treatment.
iow you is one that is Ixnng treated for ao eezema which has attacked
be fat?e, hejid, trunk, and extremities of a little girl five years old.
retard the recovery of an eczernii for many w»?eks, and llji3n*fof« it u of tf
tonoe for tlu* Buoce«s of the treatment of a cujmj of thU kind, as well as of (
and more local forms of eczema, absolutely to prfveiit the child fmni ^enitj
in Buoh CAses as are here represented b« accomplbhed only by the compl(
child's moveinfints.
Wo should flmt endeiivor to allay the itching by meiina of applioiit
akin, and secondly to bandage tlie thild in such a manner as to makf aiir <
imp<>ft&ible, I will hnvp thi-? diild while you iin^ hen^ in the ward trea.Ui»d|
which we are accustomed to coutml and almost invariably t-ur*." ihis dL
Case 2011
IL
^'
iimijii i ->i-»^p
Ebzema luilveniale. 11. Treated by complete reeL
The child u covered fri>m head to f(x>t with s<:*ft ct>tton cloth oomor
DISEASES OF THE 8RIN.
473
patient. The nurse fthould be instructed lo be Tory gentle with it, and cantinuAllj
^divert its mind from iu »kiii. UQd(?r this treutmrjDt in » few days the eczematous oon-
ijon of thL» Bkin will improve and the Uehing will dimiiiHh.
(Subset|uent liiston^ of the ea.se.) You remeraWr the case (Case 203) of
loiven^al eczema which I showed you at a previous lecture being treated iu
pd. It liad impn»ved so much within two week^ tliat it Wits allowi^d to
B out of betl aud dressed, aud to have tlie ointiyeiit applkni merely ou its
loe and head (III,),
IIL
OAfiB 208*
imiversale. 111. Tliree weekfl nfler tie^nnlnjEr of treatmenL IV. Four weeks after U'glixinii^ of
treiitmenu
You *e<? that the skin of the trunk iirid eitremitie* is alm(.>«t entirely welU The fiice
0o b 10 a much impr^-iTed ennditioD, und during moat of the day ahe in allowed tc* huve
le face uncovered and the ointioeui and bandatje applic^d to her head only (IV.)- I hope
fa few weekfl to be able to omit entirply the application of the ma*k to the fnct^ and of
e bandages U^ the bead.
The eczema hi thi.s c]ns^ of eases is very apt to recur.
It is oiteii a^kal by the mother and niin^' wliether tiae ecsema of infiuds
I cx}QtagiouB. I have seen instances where the nurse who was taking care
if a case of eczema in an infant had an eczema develop on her bandn. This
-^^SF
474
PEDIATBICS.
was apparently caused by the mirse having washed the infant's
The hands of tlie nurse were cuivd by local treatment, and by asbg
glovoi* in washing tlie napkins j^he did not again eontraet the eczema. Cm
of this kind give rise to tlie idea that eczema is contagious, but tIie]iGk
l>i]ity l^ that they are simply cased of artificial dermatitis cans^ by
sul>stan<jes of various kinds, and that thei'e is no esj^ecial germ whidi
et^zeiua. We <*jni, therefore, say that the disease is not contagious, and di
simple elean linear and prottK-tion of the hands by means of rubber gitfii
are all that h ne<x^s.^ary to [mn^ent the disease being eontmcfced.
I mitrht Diention that in this class of cases of univ^eraal ecBsni oAt
applimtions Ix^ides that which I have mentioned may often be luH
thtm^h in my exj>erienoe and in that of Dn Bo wen there is noooeappb
Cass 204.
Torticollis fkitu cnljirxecl and U-nder cvrvlciil gland«lii .
^na iL'iickT, n. ilUniis ivducMjd lu sixc and not lender.
1- *r^uW. 1. n\.'.
Female, 6 :
I
tion wliifli IS suitable for nil cases, and It k nitJicr the dctaiU of avi-K"-
the rciTiwiy. k«>].i.,!r the cliild quiVt, and thus allowing the skin to tw-v.r
it» \itjilit.v, tlmt institute the important part of the treatment Wbcw tie
eczi-ma i.s of a simple erythematous type, with slight itching, an appli^tio.
DISEASES OF THE SKIN.
475
f some powder sueh as this one (Prescription 67, page 466) is often
sefuJ, — the child being placed between two sheets and thoroughly dusted
rith the powder, while a nurse is in constant attendance to prevent
cratchiiig.
There is one interesting form or rather oomplieation of universal eczema
■ttie of which I happen to have here in the wards to-day to show yoiL
This little girl (Case 204) came to the hoRpitnl to be treated for torticolUa. The bead
ruB drawn to the left side as fihe dow shows you (I.), and she eouM not stmig^hten it. This
ndition had la!*ted for many months.
Un examining the child I found that she had the uaual imiversal eczema of a chronic
ype ttffecting the heod^ lace, and extremities. On examining the neck I found a number
enlarged tender glands. These enlarged glands were evidently caused by reflex irritation
im the eczema, and were the cause of the torticnlliB.
She was treated with the ointment which 1 huve just described to you (Pre«cription 60,
lage 471), and the usual bandage and mas^k, and to-day, although the eczema i^ not yet
ured, the irritation in connection with it has been so much lessened that the glands of the
eck have gradually subsided and have now disappeared , and the child, as you see, is able
9 hold her head straight (HO-
1 expect the child Uy receive still f\irther benefit from the treatment, and that she
rill be discharged from the hospitul cured.
la additirm tii the forms of eczema of which I have already spoken » you
Ivill mcfi with many mstant'es of a l<x^l eezema which has l:>een pnxliieed
\y sKjme irritation either at or near the place attti-ted, or perhaps in some^
tirely different part of the body* Thb is usiialh' called rejfen' eezenuK
Ln example of this form of eczema ia where the irritation is on the t^calp,
Lich as occiirB from pediculi, and develops a IcK'al reflex ecjcema on the back
f the neck,
PSORIASIBi — This little girl w^hom I shall now show you has certain
eeions on her back which it will interest you to examine* These lesions
.re characteristic of the disease called psoriaMs, Nothing is known of the
real cause of jistiriasis. So far as we can ascertain^ it is m^t dejMiiiilcnt on
ly niicro-organLsm. When the disease is well devclof>ed the diagnosis is
rery simple, and its lesions corres[K>nc], as a rule, to those which are corn-
only met with In the adult. It begins with small papules, which almost
mmediatcly Ixnxvmc aivered with scales. These scales have a |K^arly white
lor, and on removing them we find a bkt<ling surface, showing that they
"are moi*e closely connettoj with the corium tiian is the c*ase in other digeases
where desquamation takes plat^% such as dcrniatitis or scarlet fever.
■ The effloreeoence of psoriasis is general, and is, as a nile, marked on the
elbows and knees, for in these places the lesions coalesce and the scales are
especially thick.
I I have noticed in the psoriasis of children that the tyjie of the dis-
■Mt if. often BO mild that we can sctircely believe w^e are dealing with the
^niu6 aSbction that we are accustomed to see in the adult. In mme ca^es
K few leeiona scattered here and there, esi>ecially on the back over the scaji-
ntlfe, will be all that represent the disease, and will be easily eured^ even
476 PEDIATRICS.
disap))earing of themselves in a few months. BesideB affeofliiig the tak
and extremities, tlie efflorescence may occur on the scalp^ ftyeriallyata|fc
edge of the Iiair on the forehead, but the disease is not veiy ooniBflStili
face. Psoriasis is apt to recur even at intervals of yean, so that m
say that it van be absohitely cured, though at timeB it may
treatment and never return.
ThiM i'hild (Ciufo 205) has had the dueaie onoe previouBly, and ivtumft v* to- b o^
for additional tn*utmciit.
TIic h*f*inns. uri you ^iC'i^ vnry in size, and in thia case are tathar ematl, Wii^ aaJ^iia
5 out. (J inch) in diuniotor. Many of them are still smaller. Y^^^sm whal m
ref^idar outlino they huv(>, and how in the centres of many of the^^Bp Uit
stntill, |HMirly >%hito fcalcfl which at once enahle us to diag^ostioaBHto B
these sralt's ant not ))n>M*nt, as vonietimes occun in the early BtageiCff ihm iU*iaM,llli
nion> ditiiciilt to niakr the diagmM^iH.
Tli«' diM'asc \» not accompanied hy any conBtitutional eymptonu^ miudt atfaf^to
are no local HyniptoniHf >uch as pain and heat. On palpation yDti ind tlie^Mli 1» IA!
accompanied hy more or le^s induration of the Burruunding
Tkkatmknt. — The tn»atnient of psoriasis in children abanld bt
in its ionn than that whiiJi you would employ in treating the wAelL bf
this cast' 1 shall have this ointment (Prescription 61) of ^rysarobia ippk4|
to thr lesions in tlio evening and washed off with soap atid waier fBlk
nioniiiior, tlieix^ Ix'ing no treatment dnring the day.
Ju-.
Prescription 61.
Mtiric.
Gramma.
K Clirysarohini 0 1 00 R Chrysarobini
l*«tn.l»ti 30 1 00 Petrolati .
M. M. ,
This ointiiKMit stains the skin, but not permanently. It should IHIHvh
ap])Iic<l to tlic fa(v or the scalp, and should be used with graal CM)#i
(•aiis4's on sonn' skins considerable irritation, and at times a i
With ordinary caiitioii, however, tliis need not occur.
Jn intractable cases where this milder form of ointment is nat(
tlic stivncrth may Ik> increased to 1 or 1.5 grammea (16 or 20 gmM^ltii
onnee.
You sh(»nl(l r<-meinl)cr that chr^'sarobin stains the dbAei tUcil
(lellbly, so that old shcvts and night apparel should be used vUbAi
treatment is Ix'injj^ earrie<l out.
In })lac<> of this ointment you can use on especially irritable akfalLfrV
the i'iXLv and scalp, this j)reparation (Prescription 62) of solphor aai^i:
PRKSCRIPTIOy 62.
''^"•"- Gramma. 4po«-«,.
B Sulphuris oiyr, g Sulphuria . .
OK.i radmi r 87 Olei cadini m
Adipis 80 1 00 AdipU . . w
M. M. *
I hav« here another ca^ (Cftse 206) of ft boy now seventeen years old^ who first came
ider trt'atijient for psoriasU when he was seven years old*
Under tht' usuaJ treat mt'nt the efflorescence diBappeiired and the child was apparently
Case, 206.
DISEASES OF THE SKIN,
477
Recurrent psoriadfl. Mjile, 17 yearn okL
ired. The leaiions, howevt^r, huve r^Mippi'annl from time to time, and oome and go without
ferenoe to treatment. The lesions whit'h you see on his back are much larger than those
lioh you phw nn the girl (Ca«G 205). They vary from 2.5 cm* to 5 cm. |1 to 2 inches) in
imvter, jind huvc u thick, irregular outline.
PRURIGO. — Prurigo fXTiirs in two fonns in infaot^ and tbildixn, —
) prurigo mitis infaniiUH and (2) pmrigo ferox.
(1) PuFRfoo MiTLs Infantii.ls. — PruTi^ nfiitis infantili** occnrs in
ifant8 t^'o or thrpe montlis old, and may last for sorae years.
S^^MPTOMft. — It lM:'gins with little iimlnlar infiltrations, especially marked
the anterior surface of the extremitif^, and ig acocrnipanied by great
478 PEDIATRICS.
itching. It may appear on the face. It does not lead to an infiltrauoa :
tli(» skin or to the formation of pns.
TiiKATMKXT. — The trt>atment consists in remcKlies to relieve the itdcj
an<l alhiy the eezema with which it is usnally cn>inplicated.
It is closely allied to papular erj'tliema, but is more chronic and bi
^nater tendency to recur. It is ver>' rare in America.
(2) PuruKio Ferox. — Instead of this mild form a more severe type -i
prurip) (KH'urs at tinu»s. This latter form is far more serious iiiit>7ti-
tonis and in its pn)jj:nosis, and may continue through life. The diniit
which is chara<'terized hy the same dermal lesion as that just describttlc
protrnssive from the In^inninfi^; it usually starts on the leg^, and tie si
Ix'i'onies thicker its it di»scvnds. The eflflorescenoe is accompanied by enlrpi
glands, esjHH'ially in the inguinal region.
The disease is rare* in America, but is common in Grermany.
Its etiology is verj' ol)seure, and it Is a most intractable chronic affwdt
Treatment. — The tivatment is palliative.
For the extn^me itching caused by the papules an application of tti
ointment ( Prc^scription 63) may be used :
Prescription 68.
Metric. Apothecary,
Gramma.
H riitriH'iiti (liachyli, I K Unguenti diachyli,
IVtiok'i . . uAaOJOO Petrolei kk*,
M. M.
S. — To b«' a|»|)li«'tl nn fliuiin'l tlin*o tiiiiod a, day for ten minutes, and to be foil- vii ''
tli»* application of thu-' ointinont (Prt-'scription 64):
PRESCRIPTIOli 64.
Metric. Apothecary,
Gramma.
B rni^ii.'Titi (liachyli, R Unguenti diachyli,
Pctrnlati fta30|00 Petrolati . . U-L
M. M.
It* there is much infiltration, sajK) viridis should be applied at night azui
washrd otr the next iiiorninj^. It must, however, be used with eautiun,*
it i< vorv irritntinji;.
HERPES ZOSTER.— r have here two cases (Cases 207, 208) to^b''
you, — a hoy and a ^irl. They represent the disease called herpes t')^*''
Thi< disease is one whi<'h aileets l)oth children and adults. I shall, thei^
fore, not <Kvell esjx'eially u|K)n it, hut shall merely give you the mail
symptoms and the eharaeteristic a])]K»arances of the skin, which will enabl
yon to dia<:novti<-ate it.
Symi»T()Ms. — The general symptoms of herpes zoster are fever, Itss ^^
appetit<s and pain in som<' partof the head, trunk, or extremities. Tk
pain is always hjeated in the eoui'se of certain nerves. In some caaes^ k^'
ever, the pain and constitntional symptoms are absent. In this Kttk gW
DISEASES OP THE BKIN.
^^ 479
|Ca8e 207) it is in the nerval wliicli supply the skin of the »ip|ior part of the
ck, the upper part of the axilla, and the iippi^r part of the elii^st in imnt.
One of the eharaetemtics of the efllareacenee is that, as a rule, it is
'tmilatcraL It Is extrr^mely rare for the afleetion to
fiu, be iiilateral and to extend around the hody. Cases ^^^^ "^^^
•pf this kind, however, have occurred, and do not seem
to l)e any moi-e severe, except that larger surfa<v.s
•%v are affected than where the at!k*tion Ls unilateral. I'he
>^f character of the efHoreseence is essentially vesicniar,
and it is iii Ix' diffen*ntiate<^^l fi^)ni variwlla, which miglit
aecjmH)auied by tlie same general symptoms and is
► essentially a vesicular disease* As I shall presently
Eplain to you, the cfflorc^^'cnce of varicella is |;eneral,
not limited to any s{x*cial di.Htril>otiitn of the nerves,
JT is it painful, while the efflorescrenee whieh we are
examining hei*t* is, as you see, limited to tlie distribii-
■^tion of a s|K^cial .«et of ner\^es, — in tliis ease the bra-
cliial plexus. The vesicles l^ecome somewhat pustular,
ad soon crusts are formed. In this case, which has
isted thrt^ days, thei'f^ are still a few vesiek^s to Im^
[*u, but a large part of tlxe efflorescence is represented
by crusts.
The ilisc^ase runs a definite course of aTwut fourteen
lays, and from tlie beginning is aecompanietl by oon-
Biderable pain, through according to my observations the pain is not ao
evere in childiTn as in adnlts, nor Ls the itching so annoying.
Herpi^ft zi>ster, so far as we can determine, is not oausi^l by a micro-
;)i^nism, but h a constitutional dbeuse closely connected with the nerves.
ner|M"s a^ivt ttf rlffht
upl^r I'lie.Ht. Female, 4
The (ipxt naj^e (C&«e 208, page 480), a boy, hfti Uie mme dUeaie, but it u^ect« n, dif-
eiit set of nerves.
In tbia case the effloreeoenoe Atarts at the eacrum^ while in the oise of the littlt' ^trl it
arted over the cerrical region* Begianing at tlie fijwrum, it follows the ctiurse of the
veSf ov«r the If^d buttock and down the left leg as far as the knee. The yariaua lesioaa
I the same ua 1 hiive just deseiilied in the previous case.
You 8t»e, then, the perfect similarity in the cbamcter of the lesions and in the distribu-
tion ao far as following a particular set of nerves is concerned.
DiAONasis. — The diagnosis of this disease is very easily made from
general syniptimis of |min, fever, and malaise, in eombi nation with
eharai*terif>tic effiore8<x^nee, and we at ont« know witli what di.sc*a.se
re are deab'ng, for no other affection of the skin has so definite a distri-
bution.
Treatment* — The treatment i^ simply palliative. What I am aecus-
>med to do is to re^uhite carefully the child's diet, as I would in any dis-
with general constitutional symptoms, and to endeavor by the appli-
4S0
PEDIATRICS,
cation of lotions to allay tiie pain. The treatment which I shall idi|Ai
thi^ case is to powder the leaions thickly witli some simple powilff(]^
fieri ptiou 2, page 130).
Case 208.
Herpt* ztj^ter uf left leg Miilo» 6 yeaim okL
PITTBIASIS.^ — PtffrktJfiA is a term tliat k now, like the woM^
st'Uloiii ijswl without ati aeetmipaiiying adjective. There are two
turmH ol" the iitlbi'tion.
{1} Pityriasis RoimA Is u ram disi^^e in children, chaiactem
hyi>enEmia and finf ist-alt^ aiTwting, tm a rule, the whcde cutaneous!!
Tt may Ik' atteDtlwi with ;ri^^'it tx>nstitntional dkturbanee and lead t«H
Its diiratiun is always mii-eiiaiti,
(2) Pityriasis Macdlata et Circinata, or Pityriasis
affcH'ts eh i Id n^n as well a^ adidts. It apjieai's in the form of small
ivi^ scales srattercHl over the trunk, le^, ami arms. Theise
spn'ad jKiripherally or unite to form larfjer patches while the
goes invfdution : we tlnis neo a reildish shilling l>order imd a char
yelinwisli et^ntre. There may or may not be great pruritus accomt
In Vienna this affection is still reganknl as a form of ringworm* i
that eaunot, however, i)e itiaititainotL Its etiology is obscure,
well sjK)ntani*ouj>ly in fnmi two to ten weeks, and is best treated bri
sooth incr, auti anti[>ara.^itie a]>pHeation5»,
VERRUC-ffi (Wart8).— Wartt^ are circumscriljed outgrowths
DISEASES OF THE SKIN,
481
ipillflc^ of the skin with an a<-'c*oiiipauyiji^ inerea^ in tlie thiokness of the
>idermie hi vers. They are common iti children, espx^iall}' on tlie hands,
[id ttie old view that they are ciDntagious and auto-inoeolable has gained
iny adhereiitM of late. They are of various a^pei'ts and shap4?8» and nuiy
>e treated, tvs a rule, k*eally with suca^ss, altliough some are quite obj*tiuate.
le most efficacious metliml of treatment is painting each with a t»olutioii
salieylic acid in flexible collodion (Pa^seriptlon 65).
PmKSCRIPTION 66.
Metric, Apothecary,
Qromnm.
Acidi .^dicylici ..,,.♦.. 3 1 75 B Acidi sftlicvlici - S^ »
Collodii 80JOO CoUodii gi.
IM. M.
This is applied \idth a camers-hair brush twice a day for three days.
en it is soaked off by prolonged bathing in warm water, with the addition
pumir*e soap if there is no inflammation. This vnW usually remove a
portion oi' the watt, and the prc>eess should he rept^atetl as Itmg as any of
ihe growth is left..
ft The treatment with salieylic acid i.s not alway? successful, and recourse
■EUiy then lie had to glacial iK^tic acid, or to some otlier caustic, cai-efiilly
Applied ; or the gn>wth may be cxeistH^l,
■^ LENTIGO (Frc^^klt^), — Freckles are small aggregations of pigment
W'positiHl ill the skin, and arc c4inimonly seen in children uf ten years and
upward, especially in thost^ of light complexion. They arc usually situated
ki the face ami hands, but may occur on the a>vend portions of the body, a
^ct that UhI Hehni to regard them im not due to the actitm of the sun.
There can U> nu doul>t, iiiiwevcr, that the sun is the chief iigent in their
production. Their removal is often difficult and requires the use of strong
irritants, such as corrosive suhliniatc. It is rarely advisable to attempt
tieir removal in yotmg children.
Melanoderma Lenticctx^aris Progressiva (Kaposi's Disease) is a
^ery rare disrnxler, and is seldom met with in this country. In this affct*tion
r>ts of pigment like irecdvles appc^ar on the unctjveixxl parts of the btKly
Irst, finally extending more or less over the whole cutaneous surface. The
[>igment-spots arc the first lesions seen, l^ut later an atrophy of the skin and
^e formation of small angiomata dottnl (»ver the surface take place, giving
be child an extraonlinary appearance* The disease is usually found in more
one child in the same family^ and its etiology h very obscure, Malig-
ant tumiH*s with a fatal ending usually result from this affection.
LICHEN. — Many of the at!et?tions that w^erc formerly included under
head of lichen are now cwnsidered by most authorities to lx*long in other
[)nps, notably in that of eczema, A diagnfjsis of lichen is never made by
iLmerican dermatologists, but Uchen planus is a well-marked skin disorder
Irliich retains a place of its own. It rarely occurs in children, hut when
31
4S2 I'KDIATRICS.
|)n's<'nt it follows ixUmt the same coiii-s^mls in adults. It is ohanict* rizdl -^
linn iKi|)ul('s nl' an inv^ular shaiK' and glis?toniiijr apjx'animv, of a jft^.^jk'
n'<l<lisli-i)hu' or vi»»l('t color, with usually a t^liglit dejin^ssion in tht «::lT^
TIh' in<livi«lual papnhs may coalcsiv, su as to form i>atcbirs of j^rrwiieriri-
oxtrnt, covinnl with fine scalers. It is often atiNunjMiniitl by gn-at iuiiii.
antl <liseonilort. It attacks all parts of the Ixxly, showinir a i)RiliKiT>:
howrv*!-, tor the tl<'Xor snrfact»s of the arms and Irjrs. It may la.-t luri-si
months, and in the most favonii»le ejt^iv d(xs not clisap]iear for s«.*vmiW.*i;
The p^'iKM-al health is not usually attlrted, extvpt l>v the exhau-tiuu ::a
may in* «-ans<il by intense it<'hinjr. It may be iN>iitouiHli\l with a m»::ia
svpiiilide, which it often elosc»ly sinmlatc^, and soiiiotiinfs it may k-nrKiakr
for an (Mzema. Ai*scnic is of value in ehnmic ea*H^, and antiiwirasitie i-ti^
and ointments, especially those containing tar in some inrm, give Klii< :
external applicjitions.
ICHTHYOSIS. — The disease ichthywuf as it occurs in infants and y. n
<*hildren din's not differ in its pt^neral jiathology from tliat which i?5rtn;
adults. It may occur in intra-uterine life, and is then des^at«l/«
The most thorough work which has been done on the ichthvoi (
infamy and childh<MMl is that of Ballantyne of Edinburgh, whode^igm:
that form whii'h luis «MH'urred in uten) and is fully developed at birth
(1) f)r((tl irhfhjfnsis^ while the form which begins in the early w«k«<
infancy he s|H'aks of as (2) /<7i^/i//rww m^onaiorunK
(1) Imktal IruTiiYosis. — Th(» severity of foetal iclitln>>?i? w
irreatly. The irrave ti»rm, acH'onlinjr to Ballantyne, is develo|vd ppVotr
al>out the tliurth month of intra-uterine lite, and is charac-teriziHl attbetir
of hirth by the txistence all over the IxkIv of homy epidermic plates "*f
rat*-*! from «»ne ain»ther by tissun^ and furrow.s, associated with detbmiiiie'
tin* nuMitJi, nose, cy<s, li|>s, and liml)s, and loading within a few day? «'r ^ri
hours to the (hath of the infant. As in nu»st (*a*H»s infants %vith thLsiiiita
are l)«>rii alive, f«i'kd ichthyosis <»imnot l^ considered to be a caiu«e of intt
uteriiH' ihatli. The dis*'a<t' dms not sivni to affect especially the fUit^
wtiLrht of the int'ant. As a rule, the viscera at the post-mortem ?!>■
nothinir alMioniial ex«vpt an unusual (U^ree of ^ingestion. The miop><i^'?
examination -liows no extension of the keratinizing process on anvi'fti
mneon-- nimibrane^.
The minntr anatomy of the disease has l)een carefully studied bv Kyh
and ('arl)one. an«l the nui>t strikiuir tWiture of the diseased oomliii™
f«»nn<l t«» U' an rnonnon< thiekeniuir of the epidermal laver. This ini-rw
in the epidtrnii*^ i- ihw almo>t entiri'ly to hyjiertrophy of the stratum i*^
neum. The re<ult< «if <till further investiiration seem to show that tl
proliieratiuir activity t»t' the eells, instead of l)eing incteased, is arttol
diminislutl. In a ea>*- examiiunl by Southworth the rete Malpurhii. ti
iH>rium, tiie -weat L'land-, the .-eluuvous jrhinds, and the hair-follicks v«
found to Iv normal.
DISEASES OP THE SKIS,
483
^B Symptomh. — Ifi the early hours of life infants with this disease usually
Itsiy loudly and enotinuousjly, but S43metirae8 the cry is feeble and oiten very
[peculiar. The respiration is xn^uaUy iuii«?ded by the blocking of the nostrils
I with epiderraitr masses. 8nedon is reudeivd diffieult ur altogether imj>08si-
[ble by tlie preseuw of iehthyotie plates around the nnjuth. They, how-
[ever, are usually able to swallow reailily. As a ruk% nothing abnormal is
found in cotnteetiou with the urine or the faeces. Insomnia is a marked
symptom.
[ These infants have a very repidsive apjwaiiince, and there is a cadaveric
[odor arisiu£^ from the abuornuil eondition of the t^kiu. This iehtliyotie
I condition of the skin is usual iy universal, but is most evident ui>on the face,
\ The mouth is oitlinarily kept open by the contraction of the surrounding
\ parts, and innn its angles rmliate fissures which simulate the rliagades of
I syphilis. The lips are thick and everted, 80 as to form an irrt^gnlar entrance
I to the gapiug buccal cavity. The chin is receding. The nose ciin scarc«}ly
I be seen, it is covered so thickly with tlic epidermic plates an:>und the nostrils.
There is usually ectropiuni of Ixith eyelids, but sometimes only of the upper
\ one, the orbits scheming to 1h? oceupieil by fleshy tumors. If, however, we
separate the swollen eyelids, the normal eyeball is found to lie beneath.
The external ear seems to have disapj>eare(J almost entirely.
In <xjntradistinetion to the opinion furmerly held that foetal ichthyoflis
f iwtB a general sebiirrhipa, it is now generally suppoeed to be connected with
' the disease as it occurs in the adult-
pRoaNOSis, — The pmgnosis of tlie disease is almost always unfavor-
able.
Treatment, — The treatment should be ac*tive and directed towards
^ softening the epidermic a-ales by means of warm oil inunctions,
, Besides the grave form of ftetal ichthyosis, there Is a much milder form
I of the dist^ase. It develops during intra-uterine life, and shows a contin-
uous layer of a substance Resembling CN:dl(xlion extending over the whole
body and falling off in small flakes resembling pieces of tissue-pa jier. These
general appc^arances are sometimes awompaiiied by ectrt>pium and eclabium,
[ The disease is n*)t, as a rule, fatal, and often terminate*^ in complete or partial
I cure. There ha%'c not l>et*n any instances, so far as I know, of an infant's
being born dead with this form of ichthyosis,
TnEATMENT,^ — The tn*atmcnt of this st^cond form should l>e by crm-
' tinual Ktiuudation of the child's general strength and by great care of the
skin.
I (2) IriiTiiYosis Nronatortjm, — Ichthyosis in tlie new-bctrn infant,
I where at Inrth tlicre was no sign of tlie disease, may f»€cur. It presc^nts the
Fsame apix'arauct^s as the milder tlirm oi' fcetal ichtliyosis and the ichthyosis
of the older child and the adult,
i This Ls the common fiirm of ichtliyosis, which occurs at all ages. It
[ usually begins in the early months of life, is essentially chronic, and is very
I intractable to treatment
be a cf)ndonsati<>n of the tibrous layers of tlie skin, so that the
niuseiilar fibre are |>ac»ked closely together aud are increased in i
is chroiiie, is not very dangerous, aod is best treated by niafisag
eating applications.
SCLEREMA NEONATORUM. — Sclerema neonatorum is
constitutional disease, and I have therefore already describe
lecture on *' Diseases of the Xew-Bom" (Di>n8ion VIII., Lector
453).
CEDEMA NEONATORUM.— (Eiiema neonatorum is a :
whi(;h some authorities describe as distinct from sclei^ma
the chief diiferc^nce being that the skin pits on pressure and is
as in the latter disease. The general symptoms of the two disea
one another very closely.
ACUTE CIRCUMSCRIBED CEDEMA. — A lesion of th<
has lxH»n termed acute oiraniuteribed oedema- is represented by
apjx^arance of circumscTilxnl swellings of certain parts of the b<
in intcMisity and size in different localities. It is closely allied
and was formerly described under the name of giant urticaria,
know much about either its cause or its pathology. I have soi
with it in children where it was evidently of reflex origin, depei
ably, u])on irritation in various parts of the body, such as the
genitals, an<l the jrastro-enteric tract.
It is not dangerous, may occur at any age, and its txeatmei
symptomatic.
A casi* illustrating this disease came under my notice not loi
A lit t If bov iCu-e 209). two and oncvhalf years old, had had diarrlicBa durin
und Imd Imm.mi l«ft in nitluT a w«'ak, debilitated condition. He had for aoE
DISEA8BS OF THE SKIN.
m
ANALYSIS 59.
Color . * , . . Nonnal.
ReHcCioii ... ....... Acid-
Urophieiii . , . Diminished.
Iridoxyl ........... lucrtased.
Ureii ... IncreiuMid.
Albumin Absent.
Sugtir ..,.,,.. » . . . , Absent*
Bile pigments ... * Absent.
Speviflc gravity 1024.
Chloride* Normal.
Earthy |>brj^phiitefl NormuL
Alkaline phnspbnt^*® . Slightly increftsed.
Sediment . Slight increase of mucUB
and of epithelial cells.
Another instancL' [L'u^<; 210) of this kind occurred in a biUi' iMpy, three yeani old, in
rhom the peripheral irritation was evidently dependent upon a tight and irritating prepuce.
In this case sudden fledematous swellings of the fingen* and backs of the hands would occur
[ftt irregular times' lasting for a f<*w bcmrs^ and would then cntir^^ly disappear. These mani-
Lfe«tationB continued until the child wan circumcised, since which time the symptoms have
I Hot returned. In this ease, alfto, the urine wft>* found to l>e normul.
TUBERCULOSIS OP THE SKIN (Lupus, SiTOfuliiderma).— The
; case that 1 liavc to show you is one of a class the caiL^ of which for
iiany years wan uiikuowri* It wa*s desiguat^Hl by various terius, aotM>rcliiig
the tiiffereut tonus which it aasumecl on the skin. Thos, in one ibrni it
called lupus, in another scrofula. We now know that all thei^c^ forms
are caust^l l>y the same micro-organism, the baeUfns of tuber cuimi>t^ and that
i^this l>acillu8 may find its nidus in the skiu a.s it dues in various other organs
>f the l)ody. That is, we may have a locul tnlKTculosb of the skin.
Cabk 211.
TubercuiofiiE of the ikiu, Fejualc, 7 yeAiv old.
This UtUc girl (Case 211), seven years old, shows the leeioiw produced by the tubercle-
illu3.
Tou a«e iheee ledoiut an the Arm where they hnve ludumed a circulAr form, and in the
486
PEDIATRICS.
iniddU' part of tho fon-ann is one with tho active part m;
^Vll0^e tin* iliMa-jO ha- d«stn»yiHl the skin in tht* middle o
whitish »*oli»r uf the utr(.>))lii('d .-kin and the resulting scar.
\iiui«T the rii^ht eye, and a^)und the upper and lower lip
ti»u«' rovon'd with small n«Hluh\s, papules, pustule?, and en
fi»llnwin^ the gi-nenil rule of tulxTOulosis of the skin, tl
ati\»<*t»il.
Th«' child was treated at the Children's H<.»ipital for the
Latrr the tuln'n'ular pn>cess ap)M>anHl in the form of nodt
und«T all oirouiiistances, is very intractable to treatment, an
This allU'tion cl<KVi not differ in the child, in i
and its gonoral symptoms, from the same diseoise
I shall, then»foit', not sjK^ak of it more fully. A
syphilis, the ^rcnitost destruction of tissue of any I
The time of its apiH'anuux? varies, but it is more <
yoiinjr ehildren.
TuKATMENT. — Tho treatment is the same as i
ease o(xurs in adults. The iundamental ol)](H.»t to
tion of the diseasinl tissue. Where there is a small
easily HMuoveil hy the knife, this method of treat
We must rememlHT, h(»wever, that by this metho
to avoi<l removing the s/uuid tissue with the di!«
n'siilts as the avoidinjj of unsightly si»ars are not
meth(Kl as hy otliers. Theivfoiv where the tis8uc^
an«l areas are invnlve<l where it is desirable to av
face, a locality which is yory frtHjuently attaekeil I
cautery or <*lcctro-canfery may preferably be used, i
of which the solid stick t>f nitrate of silver as rtHN
Si'hool is a <ro(Ml example, have l)een found to be v
DIVISION X.
SYPHILIS. ERYSIPELAS. THE EXANTHEMATA.
LECTURE XXII.
SYPHILIS,
Ttie 8]KK*ific organism whioli aius(*s syphilis has not 3Tt been dii»-
covered. The disease as it is muiiifettH:! in early life apjx^ars iji two forms,
^-(1) acquired and (2) hi^rcdUarif.
The former diflers in nt> re8i>eet from the dieeaj^ as it occurs in Ediilta,
and 18 transiuitt«xl hy direet inft^etion, usually tlxrouij^ti one of the nioeouA
menxhranes. It8 treat inent and ^enrral rliumt teristii^^ am the same a.s in
adultH^ and I shall, therefore, not do more than refer to .so broad a siibjecl
as at*<|iiirtKl sypliili.s,
HEREDITABY SYPHILIS. — The hereditary form of syphilis, on the
other liand, plays an impirtant part in the di^^iises of the early montlis of
life, and is an ailwtion which in all it*^ pliasis should lie thoroughly imder-
Btood by those who pnu'tise among ehildi-en.
By inheritetJ syphilis we mean a eongenital disea^ which has been trans-
mitted to the child through one of the parents or through hijth. It makes
its appearanee either in the early months of life (syphilis of the new-born)
or at a later iKTitKl to^Hanls pulierty (retankMl ,<ypliilis). The stage wijieh Ls
met with at birth usually ct>rris])4)nds to an early stage of acquired f^yphilis,
while that which Ls delayed until later cbildhm>d or pulierty corre**[x>nds to
a later stagt*.
The quesiition whether the infant can Inherit syphilis fwm the father
without the infcH^tion of the mother is one which hji.s imt yet \m'n deter-
mintHl finally. The weight of evidence is in iavor f»f the view that its oc-
currence in thii^ w*ay Ls not |K»si?ibk% The probability is that &i>me mild
anfl transient form of the di^t^se has l>een overhmked in cases where the
mother has Ix^m appart^ntly hcaltliy, t^jRvially ils the nn>thcr of a syphilitic
infant is always immune ti» infection ljy her infant. InstiiutTS, however,
fXKur where it h impo^ible to say that the mother of an undoubtedly
syphilitic infant is alsi* syphilitic. A ease of this kind I have here to sh«>w
you to-tlay.
IB7
488
PEDIATRICS.
Tlio f:ith«T of tbU infant (Cast' 212) acknciwledgcs havii
pypliilitit' l«-i«'n wliii-h wn.- followed ])y pronounced j-ec'<ind
(Ca.-i- 'JVi) i^. :i> ymi >iv. a h«'althy, ."•tn»nj^ woman, who has ul
i;ivf any iiitHrniati«'n rit|uind rithi-r us t«» her own or as to hoi
to aid in ll»«' pn-siTvutinn ••1" Iut infant's lifi*. She i?tnt05 ihi
carriairi-, that >li«' was jM'rfj'ctly Wfll lioth lH»forc and after the
.-}>»' ha^ iH'ViT liaii an rlllnn'M-i-nin' on lior >kin, a sore throntf
nn'iu]>ran«"!. Sln' i-aiiu' umliT my oliservation whi-n her iiifu
siiuT th« II Ihi'Ii HHii .•.ntlirii-ntly often lor me to say that so 1
had no syiiiptoius that in any way eoiild ho attrihuti'd to syj
ph'iititul >iipply «»t' hreaftt-milk, whith was evidently of gocKi
The severity of the disease* dotormines the ty|x»
is also iiifluciiciHl hy tlic time* wlion the hiteetion <
Thus, tht' lat«T th«' jK-riml of infwtioii the miUler
efllorcsti'iKi' wliicli fii-st apiK^ars, while the less seve
the lH'tt<T will U' the propiosis and the jjreater the
tn'atineiit. The i-everse of these rules is found wher
|)lae<* early, and when*, as a residt, the infant is bori
such a<lvau<'(Hl state's of the tlisejise jis arc repK?seiitt*<
ftuuis t>f ellloroe^'uee aJid seveiv general symptom
exeeeiliuirly grav<'.
It is proi)al)ly |M)s.Hii»le for a syphilitic fietiis
utero. This theory of irtro'infivtion, however, lis
are«'pte<l. F<»uruier U'liev<s that there is a elass of ^
at the time ol' niarriaiic has no lesion which woiil
nmtlier, where th<' mother never shows any initial
frniii >yphili^ .-«> Nmil!" as sh<' is uiiimpre<rnate<l, and \
slie lM•<•^lm("^ syphilitic and eith«T alnirts or pvcs bii
In «'nini«ciiiin with the <ui)j<Mt iA' retro-iuflvtion the
a mntln r wliu iHrnmc^ >yphilitie durinj^ her pn^^m
{ jinsf-nniiu i,f/n,nt/ si/jt/ilHs), There is no doubt th
her (»wii -yphililic infrctinn, hut it 1kl< not yet Ut'ii
lii'tii- in tlir-r «'n-r-. j- al<n -vphilitic.
It h.i- Iwrn liinnd that wlu-re a woman is syj)
<'ninn»nn li>r \uv t«» nlmi't. Mi>cjirriaire is niort* fiXM
pM--inL: thn»n;:h the early >ta_Li-e< of syphilis than hit
nit. rr Ml- ir-- lial'itnatrd t«» the <li-ease. The tivatnu
(•aM'< sonn aTtci- IinprcL^natinn, and e<»ntinueil durii
valnaMc mean-- tA' aNcrliiii:' aiiortion. You must r
ihr alun-tid Intu- it{' a .-yphilitie woman is usual
a condition of the llitn-^ may l»e pnMlu«-ed hy otho
syphilid. P»iivh-IIirv(.|,i;.l,l |,a< foun«l from an c
nnmlM-r ai' mar«ratrd llitn-('< that seventy ix?r c
sy|)hilitir.
AitlmuLrh the tcnd<nry to transmit the disc»ase
time, yet tin- thonMipli treatment of the parents b
^ SYFHJI^* 489
^,, powerful means of preveoting such tniTisniLssioD, aiid the careful use of this
r-,,. drug in proper doses is never cjontra-indii-ateci It is, tlieretbre, evident that
^when a syphilitie woman becomt?^ prt*gnant she should Ix? treated witli
Wmorfury whetlier she was infet^tetl before or after coueeption. Wheii both
|>arc»Dts are syphilitic, and when tlieir syphilis is in the early stages, tlie
, infant is most likely to inherit the disease, and under like conditions tlie
(disease is apt to be of a severe typie.
Infants entirely free frtjin sypliilLs, either at birth or later, have been
known Uj lie l.iorn of parents of whom one or both were undoiibttJly
8>"philitic. Through the e<:)urtesy of my collca^ies at the Boston Dispen-
sary, Dr. Dixwell and Dr. Greenongli^ I am enabled t*i show you S4>me
'- cases of immunitv in children Ixirn of syphilitic parents,
^^^B The£« children (Cases 214 and 216) are two of u family of five, all of whom were
,^^^^B^y at birth iind none of whom have ever «hovvn uqj esyinptums of eyphilis. The fEther
^^IB infected with syphilid befi>re murriagef and Liter mfected his wife* They were both
corefiilly trented with mercury. The wife has never had any abortions. She has had five
chitdrL'ri ijud hm Wt none. Both father and mother have had undoubted secondary and
[tertiary lesions, some of which stiU exist.
The father of this next child (Ctise 216) is a nig-fiorter, whr> hud a primary gyphilitio
llesion nu his hmid twelve years ago. This lesion wiis followed by seeondury symptoms*
f He never hud any lesion on the penis. While he was beiui; treated his wife showed sj'mp-
b toms of syphilis and was also treated with mercury. This child hus always heen heallhj^
ltd is one of three^ nonu of whom have ever developed any syphilttic legions.
PATiTtJLOGV, — The piithological tissue-cbangt^ wbioh take plac-e in the
hereditary tbrm of syphilis ai'e of the game nature as thot^e which occur in
the a4M[nirt4 form. Diffuse lufrn^fifial htffM^rphmn h nitich more common
iti ttje htTHlitary form than are ciiTinnscriUd giinuny tnnn>rs. Changes in
the bones are very common in hereditary' syphilis^ and in fact s3o much so
tliat it iH nsually *»nf*idi'rt'<l ne<*(^sary to find these ostseous change?^ in order
to establish a diaj^noHis^ of sy|)liiUrt in the fietns.
Liver.^ — Gnbler'f^ de^cTiption of the alterations which take place in the
ivers of syphilitic infants is n^ graphic and as reliable as any whicli have
!n sinc^ given. The liver is aUvay8 larg«T tliaii in the normal aju-
dition. He states that the hepatic ti,«sue Ls hanker and more elastic than
tisuah that it is of a yellow cok>r, and that there are ^mall white grann-
hitions Boattered thronghunt the parenchyma. The hepatic acini mider
normal n>tidition8 are in nnitact, ex^x^pt at the prismatic spaces formed by
their union, in which spaix»s the capside of GliR'Sion Ibrms an envelojie to
the afferent jH:»rtat vessels of the l^rbnle. It is in these spaces that the
rmnnl lympli-cdts tMnn and eiillwt into small lobules representing micro-
Soopic gnmmata. The gumniata of the liver which are found in young
children with herwlitary syphilis resemble those which occur in adult*?.
Spleen. — Parrot states that next to the osseous system the s[)leen is
the part most often atJeeted by syphilis. It is enlarged, and tlie degret* of
0plenic enlargement is usually chaiacteristic of the severity of the disea^.
I
traoh(?a, aiul neighboring parts, and also with the thymus gland
the mus(!le8 of the heart.
Lungs. — In cases of hereditary syphilis born before term, am
born at term who live but a few days, the lungs present certain p«
conditions represented by nodules or small tumors, usually supei
varying in size. Sometimes an entire lobe may be involved, and
altered lung-tissue is colorless gray or white, both on its surfiuse
8ec*tion. This condition has been called by Virchow pneumonia c
hepatization.
Kidney and Teatiole. — ^The kidney and testicle may show i
of syphilis. It is to be noted that the lesions of these organs an
to treatment. The disease in the testicle is represented by
enlargement, and is usually bilateral.
Osseous System. — The changes in the bones which take
herc^litan^ syphilis are so imiK>rtant, not only on account of th
logical interest, but also because of their clinical significance* thi
attention should be paid to them.
In this conmvtion it should be remembered that in the latt
intni-uterine life the long bones are cartilaginous and the process i
tion is intra-eartilaginous. As the cartilage changes to bone the
cells incn^ase in number and are closely crowded together. Tl
the area of ostiH)blasts, then the calcareous matter, and deeper
th(» ossifiwl jKirtions are the blood-vessels nmning in from the p
Th(» epiphyses of the Ixmes of the arm are cartilaginous at birth,
remain separahnl from the shaft of the bone for some time bv
SYPHILIS.
4i»l
I
I
Ostctx'lKiiidritLs is ordinarily the forra of bone-<lisea^ in infants,
06te(>i>erios4titiri Ijelon^ ulmovSt exelusively to the later lormB of hertJitary
jsyphilis as they appear in well-grown children and iu youiag adults.
The bones which er* aflected most commonly are those of tlie arms and
of the legs.
Besides these common osseous lesions a morbid condition of the fingers
and toes, c*iilkxl daeit/HtiH, wt-nrs quite freifoently. In tliis condition the
fingers^ and tues assume a jxKudiar pyriform shajMi,
In addition to these pm^ly syphilitic changes, local thinning of the
bones of the sknll, called cranioiahm, octusionally occurs. In thi.s condition
the bone-subntance i^ absorbed, leaving only the iutcgnnient^ and membranes.
Symptoms. — In the mild ibrm of the disease the infant may be LH)rn
apparently healthy and may show no indications of itei syphilitic inheri-
tance for ?iomc wet^ks. It Ls rare, however, iS)r the symptums to be delayed
beyond the first three or four months of life. The earliest symptoms of
hereditary syphilis correspond to the secondary symptoms of acquired
syphilis. (Vminiuuly, unless the infant is ixjrn with the efflon^cence,
it is n*:»ticcd at birth, or within t^^'o or three weeks, to have occlusion of
the nAn^s (snuffles), and, soon after, a hoarse cry and an efflorescence of a
macular or a i>apular variety. Tlie efflorescence is geneml, int*hides the
palms of the hands and the soles of the fei*t, and is es|)ecially prominent
on the forehead.
The ctinditton of the infant dejiends consideralily on that of tlie mother.
The rule is that these? infants when born are ematnatetl, ]>resentiug somewhat
the ap|*earance of these premature infants ((_ases 102 and 106, pages 291
and 303), but I have sec^n them well develope^J and appai'ently in gruxl I'ou-
dition, ?L^ is shown by this infant (Ca^* 218, jmge 501), which 1 shall
presently allow you t*> examine. Tlu^ disease*, with apjipjpnate treatment
and goixl feeding, may in some easels Ih> arn?stcd in this stage, and }ye cured
so that it will not return, or it may advance to another group of symptoms,
which iUX' rejiresented by lesions of the mucous membranes. These lesions
consist of fia^ures at tlic angles of the month, ntiimus jiatches in the mouth,
and ctmdylomata of the anus. In addition to tln.'se manifestations, |)seudo-
paralysis of one or Ixith limlis of a greater or less degree may occur. All
the^ symptoms may arise, run their course, and completely disapjK^ar,
sometimes never to return. Again, they may reappc^ar at various times
during the individual's life, but tliey art* especially liable to return during
the niitldle |>c^riiHl t»f cbihlluKxl and at pulx^rty.
The Early Manifestations of Heredftary Syphilis. — I have
already explained to yoti that we can judge to a great degret^ as to the
severity of the disease by the tyjx^ of the efHorescence, and also by the time
when it occurs after birth, Tlie mildest and most benign form of syphilitic
efflorescence is represented by mamiw, the next by jMipnlsp., and the next by
{Im and bnUsc, Another form of efflorescence simulating pmyriamn is
of the more severe manif'cstatiouB of syphilids, as is also that form which.
i I ,j: n
492
PEDIATRICS.
^H
16 called rupiOf where tlie effloreseence consists
arranged one above the other, forming a conical
being somewluit infiltnittHL All uf thf^:^ types
known to he euixxl. Fiimlly, you will at timt*s in
form of the dL^^ase, which is almost imitbrmly f
treatment may be. Tlii.^ is what is called »i/ph
represented by large and numentiii^ bullfie.
These syphilitic effloresceutx^, nnlike most otl
appear commonly nn the |iulms of the hand.s and thi
Here in an Infant which I t^hnwed yon at a previa!
Case 127, page 367) to illustrate the enlarged spl
monly in ca^s of secondary antemia produeed by
8ec»n to-day it well illustrates what I have just said
effltu'eHeenee appt^ariufj on the soles oi' the feet*
Task 127.
^f^Ji
SypliUltic maeuhr, ulcePH, and bull© on the soles of the I
It U a male, two and one-half inonthg old. About one mon
mother had an clH<>rt^sftiice liinited U) thi* heiid : her hnir fell out,
The infant Wii^ apparently hetilthy at birth and tl tiring the first 1
no tiJinHtural Mpp+'ai-uncL'i* on its skin. It was then noticed to hiif
thematoua typt^ tui ilie body, faccT and arrn«, int'ludiiii; iho pali]
of the feet^ This efliorescence vvftri in the form of macula? of a 1
iniiig to-day the soles of the feet, we find^ in plnoe of the pp
have previously' secE^ pigmented area?. You will also notice i
at their junction with the nietatiirsitl bone* u number of bulla
and, the tissue bene^ith haviug broken down, ukenitiona have hm
of the soleg you will abo notiee ulcers **( vurious Bizea, ii few pm
and ihe pigmented i\n*A& alrendy referred to.
There is markwl oeclusion of the nares, and an exAminatioal
made by Dr. Coolid^^e show^fi that the turbiimt*^ bones on the 1
there h some intlltrntion of the mucous membrane of the na
ftero-purulent disicharjije from the left eye.
In a case of this kind, provided that we can elimi
of scabies, there ean W \\<> Aim\>tfeBi.VXJEVfe\««tfVQ&«s9k|
SYPHILIS.
493
r In addition to these general symptomi* wliioh I liavo just descriljed,
tliere occurs in tiie hereditary form of syphilis the lose of hair whieh^ as you
know^ in !50 couimnn in the aeqyiiml form r>f the disease. This alopecia may
^be cau!?ed by any of the dermal lesions which occur during tlic cuui-se of the
B, bat is probably due mostly to the general lack of nutrition in which
be skin participates with the other organs of the bmly in syphilis. In
ertitin oises the eyebrows and eyelashes are lost^ aud liarlow believes tliat
de former wndition is characteristic of the disease, or at lea-^t should excite
suspicion of it^ presence.
Enlargement of the lymph-glaods, ndnmpath/^ seems to be less marked
in hereditary syphilis tliau iu the acnuired form. TlVLs enlargement may l)e
|dae to reflex irritation from the more severe dermal lesions, but in oeiiain
it is found %vhere un dermal lesion exLst*^, The enlarged glands may
! in the iugniual, tlie axillary, or the cervi<\j-maxillary regions. They ai^
[distinct-, movable, multiple, and non-Infl animator}-. The older the child the
more likely the glands are to l>e enhirge*L
A<x'<>rding to Post, the nails are involved quite freqnentJy in hereditary
syphilis, and more frequently than in tiie syphilis of the adult. The oni/chia
aurs in two forms. In the first form a jiapule or pustule appears on the
ikin at tlie side of the nail. This ult-eratcs aud cxteuds ainng the side of
be mill, at times involving the matrix aud musing the loss of tlie nail. The
liic^k aud everted eilges of the ulcer, its sloughing F^ase and sanious discharge,
ire s(imcwhat I'haracteristic, aud are acconijiauied by a painiul enlargement
>f the distal i)haliLnx, (For sec^ond ibrm t)f unychia see jvage 0<16*)
The effect of hereditary syphilis on deniiHan is quite marktxl. The first
'teeth instead of l>eing cut in the .^ixth or seventh mnuth may not ajiiM^ar
UDtil the fourteenth or fifteenth mouth, and sometimes even later. Tht»se
Kprilmary teeth are especially liable to detmy early* There is nothing suffi-
■ciently characteristic to be of diiignostic value in the apjiearance of the teeth
Kof the first dentition.
■ Mr, Hutchinson has observed twenty-three cases of mtis in s^^ihilitic
infants. The average age for the beginning of the iritis was five and a half
months. The oldest was sixteen months at the time of the outbreak, the
youngest six months. Both eyes wcn'c atlected in eleven cases, and in tifUvn
kt»ses the eiftision of lymph was copious. The cornea w^as affected in a iew
cases. In seven ca^es the cure was nmiplete, in twelve the pupil was
imrtially occlodetl. Iritis Is one rif the rart^st of the symptoms of heredi-
tary syphilis, ami at timt^ escajx^s notice on a<x^unt of the xery slight
symptoms which usually attend it. The diagn<>sis iu these cases is not
dependent on the iritis alone, but the infants always show other well-marked
gymptomg of syphilis. There is gi*eat danger of the disease resulting in
blindness if it is left untix?ated, and mercurial ti'eatmeut is most efficient in
K fleeting a cure.
In i*egard to tlie digtdwe AiMurhanees wdiich arise in these cases of
Hereditary syphilis, it is well to rememl>er that they may depend vi^tw ^
or tliG niiicoiiH membranes. This class of cases is difficult to
from tlic liemorrhagic disease of the new-born which I have
scrib(xl. There is no doubt that syphilis has in a number <
etiolopcal significance in the umbilical hemorrhage which oc
early days of life. Dr. Uraoek has reported a series of hemorr
difierent internal organs apparently depending upon a syphilitic
infant.
The course of syphilis is so influenced by treatment that tb
must neiressarily be irn'gular. When the disease is untreated, i
the symptoms grow worse. The infSmt becomes more and mor
and either it dies in a few weeks of inanition^ or the disease pro
further and serious lesions of the various organs, such as the
spleen, and kidney, may finally produce a fatal result. The <
the narcs may increase to such a degree that the breathing of 1
seriously interfered with, and, without any other syphilitic la
die from im{)erfect oxygenation of the air which enters its Imig^
This o(vlusi<in of the nares may cause great loss of sleep.
however, imderstand that, even where this lesion is not of any |
syphilitic* infants suifer from insomnia. This insomnia is usu
panie<l by crying, so that it is probable that the restlessnesB ai
arc due to pain in the bones, as these symptoms are often pi
there is no digestive dlsturbanc'e.
In coiuHH-tion with these syphilitic lesions of the nose, flattx
bridge of the nose is at times a noticeable symptom.
Then^ is nothing cs{)ei*ial to describe oonoeming the etmdyk
are found in tlie anal ref/lan and are rare in comparison with th
the mouth. They l^egin as rounded papules, which sometimes c
I
SYPHILIS.
495
I
si[ii|>ly reprosentiug the lesions of certain iion-syphilitie afiectionSj may, by
their pecHiliur gruiiping in c^ombiiiation with other symptomifi, represent the
hereclitar)' iiwm oi* syphilis. The liA^ruis most commonly apj>ear uDuind
the Hj>{^ and on the mucous membnuie lining the ehwks. On tlie Ii}is
are ejtceedingiy frecjueot ; on the up|xn* lip tliey a)mmonly apix^ar
on either side of the median lobule, while on the lower lip they ait? usually
single and in ttie median line* The angle ot* the mouth is often the seat
of condylomata, and tliese are frequently eoveretl with enists and at time^
are de(^i>ly ideerated. A jx^euliar a(»pearanee is in some eases seen at the
commissures tif the nioiitlj, t^usfAl by cutaneous ulet^nitions, whieh make it
hj<jk larger than Uiirmal, and at timt^s pnMluee a number of line,^ n»diating
from the month to the cheeks. Ulcerations may occur on the tongue, the
lips, and tlie fauces. Foi-chheimer has written moi-e fully on these lesions
of the mckuth than any other author, and his nbst*rvations, now S4» widely
, leave little additional to be said on the subject. His description
of the fissures which tHsmr in syphilitic infants* nuiuths is very minute.
He c*insidci's that when tlicy are present they leave nc* doubt as to the diag-
nosis, sinit* they are infiltrated. The most ix>mraon place for them to api^ear
is at tiie corner of the month. In this place, a8 a rule, the most striking
feature of the fissum is tliat it is a papule which has l>een split in or almut
its middle, and that it has an infiltnite<l edge. The fissures simietimes dis-
appear in the raucous membrane, sometimes stop before reaching it, and
sometimes rmi into it> Tlie fissures may or may not be covered liy a crust,
and, unlike most syphilitic efflorescences, protlucc* more or less pain wlien the
mouth is opened. These tissures are called rhagades. They are charat^ter-
ized by their i>ersLstency and by their lack of tendency to sprntaucM tus
healing. Ulc€*rs and piaqiiat muqueuses may Im* found upfin tbe mucous
membrane of the lips and cheeks and on the sides and under surface of the
tongue. They are sujierfieial, hut cover more spaxv than the fissures. The
infiltratiim is not so well marked, but Is present to a greater or k*ss di^gree.
The most CH>mmon lesions which are found on the tongue are these plaques
muqueuses and ulcere. Both have infiltrat<xl alges, but the plague in this
situation rises alcove the level of tiie tongue, while the ulct^rations are
ciinsiderably depressed. They are both charac*teristic of syphilis. Their
locality Ls determined somewhat by the presence of such irritauts as shaqi
teeth pressing against a fiortion of the tongue.
The secretion of all these lesions of the mouth and lips is highly
infectious.
One of the striking symptoms of this early stag€* of hereflitary syphilis
Its from ostetK^hondritifl. Acctntling to Post, the form of lesion is
lally that of a tumor at the junction t^f the diaphysis and epiphysis at the
end I if the li>ng Imiucs, tliough any part of the osswms systt»m may Ix*
involved. These swellings art* difficult to retx>gnize in fat children* The
tumors rise abruptly fTi>m the bom^s ; they are small and globular, and in
some cases form a ring at the junction of the shaft and epiphysis ; in others
I
VM) PEDIATRICS.
tlie wliole i'pipliysis is inlarjrtHl. At times only a part of the canili: : |
atUftt-fl, and tlu' external swolliiig is crorrertiKindingly oiiviiiiiscTiU-l Ti-
l(*siniis apiK'ar simui af'tor birtli, and thoir development is eomplett?iJ ■::!&:
.*^l<»wly or rapidly. Tlie termination varies widely. Tlie swelliog ma v
al»H)rlMil under ap])n>priate treatment, or suppuration may tako plar oj;
till' skin hnak down ; the <lisi'a.st» may end in the .separation and de^ini: t
of tli(M'piphy>is. Tlie n-sult uixm the final gr«:)wth of the l>m« varii- :
e<»urH', with the severity of the Ijk'jU disease. When the morbid pn^-*!-
arnstiMl U'l'ore the destruetion of eitlier eartilage or epiphysis, thtn- i- 1
dei(»riiiity, hut the destruetion of ejirtila^e puts an end to gn>wth at ii
point, and a mon' (►r less shortenetl and useless limb results. Wlieiitl-
disease takts sueh a (»ourse as to separate tlie epiphysis while the iutir^uiK.'
ivmain sound, the linih lK'<'omes useless for a time and appears to I* \^e
Iv/ah], T\w diseasi' was first fully deserilxxl by Parn>t, and is knuwut
1 *a r re >t 's ( I isejise, < > r si/p/t i/iflc paemlo-para/yHis of tli e new-born . The joint? b
immediate eoniu'<'tion witii the diseascKl lKmt»s are sometimes involved. T:t^
may l>e simply an eflusion, hut, where the Ixine is destroyed, seriou? il>"r-
giuiization of the joint must follow. The jmin and sensitiveness in th^
eiw's <»t* pseudo-paraly>is are pnibahly caused by a lo>v grade of periifrtirL*
The iMines of the fin^'rs and of the toes, I have already told you. p
srnt at times the jHKMiliar hsion whieh is known as daciylith styphM^'-
The piialanx may Ik» enlarpinl to two or three times its natural sizi*. pivlEi'
the lin<rci*s a pyritorm slia|K'. One or several fingers or toes may V
involvcil, inid sometimes the mc^taearpal bon<>s are diseased. The pit'xiiLsl
j)lial:uix i> more t'riMjueutly atlirtid than the distal phalanx. Intheea:!^
>tii<:(s tlir int4\irnm('nt is un('han^*<l ; later, the overlying parts liKvoh
involved and abscesses f()nii. If the ease is submitte<l to earlv tn-atrj-i;
the dctorinity usually subsides, but if untreateil the disease mav r^ult id
IMTinanent deformity and uselessness. Daetylitis, however, is not ehanktt:-
istie of sypliilis alone, as it oe<'urs also jis a result of tul>ercular di?«i?*'ut
the l»<»ne.
(.'iMiiintalH's is one of the more unecmimon symptoms of liercditaT;
syphilis, Imt. us 1 have already told you, may in rare c*a.ses l>e found. Tln-r
softeiMil ^pot-, n<'arly eireiilar in form and alxnit 1.2 em. (i inch), mrnv'-r
less, ill (linnicter, wxwy be recoiruizcHl by the finjijer during life. Until W^
(TMniotiilM'- W.I- eoii-idtHMl to U' exelusively a symptom of rhacJiitis. Iti^
UmmhI <'-iK'riMlly in the oct-ipnt. Jt is present in rhaehitis where no traw'i'
-yphili- ejin Ik- dlM-overt'd, but it seems to 1k» most eomnion in i^ses wkre
their i> a di-tinet syjjliijitie taint. Of one hundred eases of orauiotal.*^
eolleeted by I )rs. I>arh»w and I^ees, in forty-seven there was satisfad-T}"
proof of <ypiiili>.
l)iA(JN()sis,— TIk. (liaLin(»sis of hereditary syphilis in its more advaiiad
fJ»rm>. sueh as I Imve ju.-t (h'senbe<l, is not ditficult, as no other direas
rejireser.ts sueh serious lesi<»ns of the skin with such a combination of
general synn)t(»ms u\ul Wlvms vA* \W Vl\vvv!v^\v!^ \\vLA\vViYtiQes,
SYPHILIS,
497
H Tlie iDild^r forms of the disease are frequently mistaken for otber
mnrnnm of tlie skin which Bimiilate the Bvpliilitit* lesions but which are of
a bcuign character. I have aliTady spoken of these lesions wiien describing
sucli liR'al diseas43s of the skin iis papular erythema, and shall refer tu thera
again when sjieaking of the mild forms of sypliitis.
Occlusion of the nares caused by swelling of the Sehneiderian membrane,
if persisting during the early weeks and mouths of lile without ris*? of
tfm|K*rature, should always make us suspicious of the presence of henditary
syphilis, ftir a syphilitic effloreseenoe is of\eD so slight and evanescent as
to hv (mpiently uverlooktd*
ilarkciJ ioiprovement from the admiiiL^tration of mercurj^ is also usually
oonsidercil of dia|j;nostie value, and, although not by any means ojuclugive,
is at k^Lst significant
Periostitis, esjiecially of the lower end of die humerus or the anterior
border of the tibiaj is met with iii children. It should make us suspicious
that syphilis is causing this condition, especially if tliere is periostitis of a
number of Ijc^ues at once.
A grt^at deal has lx?en written and much discussion has taken place
regnnling the r»:'Iatiouship bc»tween syphilis and rhachitis. The two diseases
are S() distinctly scpamtixl that it st^enis scarc*cly necessary to dwell, extiept
very brieflv, on the iliHerential diagnosis lK*twt^'n tln-m*
Rhachitls is so largt^ly de[>endent in its osseous changes ou a irrofound
disturbance of nntritit>u that it enn fairly Ik' said to result fmm any disease
whirh (rum its debilitating nature may interiere widi the nutrition of the
Ixmes. In this way individuals whose nutrition has lieen aeritmsly affef-ted
by hereditary syphilis may develop rhachitis. This, in my exjjcrience, has
been a rare octnirrence.
In regarti to the actual lesions of the Ixines present in syphilis and
rhacliitis, there set*ms to be a conciirrence of opinion that the patliological
conditions are ipiite difTerent. Thus, aceording to Cazin and Iseovesco,
sj^philitic bint^ ver\' rarely pit^st^nt the spongy tissue pc^t-nliar to rhachitis,
and rhachitic liones never show the osteoph>i:es of syphilis.
PutHiNosiR, — Frtim what I have alivody told yon, the prognosis in any
case of hereditary syphilis is a serious one* In addition to the results
whifh we are likely to have from the s\^hilis of tlie parents being early or
latf in ivganl to the inipregnatit>n, and fmm thrir having Ixh'U tlioroughly
trtatc*d or not, there are certain facts to be remembered concerning the
infant itself
The prognosis is grave inversely to the nuralM'r of weeks aflter birth
when the disease first shows itst*lf» The milder Ibrms of the efflorescence
justify us in giving a V>etter prognosis than the more severe ones. In addi-
tion to these conditions which rt»nder the progn^isis more favorable are the
possibility of the infant being fed with gfHid brt^ast-niilk or with a carefidly
prt*pan*d sul>stitute ftHxl, and gtKKl iiygieuic surr^jundings.
The cases in which the spleen is much enlarged are evideulV^ %ci 'V^^^
H. S2
498 PEDIATRICS.
t'ouiidly atlW'ti'tl hv tlio secondary antemia by which the enlarg^mett i?
cjiuscil that tluj ])n>^ii()sis is almost invariably bad, and the degree "f
splenic onlar^'nicnt may almost l)e taken as an index of the severin :
till' dis<*asi».
TIk' <>i>inion wliich \vc» give to the jiarents should, however, alwap k
vory giianh'il, as, even tliongh the disease may for the time api)arentlv k
entirely enre<l, it is always liable, as I have already stated, to ap|)Oiir ajiiii
in later eliildluMxl and at pulwrty. When the disease is amenable to trai-
ment tliese s<H*<»ndarv symptoms almost always disappear by the >efii»:
year, and in (piit^' a lar^ iuimlx»r of cases, where proper treatment has hi^a
tlionaighly ejirrie<l ont, the infant recovers entirely and is as well andsr-n:
as thongli it liad never had syphilis. In another set of cases, h(«wn-tf,
altliough tlie disejb;e is ap])arently eradicated, m later years it is tounJ t.»
liave lel't its marks in <listurlximx« of the difiereut functions and in tb
general lack of vigor of the varions tissues.
Tkkatmknt. — The treatment of liereditary sj'philis is first toadapisi
one<» as nourishing a ilxKl as is jK)ssible to the infant's digestion. A health;
mother with ])lenty of giMKl breast-milk wuU, as a rule, provide the bes
fo<Kl for her infant.
li' tlie niotluT's nntriti<m is rtxlneed by syphilis or by any other chmcir
dis<ase, tlie iniaiit sliould U' iU\ on a projwrly adjusted substitute food, while
the general hygiene, such as fivsli air, sunlight, and wanntli, should l)e care-
fully regulated. A wet-nui-se sliould not \ye employed unless she has herst-lf
had syphilis, in whi<'h ease the same rules will apply to her nursing a* :•'
that of the syphilitie mother. A sy])hilitic infant does not infect its luoiiyr
(CollesV law). It readily infeets a woman who either has never liad svphilL^
or who has never given birth to a syphilitic infant.
It should be remenilH're<l that the secretions from a syphilitic infant?
mouth are \i^ry iufe<-tious, whether the disease is of the hereditary oref the
ae(|uired form. If, therefore, the mother is not syphilitic and the in&nt
has a((|uire<l in any way a syphilitie lesion, the nursing must be discontinued
and tlir infant fe<l on a substitute f<K)d.
'Vhv only <lrug which can 1k' dejxuided upon in the treatment of the early
lesions of hereditary syj)hilis is mercury. ThLs drug naturallv would W
employed from our exj)erienee with it in acquired syphilis, where, as voe
know, it is more valual)le in the early stage of the disease than at anvothtf
period. In like manner iodide of potiu^li is of little use in the carlv stago
of hen'ditary syphilis, while it lKHH)mes useful in the retarded form, whiii
eorn'sponds to the later stage of aerpiired syphilis.
It is im])ortaut carefully to adapt the form of mercury which von give
to the syphiliti<' infant aeeording to its s|)ecial idiosyncrasy for the drug, awl
also to regulate the nic^ans of its administraticm according to the neoessitvof
having it act (|ui('kly, as is indieatcHl in the more severe forms of tbedisc^t
and aeeording to the sensitiveness of the individual's stomach or skin. Thns,
mercury may be administered eitluT through the mouth or through the
BYPHrLTS,
499
f
skiu. In the latter case it may be applitxl directly io the form of liquid or
oiotment or by means of subcutaneous injeetions* The la^^t mcthoJ shoulil
be used in very urgent cases only, for the tissues and skin of tlie syphilitic
infant are especially liable to be irritated to ^uch an t^xtent that sloughing
may take place, and the tissues under thenc! circumstances are readily de-
gtroyed. When used, it should be in the form of corrosive sublimate.
The t*oriusive sublimate should never Ix* given subcutaneously in larger
dos^ than 0,0(KJ6 gramme (j^^^ grain). Where tlie mercury is to be applied
directly to the skin it may be in the form of corrosive sublimate baths,
0.3 to 0,6 gramnie (5 to 10 grains) to each batli on(^? daily, but practically
it LS found lietter to introduce it into the system by means of an ointment.
This ointment may be the official mercurial ointment, either in full strength
or dilut4?d with some simple ointment, and this is very often applied by
means of inunction, as is the custom in the aec|uired syphilLs of adults.
After the infant's skiu has been tliorouglily washed, a small portion of the
Dintment should be applied to its ba<^k and rnblK^d carefully and gently
into the skin for ten minutt^. On the next day the same priMXHhire can
be ctirricd out on the front of the chest; on the third day m the axil-
lary" rc^gions ; and f>n the following days respectively on the outer sur-
face's of the arms and thighs. I have found that the most practical way
of applying inunctions to these infants is^ alter having thoroughly washed
the alxlomeu, to spread the ointment thickly on a piece of thin soft flannel
cut so as to reach fmra the eusiform c*artilage to the pulx^s and to extend
around the entire alxlomen. This ointment is made iu the ibllowing way
(Prescription tJG) :
Pbksobiptiox ©6.
Metric.
U Ungjuenti oleati hydmrgyri,
UngueDti lADollni ....
M.
ApotAteary,
I'
kk t)0 1 00
R Unguenti oleutJ hydrargyri,
UngueDti lanuliBi . , . . .
M.
3ii.
I
The band should be allow^ed to remain in place for forty-eight hours.
It shoulil tlicn l:»e removed, and, atW the skin ha.s been thoroughly wa^ht^l
with warm water and soap and dried with a soft towel, tlie flannel should
again \ye spread with the ointment and reapplied.
In giving mercury by the mouth I am in the habit of using the official
hydrarg)*rum cum crcta. 1 iLsually btgin with 0.06 gramme (1 grain) of
the drug, administertH:! three times in the twent}'-four hours. Within a few-
days I increase the dose to lour times in the twenty* four hours, and if no
unfavorable symptoms appear I again raise the dose to 0.12 gramme (2
grains) thret* or four times iu the twenty-four hours.
The unfavorable symptoms which I have just referred to aa poesibly
b(»ing causetl Iw the dnig are repn*sentetl by diarrhcea. We must remember
that the infants whom we are treating for hereditary syphilis are so young
that the salivary secretion has been very slightly develo|>ed, and that tliere-
wliii'ii l»y t'XiK'rinuiit lias Ut'ii shown not to caii.sf diarrlm/a in
inthiit.
Otiur forms of nu-n-urv, siuli as calomel in doses <»f O.OOJ
grain) tlntv or four tinns daily, niav Ik? pvon by the month in
riior vari(ais f(H'nis oi* nicn*nrv should be tricil whore loi
one of thcni is lijund not to suit the case.
|M)r tlic treatment oi' the fissures whieh ocviir around the '.
loions of tlie mouth, as \v«ll as thos<' whieh oeeiir at the anal «
in the lial>it of usin«r a >im|>le |Mmder of eal(»ni<»l, Avln<*h is di
part alVcttcil. Tlu* mouth shonhl 1k» ean'fully eleanstnl sc*veral i
thr tlay ami a wash of 4hlorat«' of ]>ota^h used at least twiet;
some <'aM's, though rar4'ly, nitrate of silver is neiHliHl as an appli
ulrcrs when tliey are intractahh*. Wheiv there an^ erusts an»i
and in the neighborhood of the fissuivs, or where anal oond
|>n>cnt, the ointmrnt (I*rescrii)tion (JO) whieli I liave just trlutv
nnich JHMiefit. The crusts should 1h' carefully removeil from
th\< snnc ointment gently applifnl to the h-sions. Thv anpHcj
ointment to the ahdomen is at times followtnl bv an <H."zeniato
of tlir skin of the alnhMuen, as has hapiK'md in tliis ease ((a
;^»<)7). I'lKler these eir<'umstane<s any simple ointment sliould I
plnee nl" th<' mercurial Inr a few days until the skin Inis rec^>vc
(•intinent <:mi tlu-n Im' furth<'r dilutinl with lanoline or some sim
and reapjilied, thus linally adjusting the strength of the niert-
vnhn*r;ii)ility of the infant's skin.
In addition to the mercurial treatment, tonics in some fon
iron, an- at tiims rei|nired. It is usually in the later stai;i>s of
that tiiey ai-e iiulieated, and in eases when* the JX'rsistenee of
SYPHILIS.
501
I have some infants here to-day who illustrate the different phases of
early hereditar)^ syphilis and the dilierent oouditions which you are liable to
meet with ia this disease*
This flret infant (Case 217) ia three weeks old. lU mother looks well and strong, deniet
having had any mk^carriages or diseaae of any ktndf and u^ertii that the father is also
healthy. Both of thej*e statements are probably untrue, an you will presently see ; but we
. have an excellent uppt^rtunity for making a diagnusis siuiply by inspection and by a
Ipbysical examination.
At birth the infant was puny and atrophic* It soon began to have oecluiiioti of the
QAfei. When one week old^ an efflorc«cenee of pafmlea appeared on its arms^ leg»^ and feet,
with pustuk'i? on the palms of the hands and the solea of the feet. It does not vomit. The
fseal movement*, aa you see on the napkins (Plate III., 4, facing page 112), are of a good
olor and fairly well digested. The heart and lungs are normal The splenic area of dul-
is elightly increased, but the spleen cannot be felt. You see that there are marked
fissures at the angles of the mouth, a muco*purulcnt discharge from the noBCi and crusts
, forming on the eyebrows. The mouth and throat show nothing beyond a pronounced ery-
I thema. There are papules and pustules on the body, and a squamous as well as a pustular
' efflorescence on the palms of the hands and the soles of the feet. There are macule on the
huttocks. The anua shows nothing abnormal. The temperature ia normal. The infant
looks fairly well nourished.
There can be no question about the diagnosis in a case like this, and the statements of
the mother regarding herself and her husband can be entirely ignored, for by simple inspec-
tion we see at once that we have a ctise of hereditary iyphilis to d«4il with.
Before referring to the treatment of this case, I shall ask you to examine
, another infant.
Case 21 a
Hinvdltary sniliflla. Hale, 0 moatbi 6td. Fed on good breast'intlk by a healtiiy mother.
This infant (Case 218) is six months old. The mother, a healthy-looking woman with
plenty of breast-milk, nurses the infant. She has had one miscarriage, in the third month,
and this is her first child. The father denies having had any venereal diaea«e.
..•v-r.
502 PEDIATRICS.
At birtli tin* infnnt wji< ratbor utn»i»lii«Ml uiid had a cconenil pnpulrir ••13 >-.■:>
nv«T it. :in«l lat'T :i -jjuaiiu»u.-i <'lH«»rfsci.*iKH' on th«' paliii:: of tht* huiid^ and lii- - 1-.- .:
l.i't. It Jilway- had iiiark«-d iHH'lu<iMii of tin; lum-.s (^iiiuftli's).
Tin- iiitant \va- iiiiiii<>diut>'ly j»lao'd uudrr ln.*utiiu»nt. and ii«»w liM>ks W'-li n url-i-i
l! i-; aK" a ta>i' nf li«T«'ditary sypliiliK, and shows the l»eiielici:»l n-sult ol' ::•.•
milk ami nnTiury. lor yoii ?<•••• that it i"* vi-ry larijo f«»r its uijo and i* fat and ."-trinj-! i":
It lia-, h'»\v«'v«r, riTtain l«'<ions of tin' Imuh's which are tlii» n*^nlt of ih.- ?;.].;.-.
inaiiif'-tatioii.. which it pn'scntcji at l»irth. One of these li'^aions is r»'pr»'-»i:l-i i ; i-
iiiMrlxi'd |ir-'iiiiii»'ni'cs whi«-h y<»ii sci* «»n cither sidt' <if the fr»>ntnl Ixmc, with :i - i.-tj;
dijir'"-' d •"Uli'U' iM'twrt'ii thi'iii.
On rvaiiiiiiinii ilh- infant'^ hands yoii will notion a still in»»pi* rhar?H't»ri-:i. 1 -: : '.
llic l..-ii«-. Yi'M >vv that th.- lir-t j)halan\ n\' Xhv left little finjjer nnd that >*f ih.- !•:": 'i*.
liriL:«T arc ."wolh'n and M»nii'what n-ddcnc*!, and that the tissues have a teri 1-r.i-T *.■ !^.i
d"WM. Thi< Cf»nditi<'M i- called .«»//i/*/7i7/V (lactylith. It is nut, ImweviT. charai t'T;-'.-
rypliilis alone, f«»r ca*»'- «»f tiilMiiuhK-is of th«' Ixinc often simulate this i'i>ndition. aiil :: ::-
.-> iM arly appn^aih it in appearance that tin* two diseui*c8 cunncit Ik? distini^ui-ohni l\ >\:.\.
in«piili<in.
To .".liiiw you th«' close n-scnililancc Ix'twccn syphilitic dactylitis and tuli^rcuL: \l
tyliti-. I have h«Tr an infant (C'a.-c lil'J) tm whose hand the same general chanictvri»ti:i ^:.
Ih- t'-und. In this case the thinl linger of the h-ft hand is atTected.
Cask 210.
'r»itM»rrnlar dartyliti&
In cmncction with the first of th«'s«' ca.-es ((?a.se 217) T havo statod that whil- :br
.•?y]ihiliti<' infant i- <li-crilH'<l •—••ntially as ntro]dne, thij* is, as a rule, the case onlv »h»rr ::
i' cl.priv.-il i.f iT'""! Ima-t-niiik it of a j)n»pcrly ]m>j>«»rtioned substitute fix^d. thi? atr* :1 ■
li'ii.ir n-'ially a fault in di«t. pn»vided that thi* intni-iiterine nutrition has been c«">i. V ;
M'«- tlj.'it n-itli"!- of tie—' <-a-i- i- -utii'rini: fi-oni nndnutrition. Thev are beinir nuivi "'■'
'tr-'nir ni'>thi'!-. wh<i an- L'ivini; tle-iu a jih-ntiful supply of milk. The PfK*ond cas*' Ci"^
lil^i i- lajii-lly r.'i-fiv»'rini:, ami will soon nei-d only to be seen and treat»Ml at iiiTrnsi*
In fai-t. it illn-tniti'.- nniarkahly Wf-ll hi>w healthy an infant may lfx>k who i? but '-K
rici.vi-ririir \'v*^^\\ tli«* in<»ri' -•■vi-n* symptoms "jf infantile syphiliH. In the flr«t ciijriCiw
iilTi til'- prML'nr.^i- i- n-'t <|uit«' -<• i^ood. as, aIthoui:h the infant ha^ been under twatment :' -'
tW" W'i'k-. til" I'-ions are marked and numerous. What inclines me however, to ]■"*
iip'in til'- ca-*' fav<inilily i* the iniprovi'inent whi«'h has iKH-urred in the mother'i' milk, i-' i
wlii.h will natunilly lind it' CMuntt-rpart in the infant's nutrition. The innomnia and >?'-
1.— FH-- whirh Win- prf.-i-nt in tlii- ca^i* have aUo i^n-atly lessened, showing that the ir.fi-'J
i.' iinpriivinL;.
An intrn'-tini: and inijxirtant pi»int to he noticed in this case was that when thenMb'.'
fir-l n«»ti«i'd th<" clllon'-r.'nr.- and liroiiirht the child to me she was so much fHi^htened tbil
luT milk had con.^idrraMy l^•-^ened in •juanlily, and the was sure that she would li«« ^
SYPHILIS.
603
' tbilk ©ntirelj and Uiat her infant would die. Judging that the milk was affected hj the
ni'Mitnl conditian of the mother^ I at oiioe caueed u inarkod re\'ul8ioii in thk ccmdition by
stuting decidedly that her mrlk would soon become plentiful, and that in the mean timo she
^oiild jL^ive her infant in addition to her milk about an ounce i>f the following mixture
(Pmicription 67) :
PRfiftCEIPTION 67-
Fat , 2M
^ Sugar , fl <X)
^1 Protcids LCH)
^B This substitute food suited the iniknt*» digestion &o well that the mother soon cea^iHl tn
^Hkve that it would diGi and the desired mivntal rtn'ubion was e^o f.*ifective thai in iw«^nty>
^^pf hi»urB the infant was receiving ita natural ^upplj of breasUmilk and the subfitituta
^ftod was omitted,
Sypliilk is so prolific a source of miMarriage that a histon* of mij*-
carririge in the mothtT justifies us in l43<:>kino; with Biispi(*iiin on a dnuhtful
legion of tlie skin in bcr infant. A woman inay have a nomlx^r of mi&-
Mirriages caused by j^yphilis^ and may then, if she has been treated with
nienniry, givo birth to a living syphiHtir infant, «»r to one that is healthy,
Tht^^ facts are important lor us to reuiemlx*r when we arc <x)nsidering the
prognosis in a case of hereditary syplylis. For instance, the motliers of
both of tlic^se infants deny having had any disease, and the motlier af the
first case (Case 217) says she hiLs liad no nii.scarriagt^is, while the mother of
the second Ciise (Case 218) acknowledges that she has had a mi.s<^rriage.
We raay take it for gmntcd from tlie healthy ap|>earanee of these mothers
that they have Wn tr»:^ted. This opinion, of course, is merely provisional,
and diK^s nut dciil with the additional argument which might Ix' hronglit np,
that both infants were infectctl by the fathers through healthy mothers.
These two infants have iKith had tlie same treatment, and that treatment has
been essentially gfWMl fo(>d and mercury in the tbrm id' oleate c^f mercury
ointment diluted one-half with rose-water ointment and applied on a flannel
to the alKlumen. In addition to this external tri^tment, hydrargyrum cum
<!Teta in d^>scs var>nng from 0*12 to 0.24 gramme (2 to 4 grains) three or
four times a day has been given.
Tfie next infant that I shall show you illiisirates the trouble that may
|Ari^' fn»m tJic physician in gt*ncral pnicticc not thoroughly undei^tandiiig
varied torms in which syphilis may manifi^t itsfflf in infancy.
This infant (Case 220), a male, four months ctld, wa* brought to my clinic three week«
Wi^ wilh syphilis of a nither agj^ravatiHl type, and among uther It^lon* this condyloma, the
remain.^ of which you now b<?*3 at the anal orifice.
It bad a general papular eiflorewH^nco on the lac«, body, and limbi, including the palmi
of the hands and the soles of the fec-t. The b^ft arm hung helplew by itf Me. You ^ee that
It can now move it a little. The lefl leg waa nUo i^omewhat affected. On eiamining the
arm T fitund that there wa/» a ?mall, hard, painfull, circumscribed iwelling at the lower end
of the hunierus. No crepitation wa*^ detected. The infant ww treated with mercury, and
a ran^fUlly proportioned substitute ftxwl was given to it. The mother was cautioned to be
very gmtle when she moved the arm, and to come frequently to the clinic for obs^^r^'ation.
She did nut bring the infant again for two weeks, but when the did §he wm very indig-^
Tbu next case (Case 221, Plate VI.) is of remarkable interest, owing to \
app'araiioe of the vfflonwcence, which , though uniuiud, it ao characteristic 1
represent no ot)ier diiMMiBc than syphilia.
The infant in hix wi>ek8 old. The mother statei that she has been maniec
years, hnn hud two children, and has had no miscarriages. She says that the :
and »tron^, and tlmt neither of them have had any efflorescence on their skin.
The older infant is fourteen months old, and is heslthy.
The younger infant is being nursed by its mother. At birth it was appsn
and well nourished. Its skin was clear, its body fat, and there was no oodusion
This condition continued until it was eight days old. It then began to have
the nares (snuffles), a slightly hoarse voice, and an efflorescencse on ite back. T^
that it has an efflorescence on various parts of the body and limbs. This efflo
sists mostly of maculae, many of which are circumscribed by healthy skin. '
size from 0.(> to 1.26 cm. {\ to ^ inch).
The lesions can be studied well by examining the right leg and fbot, where
ances ure most clearly depicted. In order to see the exact color and distribo
lesions, which at present are much obscured by dirt, I shall first have the
thoroughly washinl with soap and water. This can be done without vemoring
teristic apiM'arunces, since they are but slightly squamous, and, being nuistly
best be studiinl when the skin has been washed dean.
In addition to the macule, which you see varying from a delicate pink to
white color, is a pustule on the outer side of the leg just below the knee. On tl
and almost on the l>ack of the foot are the remainsof a bleb which hju broken d
been emptied of its contents. There is also on the inner side of the foot, nearc
a small ulc^r. All the other lesions are maculse, and you see bow distinct
muoiihe on the sole of the f(X)t. The entire skin of the heel is reddened and ]
appearance. The erythematous lesions in places on the leg are smrounded by
presenting a mottled appearance, and there are white spots on the skin. '
however, are cnus(.>d merely by the peculiar distribution of the syphilitic w»fnii
In addition to these lesions on the leg there area few ulcers on the but
addition to the niaculcu on the soles of the feet there are some on the p^lfni of tl
few scales showing a s<iuamous condition can be seen on the left le^, but this 1
prominent one.
The oycK an* not aifectcd. There are a few fissures about the mouth, but
SYPHILIS.
SOS
bticed in the early years of life, or they are so slight, or bo lat^king in the
liaracteristics of syphilLs, that it is sometimes impossible to recogniJie them
|B syphilitic lesions. The lesions of this late hereditary form eorresjwjid to
he tertiary lesions of the acquired form. They appear in ditierent jieriuds
if childhood or at puberty. These periods eorres|M>nd to what I have
Bpeady stated to be the time when a fresh outbreak of an attack of syphilis
rhich has wcurred iu the early montlis of life is apt to take place. This
^ significant as leading us to suspect that the early symptonxs of the disease
kave been overlooketl rather tlian to believe that they did not occur.
The lesions of tlie lx)iies hold a pn>minent place in these later maoifesta-
lons of hert^litary syphilis. These lesions may l^e iu tlie form of a f*eri-
JBtitis, or an actual necn^sis of the bone may take place eitlier in connection
fith a dactylitis or with a simple lesion of the osseous tissue in any of the
lones.
As these later forms of hereflitary syphilLs merely represent the same
pnditions as are met with in tertiary acquired syphilis, we should exj>ect
he most varied lesiuus. In this late form of hereditary syphilis the Ikjucs
If the nose are frequently involved, and a flattening nf the bridge of the
iDse Is not un«>mmon. The cranial bones show certain alterations which
% times are quite eharaeteristic. The fn>ntal bone may present a |jr<jmi-
lence on eitlier side, which, with a depressiuu more or less deep bet\vtM?n the
Prominences, causes such a jieculiar ccmfornmtion of tlie head as to be almost
paracteristic of syphilis. This is well represented in the case (Case 225,
pge 510) which I shall presently show you. In addition to these frontal
Irominences, at times there is a prominence of the centre of the frontal
bne, which, with the apparent flattening on either side, causes a jieculiar
hape siranlating the keel of a ship. Sometimes protulx*rances similar to
hose which I have described of the frontal bone may ai>pear on the parietal
lones. When they are bilateral the sagittal suture appears a^ a depressed
fcilcus between the*m, and this deformity of the skull, from its resemblance
p the shai^e of tlie nates, has been dasignated by Parrot as the natifat^m
kulL
I These tuberosities which I have just described as api>eariug on the
hull may also apjK'ar upm the long lK>ues, either in the diaphysis or in
he epiphysis. When the tibia is affected there Ls often so marked an in-
rease in parts of the shaft of the Ixme, i*s]>etnally its middle third, that,
i the enlargement is chiefly in the antcrinr j>ortion, the swelling when
rominent gives an appearance of curvature to the bone. This is, however^
ply a seeming curvatnn\ as the posterior |ic>rtitin of the bone Is not aflectid.
I An interference* with the gmwth of child n^n who are affected by these
krious osserjiLS k^iivns of syphilis is not unct^mmon. There is frequently a
ick of development, which .shows itst^lf iLsually in a failure of the individual
P attain the ordinary height The mental development is retaixled, the
bildren often apj>earing to Ije a numlKT of years younger than they really
be. TUb condition Fournier has designated as in/aniilmn*
^■1 u'rjstii:9 ui sypiiiiiiii; tcc-tu wui\; iii-DtiAtsuriucu, o^ J3.UK:nni»uu. J.
ill sha|)e of the tei^th is not ahvays present in syphilis, but when it i
jl certainly very HU^gcstive of the disease. As was pointed out b
the (lentL^t who examined Hutchinson's cases, in nearly every o
there wa;^ a deficiency in the superior alveolar arch at the anter
so ^n^t in some cases that when the jaws were closed the up]
lowiT incisors did not come tc^ether.
I have already de^ribed the onychia which occurs as one of
manifestations of hereditary syphilis. In the late form of syph
form of onychia is met with, characterused, according to Post, bj
at tlic base or the side of the nail, which becomes thickened, fi
brittle, with more or less deformity of the phalanx.
In the late ibrm of syphilis a peculiar inflanunation of th
times apjx^rs. It usually b^ins with a cloudiness of the subst
cornea, with ciliar}' congestion. The entire cornea in this wi
cloudiHl. The atfection is not accompanied usually by pain, ai
show any special congestion of the conjunctivsd. Hutchinson
it is always symmetrical, although at first it is apt to b^in w
and later to attack the other. The interval between the two a
extend over several years. This disease is called intertiUial ht
may ior a few weeks almost entirely abolish sight. It usually
under treatment without leaving any trace behind it. On the c
o|)a('iti(» are sometimes leil and interfere with vision. The toti
of the dis(*as(^ varies from six to eighteen months. Jnterstitii
ac'conliiig to Post, occurs most frequently in female sulgeotB, a
ooininou Ixitween the ages of ten and fifteen, although it may o
I'arlier, and, a(HH)ixling to Foumier, may even be met with at birt
Complications may arise in the shape of iritis* dioToiditiA. ati
8YPHILJ8,
507
Case 228.
ren at first in doses of 0.12 or 0.18 gramme (2 or 3 grains), and this dose
uld Ix* gradually increased to 0.36 or 0,6 gramme (6 or 10 grains), or
en more, ils cliildren oileu tolerate this drug remarkablj well, and large
pees are usual ly indimted.
When iodide of pjtash is given in eombioati<jn with mercury, you can
pn >vith airrosive sublimate in doses of 0*0006 gramme (yj^ grain) and
Bdually inerease the dose. Corrosive sublimate Ls, h<jwever, so apt to
iLse disturbance of digestion that I prefer tt) treat these cases by giving
icxlide iif potash uueombined with any other drug, by the mouth, and
plying mercurial ointment to the skin/
The treatment of thcst:" later nmuifestations of syphilis must often be
tinned for long peri*>d8.
I have here, to Hlustrate the retarded form of syphilis, a girl (Ca«e 222), thirteen yean
This case ehowB the irupnrtmiee of carefully revHewiog the previoiu history not only
the cliild; but also of it^ pttrt'iita.
Tht> riiittber has bud only tlii^ child, ha£ never bad any luucarriage&i has always been
1, and bi^ never sbowu any aiaQifestations of gyphitis.
The father, so far as I ean aecertain, until recently has
rays been well and strong, and has shown nn signs of syphi-
About one year ago he began to have cerebral eymptonis,
ich mpidly increased, were aceompanied by paralysii^, and
e undouLtedly of flyphilitic origin.
I was flrat culled to see tlii? ebild when she was suffering
n a mild iittack of uppendicitio, which did not come to oper-
n. At that lime I noticed a peculiar conformation of the
(per incisors^ which made me at once suspect thai 1 had
der my care a case of hereditary fiyphilia. On further in-
Iry I learned that she had been trr^ated some years earlier
nn fx^ulist for keratiliB. The upper incbors, as you Bde
liagram 7), are abnormally far apart and stunted in their
wtb. They are notch ed^ tus is also the left lateral inciflor,
ich is peg-shaped and by it^ clearly-cut notch repn:^Kents
►re nearly than the others ibe cha^^cte^^tic syphilitic teeth,
right upper lateral incisor has a peculiar shape, the cnjwn
the tooth coming down almost to a |K>int. The other teeth
, aa you see, in many places deprived of their deotine, and
In various stages of disorganization.
On recovering from ibe appendicitis the child remained in
ireak condition during the following year, looked sallow, and
4 continual headaches, which did not improve under the
lal remedies. Treatment with Iodide of potai^h has not only
n followed by the disappearance of the headaches, but also
resulted in this healthy appearance of the child, who ii
rfectly well.
Here is another illu.stratiun of what is prrjljflbly
retaixled tbroi of sypliilis*
Probably retarded syphilk,
Male, 7 years old.
ThU boy (Case 228) is seven years old, and U a negro,
mother, who la said to be white, has had two miKcnrriagea.
history of the father is not known, except that be was a negro. The boy has nevw
d any disease, except measles when he was two or three years old. Them ia no history
o08
PEDIATRICS.
nf hi" oviT liaviiiix lunl any «»t' \\u' «'tirliiT ijmnif«*>tati'»ns of hf.*n.'Jitiiry jiyphili*. ^ •-.:
wu- f'-ur yi*ar.-» nhi \w \im\ wlial wi-n* «l«MTilMHl a* «'iiil«'ptitonii r«niviil-i-'i>, u:.i -.■
h«' 1j:i- l«a«l tlini- \>r t'lUir nt' tlu'*«' attaiks. T\w attai*k> c«»ni«» «>ii .>mlilt'iily. ar.-i i- .-
M«iiin.»l«nt atliTtli'V hav«' pa-^^-d «»tr. Evi-r >inc-i' lu* was fi.iir y«*uPH fid hU a!-i::-
]i»»'ii iimn' nr !••"- «li-t«*rnl«'»l. His aji|»»'tili* is i;ihh1. his 1m»\vi'1s jir»' ri'irular. U'-b*-./-
Ikoii l»r«'Ui:lit !«• tin* li"*j»iial tn Im* In-alril fur licadaclu*, a di>tfiicl»-d alKJom.-n, si.i h-r
ll«' has 11(1 tMilariird inlands, i- imt rhat-hitir, liiis no enlaix<'i>>'''it «»f tin* >|-'.x-r. y .■
a>»it«'*. Tin- livtT i^ t*«»uiid t'» 1m* miu-h fnlanrfd, and, as yoii Pfe, ct)nn.'> as l...\v6»r*.- -
nt' tin* innl»iru'iH. l$«-ln\v thi- lin«' nf livtT duliK^s the alxli»nion is n'^unant. T'Lr •
iih-ntally \v«-ak. ami is vi-ry ana-init'. On cxuniination of bis tefth you .-vo ibat t"-"'
!iiarki«l abnnniial <'liaiii:i-i in tin* inri-inrs. Tlu* upper fe»ur infi.<ors an? n«»uii»J. "^.'
in -i/.i'. and uiinatundly far apart. Thu lnwer two middle inoi.^ors arc al?-.i ?: ai. :
nolili.d.
I have ln-rn tn*atinic tlii^ Imy fnr tin* past month with hydran^ynim turn i-rl:. '.j'
ni.iuth and with nitTiurial innnrtioii-.. I'ndrr this troatiiient his guiifral h«-a'.i*:i h -• :. .
inipr«»v»*d, anil In* d'"*-* iH»t ili"]day tin* sanu* di'fjri'f of mental hebetude tha: '•.■•
fntrrini; tlu' hospital ; Im lias aU«» craH.*<l to have ihi' epileptiform uttuck.s already TK*rr>:
(rnil«T tin* iin-n-urial tn*atiiu*nt tho Iwiy made a most decided inipr.'Vf^uvL: :.
i:«'iuTal in*aUh. Tin* liver divrt*as«Hl in size, th^ dii^estion and appetite impp-vrl i^.
flailed stt*adiiy in wi-iirht and in mental development. He was di^har^ged f u: ::. :
aftiT •nti'rini: tin- hM-])ital, apparently |Mfrfet'lly well, except that there was eti a » :.,
enlar«^»'iiu.!it nl* ihf liver.)
Dl.VdUAM
I havo in this (liajrram ropresontoil twelve syphilitic teeth of theses
dcntitiini. They are all, as you h(»o, more or less disorgauizcd in a •'
which might ocx^ur fn^ni any cau^vL
would iuterfere with the normal dtvr'..
mout of the teeth and cause their kx
(ItH-siy. The middle two and lert late
upjKT incisors show the notc-hetl and *.:
what i)op:-sha|)ed condition which i* ^
lM)s<'d to be charactoristic of sypLilk. a
wliich you see I have copied frcrni :
mouths of the girl and lx)y whom I b
just shown you (Cases 222 and 223!.
Art an illustration of these var>
tertiary h-sioiis of syphilis, I will now show you a child who ha« iv
treatctl here in inv clinic for s<mic mouths.
Syphilitic t«***tli <if tin* mtoiuI dentition.
It i- a i;irl i('a-«- *J*J4), tliPM- atid on«'-half yoaiv old. You will notice certain l^ix«
th.* t':i.-... tirni-. hand-i. :ui>I T.-.t. whi.-h are the n-sult of c-ongenital syphilis. Wbri -
.liild \va^ l.nrn it wa^ aj.jKiPiitly liralthy. When it was three months cdd it Wll^ ii'ii-^
liav.' Mi'clnsi.in ot* th»' M:in>, :md at that tinn* it had an attack of bn>nchitis la5tins!«.Tii:
\v.-.k>. It is -iiifj tliat ii.> j'tllni-i'^f'.'nt'f was »'V(*r n«»ticed on its skin. When it usi* .-'■•
ni..Mtli< mM it- haii.U iM-.j^an t" -well, and at lourt»'<*n months the tissues anmnd xhe • •■
carpal Im.h.-s ..f tli" littl-- liiii:..r- ..!' hutli hands became n>ddened and ulot'rat».d iri -
liiii^.-r- a-suiMi-d ili- p\ rit'..riii -luip.' ^■ha^act^•^i^tic of .syphilitic dactylitis. When tbr -•
\va> al.out M\ti'.-n iii-ntli- ..jd, tli- f.-.-t ]»-iinu t«. swt-ll, and in certain pjirts. ♦.-rpoiiil'y '^
ni«tatar-al }m.i„.. ..f tli- ri-lit t'.M.t. tie- -kin liccunie reddened. When the child w« ii-"'
yar-s ..Id, pi.c... ..i' d-ad }...ii.- l-.'^'an t.» cm,, away fn»m the bands, and this ha.'.sLnrfi
tiriu.-d. At tin- lim.- al-. ^w. Iliri.^^> Iwiran to appear over the upper maxillary Kce*,*-'
a> v.. 11 — c, an cxtrn-iv.- r.-.ldt.n.-d jind >«w..llcn e.»ndition of the tissues exists under ibtn:-
SYPHILLH.
509
The fontanel lod are closed. There are evidently a perioatitia aod an oeteochaadritia
fthe right ann, and there is also un enlargement of the left ankle, accompanied by uloera-
I on the outer side of the mulleolus.
Case 224.
Late mtmif' -!
syphili*. Female, 3^^ yeann old.
The child hus been treated with the conibination of mercurv' and iodide of potash such
\ yim sett in this prescription (Prescription 68) :
Prkscbiption 68.
Metric,
HydraTg. cWoridi corrosivi
Potasflii iodidi .....
Aq. destlL ..,.,.
Apothecary*
0
S
60
08
75
Oti
S Hydrarg; chloridi corroeivi . gr. ss ;
Pf>tJMisii iodidi 31 j
Aq. destiL ..,,.,,, Jit
8. — 2 CO. 0 drachm] S or 4 times in 24 hours.
I ha^e noticed that while it wm taking thia comhination of druge al! iti lymptomjs
latedf it teemed better iiiid bri^hter^ and the lesions showed a tendency to heal. When-
the medicine it omitted all the previou* ftymptoras return. I Rbould advice giving tlia
lild much larger doses of the iodide thun are contained in this prescription.
610
PEDIATRICS*
The following ca^ ilhistrateSi among other interestiiig poiDt6, 1
lesion of the bones.
The Imy (Cam 226) U eJx yc»r» old. You will nc»tiee chiit he is rather pftk^ i
tui$ a Bomewhftl |MHAiliHr fn^ntal d^^volopmi^nt, which well illustrated the (atmi
head to whtch I bavts already referred (Caee 218).
Ca»i 225.
/
BeradltUT fyphillfl. MAto« 6 ymi did. AUarirmjii promitieuccs of fttntal iMoa
You see the alight depression of the bridge of the noee and the baling of the
on eithfT side just nbove the orbital ridges. These prominpucc* ar« aec^QtiiAted bflk^
Bulcua between them,<?itendiijg from the depresaed nwal bcmtfs upward almost to the n
of thy hair. This condition rt?presimt« the typical syphilitic head.
The boy h in fair health, iind I imn detect nothing abnormal about him <a H
physical examination. His mother brings him t<> the clinic by my dit^tction tonoi^
that he is entering upon the period of the second dentition , a course of meivurtil tB
for a few months. Po*§ibly some iodide of potii^b may be given with benefit
He \& a case of prt.>l>jible recovpry frura hereditHfy syphilis ^ as up to the pnstnt
h&H praetiealiy been cured. The various lesions of the bones and in the onraoft
nectf^aary now to guurd against correspund t4:> the later lesions of aoquirvd frphflK
hence my pt^ference in the in^fi of ii>dide of pjta^h, which in conjunction with meBtort'
great value in tht»«o later manifestations of sypbilift, and will be ^ven to him in ibifti
the stronger chloride of mercury in combination with the iodide of potaah.
The mother of thia boy first brought him to gee me at the Children *t Hon^tal i^
was iix weeks old. The mother bad been well and strongs and had never had iftf
children nor any mif^cArriagea. The fatber liad had a primary syphilitic lesion oj
vinua to the birth of the child, which waa followed by secondary maiiifestatiom.
had plenty of goml breast-milki and nureed her infant until be was ntneteea
The infant was never atrophic, and though pale was apparently well noiimhcd. At
he showed a bullous efflorescence of medium grade. During the early weab nf
he did not receive any medical treatment, although he had a genend
SYPHmiS.
511
ales, pustules, and bulloe. At about the fifth week he lost the use of hk leH Jirm.
i BeeD by me at the »ixth week he thowod a rmuiber of l<^ium bo^^ides those debcribtidt
i it WAB doubtful if he would live. The&e letjiouB eonBisted of firisures at the corners of
mouth, mucous patches in the mouth, condjlomuta of the anu£, and oceluded narcs.
bere wm uot at that time the ptsculiarly formed head which is now prejsent. The left arm
; helpless and was supposed to be broken ; in fact, there was wime erepitatifm, and pn>b-
Hy there wm a slight ^paration of the epiphysis of the diatal end of the humerus. There
Qed to be considenihle pain iti the arni^ which made the infant refitlee^g and fretful. In-
^^mnia was a prominent symptom. The arm was put in a light splint, and the oleate of
mereury ointment (Prescription 66, page 499) was ordered.
The infant was then not Been for a week. On t>eing brout^ht back to the h<*pital iho
right arm was found tc* be helpless, and the mother stated that the ointment had been dis-
continued^ as it caused <iXcoriution of the Bkin* The ointment wai« then reduced one-half
with lanolinet and hydrargyrum cum creta was given three times daily in doses of 0.06
gramme (1 ^miu).
In three days the infant was much better, the panilyds soon di^appeai'ed, afid nothing
obnormul was detected about the arms. The hydrargyrum cum cret*i wii^ iiiereaiied to 0.24
gramme (4 g^ns), but, as this caused diarrhoea, the dose in a few days had to be reduced to
0*18 gramme (3 g^ins). In the course of the next month the nasal symptonos and the
effloreBcency bad diisappeared, and the infant seemed perfectly well.
Six month;; later it was brought back to the hospital with a return of the condylomata
fend a slight papular efflore^cenee. The same treatment as before was carried out. The
^^hilitic manifa^tationa disappeared^ and have not returned since.
The child was kf^pt under observation and treated from time to time for three or four
ri. The first teeth wert^ cut at nine monthi^j and, m you see^ are in fair condition UMiay,
In conncctiun with this case, and for the purpose of aiding you in your ditfurential
diagnosis where an apparent paralysiti is present, I would etate that the possibility of the
paraly^^is being a poliomyelitis anterior acuta waa considered, but haitlly seemed to explain
the symptoms and the result, both arms being affected and entire recovery taking place three
nys after the merturial treatment was properly carried out* Pain, also, would not have
en present in a poliomyelitis. A central lesion was then thought of^ but the rapid re-
very from the paralysis before the efflorescence or the occluded naree had begun to be
cted seemed to show that such a lesion did not exist. The evident pain experienced by
bt* child when the arms were touched, and the speedy disappearance of this sensitiveness,
1 well as of the paralyais, under mercurial treatment, pointed towards a lesion in the arms
emselves. The infant did not choose to lift or use its armS| because moving them caused
|in. No traumatic history could be obtained* Hheumatism occurring at six weeks of
I and affecting a child in this peculiar way would be very uncommon.
512
PEDIATRICS.
ERYSIPELAS.
TuK Wrm orvsi|K»liL'^ is applkil to an inflani
i'litanrous ti'^>!i(', ami imicoiis meinbnine^ whicli 1
t«ii>tirs. It ('S|Mciiilly iiivolvt»s the lyniph-spacH?
has a tt'iKlcncy to sjiivad, and is atteuJwl by uiiiisi
tancHus tissue and an intrnst' nil color of the skin
In addition to tliese hntd apiRnirances it is acxxii
symptoms, \\hi«*h nvo mostly tlw ii»snlt of a hei^iit
It is ranx-d hy a mi<*nM*<Kriis which Ls found
spaces <»i' the skin. This organism is a strt*pt4KXK3<
is identical with the stix'pt(K'<Mrns pyoj]:i»nes. The
exi>t<'<l a s|MM'ial orirtinism which caused erysijK^la
l»y rcernt inve>ti.irations.
The disra>e runs an a(Mito course, is cH)nta^i<.
tlironi:;li some abrasion of the skin or niw-ous mom
Tin* mo<t earethl an<l complete work which has Ix
<liM'a<e is by Fehlei>en.
i*ATiioi.n(;v. — Aceordinjr to Delaficld and Pr
.-wnjlrii by an aciiimnlatjon of sei-ons ilnid. T
transparent, or may be tnrbid from admixture ^^
rr\\< may infiltrate the tissnes either spai"sely or in c]
vc-iclc-^ are fnnnd on tlie snrface, or theiv may Ix^
t.r h -> lA' tlir allrettil n-i-ion is filltHl with abs<"ess<*>
In -onif ra-«'-. a-ide tn»m the liMid Unions jK^twhi
ni'!nbi:i!ic.-. nntj -welling- of the sj)leen an<l pan-ml
tli«' kiibny- nnd liver. When the mucous mom
sliuw the same aiipearain-es as the lesions of the sk
arr nuidifuij by the dillerent strnctinvof the tissue.
th<* larynx and upper air-passajj:cs and may result
may ncnir a- a rnm|»li(':ition.
AhhoULih thr ditlerent or^rJUis, such as the S]
liv« r. :it tiiiw- >h<»w ])atholi)tiieal ehanjrcs, nothing v
lias bcrii i\)U\u\ in tliese «»ri:ans, l)ut only such chai
iionlinned hiiih t<'niperatnre or as tin* nsult of se|>g
Kry.-ipela^ may U' dividc<l into two forms, (1)
snrfae<' to siul'aee, and [2) (Hiihiift/ns, i}(v\\rv\u\i; in ^
It may al-o Ix* fimfc or rlirnnlr.
In cry>i|M'la< ini<rnins, which is the most commo
ERYSIPELAS,
613
I
of the body may be attacked. It is very prone to return, passing over the
same surfaces of the skin again. The fac?e and head are not so wmmonly
attat'kt<l in infants as in adolt;?, and the disease seldom spR^ade from another
part oi* the body to the head. When it does attack the head^ it is apt to l>e
fatal from a secondary purulent meningitis. It at times causes great swell-
ing and tension, and may go on to gangrene in certain localities^ such as the
gcnitum.
After the first year erysipelas so closely resembles the disease as it occurs
in adults that we need not consider it in this later [leritxl of life. It is a
stjmewhat fref|uent disease in infants up to six months of age. It then l)e-
comes less frequent up to the first year, and after that and in childhood is
rather rare. I shall, therefore, speak of erysipelas as it affects infante only.
The erysipelas of infancy may be divided into (1) erysi{>elas of the new-
born aud (2) erysif>elas of sucklings.
BBYSIPELiAS OP THE NBW-BOBN.— Where erysipelas occurs
before the end of the third week the infaut seldom lives» and indei'd it is a
most dangercnis disease up to the end of the thir^l or fourth month. Ery-
sipelas of the uew-Uirn is apt to occur during an epidemic of puerperal
f€»ver. If the mother has any septic symptoms, the infant should be imme-
diately taken away fr<im her. I have seen a case where the mother had
pueriK^ral |>eritonitis following her delivery and w^here the infant (Case 226),
w^ho was alh*wed t** nurse her, was atta<*kcHj by erysijjclas*
In many vdm^ wx-urring in the early days of life the disease starts on
the genitals, and may be complicated by other diseases, such as empyema
and es]>ec4ally pneumonia. During the course of the disease tlie fontanelle
sinks, the spleen is enlarged, convulsions may occur, and jjcritonitis awom-
pauit^l by vomiting may arise as a complication. The disease is liable to
invade the tiasues at any pcnnt of abrasion^ whether from the forceps or
from vac<»ination, or at tlie p<niit of separation of the umbilical wrd. The
latter is the most c«3mmon hx-ality for the inft^-tion to tiike place. From
this point the infection may extend aud produce a gangrenous condition of
the stomach or alxlomen.
Although the temperature in the early hours or even days of the disease
may not be raised, yet, as a rule, fever soon appears, the temj^erature varying
from 39° to 41° d (102.2° to 105.8° F.). RcKldening and swelling, not
of a high grade at first, appear on the parts atlected. The infants show
symptoms of a general sejisLs. Vomiting frccpicutly occurs, followed by
collapse* and almost without exception by death.
Treatment. — ^The trc^atnicnt uf this severe form of er\'sii>elas is by
stimulants and a substitute tiHKl ada|it<xl to tlie infant's digestion.
I ERYSIPELAS OF SUCKLINGS.— The stage of the imabation of
erysipelas lasts, according t*) Orfler, from ttiree to seven days.
When the disease occurs m the early months of life, its lieginning is
usually accompanied by cold extremiti£?s and collapse. The temiierature is
raised, and the higher its degree the graver the prognosis. The tem|)erature
L 88
for a certain number of days^ depending upon the amount of the i
the skin involved, the extension of the disease oeases and the te
falls. The redness gradually disappears, and the skin becomes coi
yellowish-brown crusts. Finally, desquamation takes place, and
recovers its normal appearance, the disease extending over a varia
according to tlie greater or less extent of the sorfkoes invaded.
Although the disease when involving large sur&oes is dang
cases in the later months of infancy recover even where the attacl
a severe one. An instance of this kind came to my notice where
ten months old was attacked with erysipelas, the point of infee
tlie right labium.
In this cafle (Case 227) the whole Tulva ihortly became very tender and
. extended to the pubes and abdomen. It invaded every pert of the body aa^
( and the head and neck. The eyelids and lips were the lest points of attack
palniB of the hands and soles of the feet were afiected. From the time that h
one part of the body until the skin of that part aasumed its nomial oulor ae
days. When the erysipelatous inflammation extended to the feet there was »»*»
The duration of the attack from its first appearance at the TuWa to its disumi
eyes and mouth was about fifteen days. The infknt was treated with ■wn^n i
and quinine, and recovered entirely.
Treatment. — No treatment of which I know is of any avail
short the disease. Where large surfiEK»B are afiected, the ^pplicatii
corai)rosseH tends to depress the vitality of the in^t, which it is so
to sustain. During the height of the disease the infimt's Strang
be sup|K)rted by stimulants and by the finequent admiiiistniticHi
adjusted t() itA digestion.
I have here an infant (Case 228, Plate VI., fiusing page
■ EHY8IPELAB. 616 ^^^|
^ Th« MialpiB (Analysis 60) of tbe milk was as follows. The nAtUT« of the micro-organum ^^^H
wbir,h produced the green color was nut deCermiDed. ^^^^|
K ANALYSIS 60. ^^H
■ Fat. _ _ ^^H
■ Sugar ^M ^^H
■ Froteids 8.46 ^^H
■ Ash ...... . ai3 ^^H
B Later in the day a pink efflorescence appeared just above the pubeSf and there was found ^^M
to be considerable irritation in the neighborhood of the vagina. The redneas extended from ^H
the vagina to the Bupru-pubic effl<>re$€ence. The e:fflore£cence was of an ei^ythematous type. ^H
On the following day it spread to the left thigbT ^^^ tli*^^ ^^ the left lower log. The tern- ^H
peratnre continued to be raii^ed, and the infant refused to nurse. Small ijuantilies of a ^^M
substitute food with the following percentages (Fres^^nption 69) ^ which had to be varied from ^H
^ day to davi were given to it : ^^^^M
H^ Prescription 69. ^^^^|
■ Fat 2 50 ^^H
^1 Sugar * 6.0a ^^^H
H Proteids 1.50 ^^^|
H There were no convulsions or other symptomsi but the infant leet somewhat in strength ^^M
^t And weight and iU face looked pinched. ^^M
H The efflorescence on the le^ leg began to fade on the ninth day of the disea&e, and on ^H
Htbe tenth day the tempemture became almost normal. Un the following day, howevt^r, it ^H
H again rose, and a fresh t>tlic>re6c©nce began to appear on the right thigh continuoui* with the ^^^H
H CHABT ^^H
ZXoffS O^J?lSC4iSG
eg to ^^^H
n ^^^H
F
\<XP
102*
IOl*»
100°
HP
§5^
5
6
7
e
^
IP
II
12
13
K
15
16
17
18
19
20
2t
22
23
24
25
c
416*
41. l<*
40.5"
40.0^
3^.4*
30,00
1 s
H-i^
ex
t a
% %
If ■
pl>
< R
MX
i a
t a
C E
N X
IC E
« M,
H i:
hi R
H K
HI
>c %
k 1
i
K
/
V
J
,
1
V
/
i
/
i
/
1
SB J"
37.7*
17.2'
37,0*>
36.1*'
as.o°
r
S
/
f
i
,..
—
...
L-,
-,.
.-,,
.,.
-
A
r
T,>
N
\
V
. —
^
— ■
__
-^
efflcw
^■amo
^■mlm<
ErytdpelSA of lugs. Female. 6 moiitliB old.
rescence of the supra>pubic region. Tliis efflorescence extended down the right h
mkle, and you see the condition of it to-day.
You will notice certain points in regani to the efflorescence on the left leg. A »
unt of redness h pnaaent, but it has mostly disappeared, leaving the akin in parts i
3ft normal conditioni in other parts covered by thin bftjwnish^yellow crusts, The si
616 PEDIATRICS.
pubic n'^i.iii and the rij^ht let: a* far as the ankle are, as you see, covered with & brich:
('t1li»n'>('«'iict.' shurply iMiuiulcd by uoriiml likin below, just above the ankle, as th-.i-JL'£. Itv-
a stocking. The whole leg is swollen, is hotter to the touch than the sound tkic. i
pn-scnts a sonu'wliat niiswl, f;li<tcning ap}>eanini*e.
No I'.xtcriial applioati<»n» and no drupi have been employed in this ca^e. Th;; l!
has hci'ii i-an'tully iiioditicHl, and small doses of brandy have beeu given.
(Tin- >ubs»Mjuont hi-itory of the case is as follows. A few days later the temfirrsrc
lM>i>aim> normal, the elllon'scencc began to fade, desquamation subsequently ux-k plk
and the skin tinally n'coven'd its nonnal ap]K>anince. The infant ||rradually ivciiici :
>tn*ngth, Ih'cumic ]H'rf<i'ctly w<'ll, and has had no return of the disease.)
Hen' ix tlit* chart (Chart 10, page 515j showing the temperature during thecc-urs«(tft
ery.-ipclas in this case.
This form of orvsi|>clas may become chronic, and this is moi« apt
o<vur in cliildrtMi tliaii in iniant>(. It is also most common in children wi
an* in a (l('l)ilitat<»(l condition, and may occur at intervals of three or fin
years. It is freciuently in older children connected with chronic infla
niations of the Sehneiderian membrane^ and in these cases is peculiarly i
tractable to tivatnient.
THE EXANTHEMATA.
617
LECTURE XXIV-
THE EXANTHEMATA.
Variola— Varicella.
In oontradistinctioD to the various diseases of the skiD which dermatolo-
gists are atx^ustomed to designate as exanthema of loc^ origin aru wrtain
► acute, specific, infectious diseases which they call the exanthemata. This
class of cases is of esfjecial interest in connection with diseases which arise
in children, as it is among children that they most frequently occur. They
can, however, attack individuals of any age. Although none of these dis*
are entirely self-protective, yet the instances in which they develop in
individual more than once are rare.
The exanthemata c<>mprise five diseases, — variola (small-pox), varicella
(chicken-pox), scarlet fever, measles, and rubella. In regai-d by the latter
there is a question whether it is a disease distinct from measles.
This group of diseases is characterized by certain wnditiona common
I to all. Besides being infections, each disease nins a definite course and is
Bclf-liniited, facts w^iich should be remembered when we are studying its
diagnosis and treatment.
The ciKin^ of these diseases from the time when the infection takes place
up to the appearand of their later manifestations may l>e divided into dis-
tinct stages. In tlie first of these certain micnxvrganisms are snppose<l to
enter the system, and, so far as external appearances and general symptoms
I are oonccrnoil, to remain dormant for a time, constituting what is called the
i stage of hwttbfdhtu This stage of inriilmtion is fi»llowed by certain general
> symptoms resulting from the supposed development of tlie special organisms
[and constituting the prodromal dage. These prodromal symptoms are,
after intervals varying according to the s|>ecial disease, followed by an
efflorescence on the skin, which marks the thinl stage of the disease, called
[the atage of effioresoence. The efflorescence in its turn is followed by what
lis calle*! the fifage of desquamaiion, thi^ desfjuamation being more or less
Iprononncetl in proportion to the intensity of the lesions of the skin which
lliave occurred during the stage of effloresr^nc^.
Although in a large numWr of cases the diagnosis of these diseases can
[be deti^rmineii by the appc^arance of the efflorescence and its location, yet
I instances occur not infretjuently where the efflorescence is very misl catling.
I We should, therefore, Ije familiar with the characteristics of the other stages
of these diseases, for it is by carefully considering the pictures which they
ipm^ent to us as a whole that we ai'e enabled to make a correct differential
[diagnosis of the especial case. Thus, a papular efflorescence, although signi-
518 PEDIATRICS.
ficant ill most rases of ni(»asUs, may also be prc?sent in any other menilierf
the «rrou|), while an erythema elosi»ly re.si»mblingc .sc*arlet lever may -murii
variohi, mea>h's, or nilH'Ha.
VARIOLA (Small-1'ox). — The first clisc»a.se of this jrroup whit-h I-:.ii
j*|M'ak of is varic»la. Variohi is one of the most virulent of the iuftiij :.-
<li«^ea>es with which we liave to (h*aK and is jmrticiilarly iatal amt.uii: iahir-
and vnuntr ehihh'en. It is an aente disease^ caiistxl evidently hy a mi >
orM;:mi>iii. It is eharaeterizcHl by si»vere eoii.stitutional sympb.nii*. atv::!-
|ianie<l hy a pro^res>ive efflores<vnet» fnmi niaeiiles and jiapnles t'Vis:!-
and jinstules, followeil l)v the iormatitm of erusts, these lesions haviii: u
t<'ndeney to resnlt in ei<-atrie(»s. As I have stated to you in a j»nv: ■.-
Icetnre (Le<tnre V., pajre 147), sincv vaceination has bi»eu estabHshi.<l, variJi
in (Hintradi-tinetion to vari<*elhi, seariet fever, and mea.sk>s, is an exiRHi^.y
rare diseas<' amontr infants and yonnji: ehihlrt^u who have lx.»eu vaiviiiatnl
Ahhonjrh tlieiH' an* no eharaeteristies of variola whieh art* distiiKtiv: ::
ehihh-en from those of tlie diseas<* tKHnirriug in adidts, it is iinjii.'rta.nT t
n'<H»Mni/(. its chief ftatnivs for the pur|)ose of ditferential diajrno?i<. hi*
l>o>-il)h' for the fetns to nmtraet the disease in utero. This, liowevt-r. L-
rare, and it is well known that intants whose mothers are affei-tcJ «t.:
variohi can, even wh<'n horn in small-i)ox hospitals, be pn.>t<H^i'il tTi»m tb-
di-ca>c if vaccinatinl iinme<hately. It is rather remarkable that the mivP-
(»r«rJnn>m which ean>es varicda hits never been diseoverod, when weouw-k
fl»r how l<»n^ a time the discjise has Ix'en known to Ix? highh' intt^-tii lv
Tlic coiitaiiiuiii is snpiMw^il to exist in the s(H'n»tions and exeretiou.*. auJ r.
eniaiiat*' from the cxhahitions of the hiu^ and fn»ni the skin. It i^in J-
proLahility tran-mitt^il principally hy means of partieles of the erusts. ''
ha- a wtiiidcrfnl tenacity for clothintr or any like means of eonvovanc»-. I'.
ha-^ Im'cii proved that tlie e<inta^ium is active ljeft>re tlie efflores<x?niv<-:<^irj.
tiioiiuh not >o nnicli so as later. It hits also l^een fhirlv well pruvol tk:
it> activity cca-c-; when all the ernsts have fallen off and when the t-mirf
skill ha- hrrornc smooth. The most virnlcnt form of the disease cau ^
coiitiarti-d from a mild l()rm, snch as varioloid.
l*AriinLn(;v. — The patliolo«ri<"d conditions found in variola are chi^^''
thoH' ot' the >kin and the mncons membranes.
Acmrdinir to Wci^vrt, the progressive ehanges of the lesion of vari* i
an- M< t'nllnw^. The Irsion U'trins as a nmud, somewhat raised marrje.
This d<'vclo|» into a hard papide. and later a small vesiele arises on its^^nz-
init. rhi< voiclc ciilar<;'<s very rapidly and ehanges to a tonselv filkJpn-
tide with a central (lc|)nssi(»n. The size of this pustule eorresixinds to tb:
ol the oriiiiiial macule. Microscopically the maeule consists of a circiini-
scrihed >p(,t of liy|MM*a'mia in the capillary layer of the skin. The iiainik>
lormed hy a <harply defincHl necrohiotie dej^»nenition of the under lave^'•:
the rete nnicosnm, hy which process the imelei of the epithelial cells aivd^
stroyctl. P>y the traiMidaticm t)f llnid into these areas the cells arepuslitc
apart and the ejiithelial layer is lilunl up as a whole, ooveriDg tlie iRS
THE EXANTHEMATA.
619
I
I
I
affected, and forms a vesicle the inner part of whidi is oomposed of a mesh-
work tilled mth lymph. In the vicinity of the uecnibiotic foeus au inHam-
mation Is set up, eaur^ing an iuei^eanod gix)wth of the eelk ol* the rete which
BurrLnmd and \\'all in tlte foeuH on all sides. The dcvelojx'd pustule extends
through the whole thickness of the cutis to the sulxjutaneous tissue, A net-
work inside the pustuh:?, which is most tense in tlie central jmrt, connects
tlie itH>f aud fltx>r of the pustule, and, in c?onj unction with the ubjve nicn-
tionc^il growth of the cells of the i-ete aroimd tlie focus, cau>ies the central
depression. If the vesicle is pricked j only a jmrt of the lymph flows out
of the mcsh'Work within. The lymph is clear, and contains some white
aud rkJ hltK>d-*'orpusclrSj strcfttococei aud staphyliK'uix^i, libriu-floceuli, and
molecular granules. The contents of the pustule ai-e purulent, aud those
in the hemorrhagic form c<»utain Idootl, Clumi\s of bacteria with analogous
localized degeneration and its associate<.l changes are ibund iu the neighbor-
hood of the pustules, also in the parenchyma of the internal organs and
IjTuph -glands, as well as in the skin, \Vhcn the variola has rt^chal its
height the central depression in the pustule disappe^irs, because the increased
tension in the c<:)ntents tears away the mesh-work. The vesieulation begins
in the upper central part aud spreads downward towards the periphery.
The pustule then collapses and changes to a crust, which afler a ivrtain
numlxr of days lalls off, leaving a more or less deep scar angered with
young epitlielium. A distinct difference in the anatomy of a pustule of
variola wrd umi one of varioloid does not exist.
On the mucous membraues of the mouth, nose, conjunctivfej bTODchi,
jphagus, rectum, sometimes the vagina, and also on the timsils and the
tongue,, the same pnstidar effloresc€*tjee may Ix* fi>uiid, and is either siijw^rficial
or extends more deeply. At times also a psendo-mi-mbmne is found on the
nlcers,
Act'ording to Osier, the papillfc of the true skin IxJow the pustules are
swollen and infiltrated vvitii cmbryc»uic cells to a variable degree. If the
suppuration extends into this layer, scarring invariably rt^sult^ ; it does not
necessarily follow if the suppuration is cLJutiucd to tlie upjier layer.
In the intestines swelling oi' Peyer's follicles is not uncommon. In
the larynx tlie cfilorest^ntie may be a-*s(K4atal with a Hbriu exudate, and
sometimes with oedema sufficient to cause death. Occasionally the inflam-
matitto extends dw[KT and luvijlves the cartilages. In the trachea and
bn»nchi there may l>e ulcemtive erosions, but the characteristic lesions seen
on tlie skin do not occiu". There an* no special lesions of the lungs, but
<30DgeBti(»u or bmncho-pneumonia is very c<»ramon,
Acccj riling to Gaixiuer, iu addition to the conjunctiva almost every part
of the eye may suffer, the lids, lai'hrymal sac, cornea, choniid, and even tlie
netina and extrinsic muscles.
These compUcatious may occur either during the course of the disease or
afterwards.
According to Adier, keratitis may develop from a purulent o^jujimctivitis,
520 PEDIATRICS.
or (jiiito inclejK'iulcntly of it, never, however, earlier than the twelfth daj.
It may (Kxiir lus a fin*um.scTil)e<l sui)erfioial iuflamniation which, even uder
atropine and hot lomeutations, may take the form of au ulceration var
dan^'r«)us to the eye.
In the ear, aeeoixling to Wendt, complications are more frequent than io
th(^ ey<'. The milder IbrnLs of hypenemia are generally overlooked, a^ iliev
causi' no sym|)toms. Congestion of the middle ear is common, and is piKmliv
diiiH'tly due to sw(»lling of the naso-pharyngeal mucous membrane il>ix
the Eustachian tulK»s. S)metimert this prognoses to acute inflammution *«:
th(» midtlle lar, whieh may end in extensive destruction of the ssoft parts, vriih
substHjuent jH'rmanent deafiK»ss.
Aee<»nling to Osier, in exceptionally rare cases the eruption enewt
down to tlie (esophagus and even into the sttmiach.
Tlie pathologiejil elianges in the other organs consist of enlai^ment of
the spleen and fatty degeneration of the liver, kidneys, and heart. Mfis-
static pHHt'ssis in the various organs and in the joints sometimes occur, h
tlu' h( inorrhagit^ form hemorrhages in the various cavities in the different
orgjuis, ami, according to (lolgi, in the medullary cavities of the bona:, mair
occur, also in the serous and nuicous surfaces and in the muscles.
iNcriJATioN. — The incubation of the disease varies from twelve to fjur-
te<Mi days, tlie latter being th(» most trnjuent period.
Symptoms. — Ai'conling as the symptoms of variola are mild or s-vti^
the disease has Ixvn dividtnl into a number of forms, designated as iMIows:
(1) <fisrrrfr, (2) vonjlncnt, (8) hanorrhaf/ic, and (4) m€xlifi€d. In all tri^^e
foniis the initial fever, convulsions, and gt^neral symptoms may Uv-^vi-n,
and do not necessarily indicate which type of the disease Ls alK»ut t'»
il)ll(>w.
(1) DiscKKTK. — The mildest and most typical form of the diseaje i?
that which is <'allcd dixcrctv,
Prodromata. — In this form, the invasion, though .sometimes lesjjsvtre
than in the conllucnt antl hemorrhagic forms, as I have just stated, in infau'^
aii<l yoiiiiLi children is almost always of a grave type. In infancv aiideark
chiMhontl the <lisease c<»nnnonly Ix^gins with convulsions. There mavl^
viunitiui:, i:reni rotlessness, tjuick pulse, high temperature, and in a uuniber
of <'ase-; the .liildnMi (jiiiekly succumb to the disease fn")m the vinilem* iff
the tnx.-einJM. 1 1' they Mirvivc this early stage of tlie disease tliev u^siiall^
|)reseiit the saiiK' -e(|uenee (jf syni]»toms as in cases occurring in later life, hi"'
may eventually die I'roni tlic^ exhaustion which often rises from a pnJnnj^J
>nj>purative liver. In the ])rodronial stage the pulse is much qniekt-iini.
and the temperature may 1k' as high as 40°, 40.5°, or even 41.1° C. il»'4'.
lOo \, (►r Km;' F.). In this stage w(» at times, especially among chiWn'n.
meet with an evanescent erythematous etllorescenoe. According to Sim'.*a.
thi> nianilestation i> distinct from that of scarlet fever. It has a iKiniliar
di.-trihntinn and generally a limited extent, usually affecting the I WTf al^-
dominal areas, the inner surface of the thighs, the sides of the thorax, aiil
THE EXANTHEMATA.
621
the axilliB ; sometimes, however, it involves the whole surface. Tins efflo*
re9oeDc?e Is distinct from the typical lesions of variola which oc5cur later,
EffloreBcence. — On the third or fourth day of the prtxlromal symptoms
[an efliorescence appt^ars on the skin, and at this time the iTeqiieney uf the
I pulse lessens, the temi>erature usually falls considerably, and the more severe
symptoms improve, so that the patient ap[>ears much more comfortable. The
eflBorescenc-e is at first represented by small red macules or papules, which, as
a rule, fii'st ap|iear on tlie forehead, or on the fa<^e and mucous membranes,
and later on the trunk and limbs. The papules are rather scatteretl in their
distribution, and ha%'e a fJseliug as of shot under the skin. The niaeules
when present soon become papules. On the third day by meau.^* of a ^nnd
[light a small vesicle cau be seen at the ajiex of the jiapule, and by the fifth
^ or sixth day the vesicular stage is well establklied and the vesicle Ijecomes
distinctly umbilicated. This appearance on careful examination i^n also be
f Been in the lesions of the mucous membranes. At about the eighth day the
vesicles become pustules, the tops soon flatten, and the umhili<'atinn dis-
appears, leaving au are^jla of injection and the intervening skiu swollen.
The temi^erature at this time rises, from the suppuration which is taking
I place in the pustules. This rise of tcmi>crature is called the secondary
fever, or fever of suppuration* The tcmjierature i-emains high for from
twenty-four to forty -eight hours, and then gradually falls luitil by the
twelfth or thirtc^t^nth day it usually becomes normal. The contents of the
pustules dry up, and cnists are formed. On the palms and soles small liartl
disks form, which may of thcmst^lvt^s fall off in infantSj but in child rcu as
■ old as ten years would remain for a long time unless removed with the point
l€f a knife,
I DesquamatioQ. — By tlie fourtec^uth or fifleexith day the stage of des-
I quamation is established. In some cast^ extensive s<*ar8 are left on the skin
I w^here the crusts have fallen off. This is most a|)t to iKx*ur in severe cases.
I (2) CoNFLUE^^T. — lu contradistiuction tc» the mild or discrete form
[of variola is the more severe form, callccl coufHaiiy on account of the ten-
Idency of the lesions to coalescse. In the confluent form of variola the eftlo-
Irescence usually appt^ars at the same time sis in the discrete form. At alxnit
Ithe fourth day the lesions Ix^'ome t-tinrtuent, the skiu Ix^tjmes nddenetl and
Iswollen, and the face may be much distorted by the severity of tlie Unions.
I In this form the initial tem|>eratun;* does not fall to the same degree as it
I does in the iiist-retc form, and, accxmling to Sydenham, diarrhfca is likely
Ito occur, particularly in cldldren. The pliarynx and larynx are c«|>ecially
mUt to Ix^ involvixl, and tlie c*ervical lyinphatit^ to Ije enlarged* The crusts
■Bhere longer in the stage of descpiamation than diey do in that of the same
^^■e of the discrete form.
f (3) Hemorrhagic, — The thiitl or ketimrrhaffic is die most\nnileut fi>rm
I of variola, and may occur in dii Id n^n as it does in adulti^, diough uut so
lfrec|uent in the former as in the latter. Its symj>timis in children arc so
hevere that in almost every case it very quickly proves fatal. It is characK
till' oXUrr tonus of variola, although tho initial tover may Ih} a*
srviMi* *as»». Tlu' ]Ki|)ul('s aiv ii'wcr in nuinbc»r, the temjK-rai
normal Mwiucr, anti tlw child s(vnis conifortahlo in a shorter jk-
since tlnTc is usually no st^HUulary fever from suppuration. T
attark n>iues to the time whon the child was vai-eiiiatcd, the le;
Ih' the sym|)toms.
In any of these il)nns of variola the i)rodn>nial symptoim?
very seven' nervous type, and this is esj)ecially characteristic r
a> it oeeuis in children. Fur this reason variola may Simula
ea-es in its |)rodromal sta^', and may often cause death befbn
ii-nce has a|>|)eare<l. This is esjKvially the case with the prod
tonis of tlu' hemorrha»ric form.
CnM PLICATIONS. — The uiost (H)mm(m complications of vari
of the hirvnx and the lunp^. Where the larynx is afflicted, a
^lotii*- may sutldcnly aris<» ami death take place fri^ni siiff'ocatioi
In the throat the presence of the efflorescence cxfasioiis gre
ami the a(comj>anyin<r secretions cause nausea and at times d\
a cout-ii whieh in weak children is very exhausting.
Where acute inllannnation of the middle ear has taken pL
<lurint^ the l<>rmation of the j)us is very inteiLse, but it sul>side
the sai* \mv>x< op is incisi.'d. This complication, therefore, re
and careful treatment.
Where a le<iun of the lun^ develops, it is usnallv in th(
hrnnrlui-pneninonia. Lobar jmeumonia raivly complicates the
Althuuiih alhumin is very frapiently present in the course oi
ncj>hritis is rare.
Thi< chart (Ciiart 11. ])a«rc 528) re])restMits the usual temw
of the initl.'il f('\'i>i' Mini <imitniM)ti\*^i> fi^triii* t\V n f\'i\i^nl .«w*.-.^ ^^ — .
THE EXANTHEMATA.
623
The alraof^t complete alw^enoe of priKlmraal symptoms in varicella, and
the pronounced catarrhal symptoms of tlie nose and eye in mea:?les, make
the differentiation from tlu-se diseases comparatively easy. Altliongh the
prodromal symptoms of scarlet fever and of variola are utten of e<|ual
CHAKT
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Fener of tnyastovL Fever of BUfiptKntlaii.
VarifjiA
severity and somewhat similar, sneh as the convulsions and v<imiting, yet
the prononnccd Rvrnptonis crmnecttd with the thmat in swirlet lever, and
the appeamnc^e of an erythematous efflorescence iiij^tead of the t^cattci^
papules of variola, serve to ditlereotiate clearly the two diseases. We
must, however, be careful not to mistake tlie evanescent efflorescence which
I have already referred to as mtnirrin^ in the prodromal sta^e of vari^ila
for the cpi^henia of scarlet fever. The distiiietion caii nsnally 1k} made by
remembering^ that this efflorescence in variola affects the particular areaj* of
tlie skin aln^idy r«?ferr(*d to, and that these areas in S(*arlet fever, measles,
and varii'<'lla an* unlikely to ]ye affcctctl early in the stage of effloi*escence.
The typical l<:)eation of the effloresci*oc^* of scarlet fever is first on the neck
and chest, that of measles on the face, and that of varicella on the Imck,
face, and hc*ad.
In makinj; the diagnosis of variola wc must, of ctDurse, bear in mind the
efflorescence which ap]K»ars on the skin a^^ the result oi\'aeeifinflfmj ami that
which occurs in the ofdirse of the disf^asi* rocrinta. In vacvinati^JU the single
lesion and the absc^nei* of severe* ctinstitutional symptoms make it haixlly
Becessarj* to do more than refer to it in this connectif>n. The diflerential
diagnosis from vaccinia is not ditWeult, and yet tliis disease is so nire tliat
when it appears it almcist always creates a suspicion that we may Ix^ dealing
with variola. As a rule, in vaccinia the general sympt^>nis an? not severe,
I
524 PEDIATRICS.
the disease beinpj represented almost entirely by a slight malaise ai>il>t
a|)|K*tite, in conjunction with the ap])earauoe on the third or lounhdr
an cffloresix^mv on the skin. This effloresoenoe, as I have stated il si
vious livture (Ixvture V., |iage 152), is represented by papule?, vtskk a
pustuhs, few in number and irregularly distributed, some on theiftui
nose and a few on the IxkIv and extremities. As the disease alm-^nn-
riably apjK'ars alter vacx-ination, this fact is of great aid in ditferwjas;
it inini variohi. The sul)seciuent course of a case of vaccinia i* 5.)!ii.:i
milder and shorter than that of variola that in a few davs the diff*3L
diajrnosis can Iw made easily.
Trkatmknt. — There is no specific treatment for variola, but hi?rfn
utmost imjK)rtaiut» that the best hygienic care should be emploved Tka
of the room should 1k» jx^rfectly fresh. The crusts shoidd be kept sotfeorfiii
a mixture of ^lytvrin, oil, and carbolic acid, and the odor arising fr>mtla
should Ik» nuKlifitnl by the applicatum of a dilute solution of carkJic iit I
In the initial sta^ of the disease stimulants should be Ircolvgivrti:
the sym|)toms arc stn-ere, and the high temjwrature should be conm)Ms
sponjriu^ with water at a temperature corresponding to the power of i
ohihrs i-eaetion.
The ^n^atcst care should \>o taken during the stage of convakwoi
and when tlu^ child is (X)nsidered well the most rigid measures forp^^
in«!: th(j spread of the contajrium should be enforced. The clothing rJ
everything eoniie('te<l with the (^hild and its attendants, and the nm h
wliich they have biH^n kept during the sickness of the child, AodWf
tiiorou^hiy disiiifeetcHl, the same precautions being taken to prevent t!t
spread of variola that 1 shall presently descrilx? to you in speaking uf !«?ark
tevcr ( I .ectiire X X V., |)age 549). The immediate transferrence of a fsskc
from its room t4) a small-iM)x hospital Ls in most communities coa^idewltii
wisest nictiiod of dealing with the disease, and is usually eufon*ed bvlaw.
VARICELLA (( 'hieken-Pox).— The next member of the group of a
antheinnta which I shall sjH'ak of is varicella. It is the mildest in is
symptoms and the most favorable in its prognosis of the whole group. I
is hin;lily infectious, an<l is characterized, in distinction from the other eus
tlicniata, l)y its l«ui^ staire of incubation, the shortness or absence of tL
prodromal stai^v, vesicular eilloresceuw, and absence of sequela?. Var
cella lias Im-n known as an inde|K'ndent disease for the last t^vo centariR
At one time it was not clearly differentiated from measles and scarlet frvs
cUkI in some parts of the world it is supjKised to be closely allied to yariA
T\\\H opinion, however, is not ircuerally sulwtantiated, and we can art^
varicella as a distinct disease.
It can occur at any a^^c, hut the most common time for its appearawv
in the middle and latter part of the first year. It continues to beacomron
disease all thronirh {ho early and miildle years of childhood. Thesuiwp
hility to the conta.L^inm of varicella Iess<»ns after ten rears of age, and alma
disapi>ears at \Hvl>eny. ll \^ ^i^w^v^\:\w\v.^ -.y^^c^Sr ^sxA. <^xssfi3lim€8 epidemi
THE EXANTHEMATA.
625
Kmrs with equal fm|uency at all |>eriods of the year. The vehicle of
riuru Ls nut knowUj but it probably eiitei's the system by the lungs.
ifhe specific orgaiaii^m which produces varicella has not yet been determined.
Pathology. — Deaths from varicella are so extremely rare that our
j[jCnowledgt^ <>f the }>athology of tlie disease is necessarily limited. It h
|3vident, however, that the efflorescence of vesicles, which represents the
|iiriuci|)al murbid lesiou of the dtsc»aj*e, is of a somewhat diffcreut type from
kthat which oi^eui's in variola. The vesicle is much neariT the surface than
in the latter disease, being formed ma'^tly by the upjier layers of the
[epithelium. The vc:^icle itself is .seldom multilocular, a couditiou which is
^frequently piviveut in variola. The contents of the vesicles are usualh' a
[clear serum ^ the progression to a pustule Wing rare iu comparison with the
lesion of variola. The lesion so rarely involves the deeper layers of the
1^ Joskin, and the process is usually st» very mild, that it is seldom that suffi-
^ dent dLi^tructiim of the tissue takes place to produce a scar.
^m The lesions may appear on the mucous membranes as w^ell as on the
^^skin. At times the lesions assume a much more serious form and may
^^bec5omc gangrenons. In gangt'enouH vanceUa^ aeconling to Eustatie Smith,
^■tiie vesicleSj instead of drying up in the ordinary way, become black and
larger, so that a uuuiber of roundcHl black crusts are scattered over the
J^ 8ur&oe of the body. If a crust be ix^moved, it is found to cover an ulcer
H more or I&(43 deep. Around it the skin is of a dusky red color. All the
^m vesicles do not l>ecorae gangrenous, so that we find crusts of the ordinary
" appearance mixing with the blackened crusts. The gangrenous pnxH?ss
often f>enctrutes deeply through the skin to the muscles. The lesions at
[tunes are so extensive as to form ulcers which may invade and destroy
I large areas of tissue.
Incubation. — The stage of incubation is variable, but lasts fipom eight
[or ten days to three weeks, the usual time being about seventeen or eightc^en
Symptoms. — Prodromata, — There are rarely any prodi-omata in vari-
cella, beyond a slight malaise for a few hours. At times, however, esjjccially
in young infants, the onset of the disease may be severe: it may be clianic-
terized by vomiting, and, whcrt* the temperature is high, even by tx>nvnlsions.
' In rare cases the [>!'odromal stage is of considerable length and the prt»dro-
mata i*esemble somewhat those of the cither exanthemata.
Effloreacence. — The di?^'asc usually shows itself in the form of an
[^ efflorescence^, the characteristic and most common lesion of wlxich is a
icle. The lesion, however, is in the bc^ginning a macide, which tpjickly
omcs a pajmle, and the papule so rapidly develops into a vesicle that it
is in the voiirular stage tliat we usually first notice the efflorescence, Tht^se
macules and papules are sa superficial that they are soft to the touch and do
not give the shotty feeling whit^h is sr> common in thei^K* lesicms when they
[occur in variola. The vesicle of varicella, as a rnk% is not umbilit^ted,
land but rarely do its contents become pustular. It may be surround^
526 PEDIATRICS.
l>_x- a IF^'ht rod arrola, but this is „ot present in all th« l • ,.
tMHirs*' of i)n)Kn'ssi«)n in tho lesions is that tlio • i a^^' "*
u,H- .lis,K.rso.i <m the skin or absorlx^, and a «m„n "*"*"''•'* ""^^t:
Is off, leaving tho skin ^n.rLu J^T'^ll *-""'*» '•"^ '^'n-^i-ww
and h.a.l, in my cxiK-rioncv osiKH-iaUy behind tl,« aPl'earing on the u.
,i,.t .... th. I.a.k.ancl finally on the extreniit I^?/" the Wy.u^al
sivr <r..,,s, so that very cliffm-nt Unions may be fonnH "^""t"^' ""**
„.,,ns..ntin>: the early and late manifestations of the .ffl"° '^'°"'"
..vU, n.ay first a,.,K>ar in the tlm>at, but is L^t J^f „f °"^"""- ^'^'
.:,.» MS is the efflon-scvrnv of ««rW f.„_ „_ *' ?"™ *«^n i" tfai^iw
with \vlii<>h we should Iw likely to cc
vaccinia, and iH»s.sil)Iy heiixw zoster.
Tlie <-oursc of variceUa is rapid. It jg charaft/> ' ^ u
,.,„stitMti..naI svmi.tonis, with the almost in.m!?- * "^^ « ^"*'*'"«
s....„,v. The eflIon-scen<.. runs a mpi,l „,„"!r «PI'«»">"* -« "-
•nt ..arts of the skin, and disaniK-arinc, oi..'. ?*' appearing ,i„iok]v.c
of col
cfllorcscciicc. Tl
ctllorcscciKv. 1 lie ciiion-Mxu.v runs a moid c>ours«
.lillnvnt paits of the skin, and disapiK-arin^ alino-f ""^'^"''^ '>^'
The disease hists al..ntawtvk or ton dav« ^^^"^ ''Quickly a. it ap^«^
s(.,uel;e. It is rarely co.nplieato<l by any other dise.^ ^'^ "" *"**
CoMi'MCATioNS. — Durln}; the ctmrse of t>irtain ' • j
has lH-..n noti.-(Kl that the ki.hiev is affbotod TJ " ^'J''***'"''^' ''<""«™' =
o,v,M-s after the ..t11ores<-(...<r has almost disap,x«red '""^ ?™P''"'^™ ""^••
firm, the time ..f the lK-iri„„i„jr „f the attack In ti '° ^^ ^^'^ ***'
is ,.,vsent. an.l in all probability is eansed by somTfo'^ f "t'^
althoiifrh nothin-r definite is known alwut this clkss of °
(JAMiKKNois Vaukki.i.a.— A complication wliifb ***• • •
vari.rlla is what is eall.d the jranfrrenons form of ^n^ 7, "f^ "**'"
of whi.h I have alreadv des,.rilH-d. Although it • '^**"«' ♦^'^ Ft""'-"-:
nomished children, vet it <loes not nm>ssarilv attaoL- *k™*^!^ common m ill-
1 • -1 . ■ "■ ™'8 class of oijw aiJ
it se<'nis to have some conneetioii with tiie saiiirrenniia ^__ ^.w-^^
iiHlividuals show a tendencv to develop. ''"^ P'^'oesses which <*M
ulividiials sliow ii ti'inlcncy to develop.
i>r.. w,x-/w.o Tiw. , :. ..i* :
PmMJNosis.— The |>ro^rn(»sis of variwlla is usually l
nientioiuHl (M)nij)li(ati<nis arise, extremely favorable C ' ^^ "^
prognosis is iviulercMl untavorahle l>v laek of proner o« **^ ^pcur where tb
1 1.- • 1 1 , ' care dunna tW iwn-
leseence, ivsultiiig iii bronelio-pneumonia and other diflAo r
^*^®®*e8. In some i*s
THE EXAIffTHEMATA.
627
prognosis is rendered unfavorable by the iinjemia which is apt to follow
rattat^^k uf varicella, and is at times pronouiieed*
DfAGNCxsrs. — The diagnosis of variet^Ia m not diffitnilt if we bear in
id the charactcrifitii's of tiie di>>ease8 whieh it is most apt to simulate.
In differentiating it from variola we must consider the great difference
the rapidity of the development of the offloresc^ncM* in the two diseat^^s.
variola it Ls essentially slow, in varicella it in elxaraeteristieally quiek.
le papules of variola are hard to the toneh, tbjtse of varicella are soft.
le vehicle of variola, as a rule, m ninbilieatwl and *s*M>n 1xx^>mes a pustule ;
characteristics are absent in varicella. The whole coiu'sc of variola
lupies a jjeriotl of from two to three weeks ; the course of varicella is
tich shorter, and is often 1 united to one week. Finally » thi^ S4'vere con-
Itutitimal symptoms and the long prodromal stiige in variola differ essen-
illy from the luck of pr4xlrooiata and the mild coustitutitmal symptoms in
ricella*
In vaec^inia the slow progression of the legions from papules to pustuU^,
d the rather liniiti?d areas affected, serve to distinguish it fnjm the succes-
fe crops of vesicles, with their rapid development and extensive areas,
lich are met with in vari<"c>lla*
The differential diagnosis of varicella fn?m herpes zoster is not difficult,
we consider tliat the vesicular efflorescence in herj>es zoster follows the
tirse of some 8t»t of nerv^es, while that of varicella is perfe<*tly irregular
id IS in no way connecttxl with the distribntiori of tlie nerves.
In this table (Table 03) I have ari*anged the chief pt^ints uf difference
Itween varicella and variola :
naia
qunmntion
npemture ,
TABLE 98.
Vnrift'llA.
Two tf> thrt'O weoks,
Nont! i>r sHght.
On the fekin. Rapidly becomes
vesiculnr. Not iimMIicat*id.
Unilocular. Irtvt^uUr. Xii-
iDCfDua. UniTenaHy distrib-
uted in FUC(?eBeive crrips* V*"*!-
clea differ grPAtly in j^ize On
pricking, collapses entirely.
Slit^bt eruftt formation.
Short, one week Uy ten days.
Mild.
Irrcj^ular, not high.
V^oilola.
One to two weeks.
Three la four dftve in length.
Active. Sovere.
Undor the fikin. A alow pro^rea*
t*ive development from a mac-
ule t4i li papule, trom a papule
to an umbtUeated vesicle, then
to a pusttile. Multilijcular
Regular. Not tiumer<ni«* Di*-
fined in its li>cntiKation. Le-
sions, e£ a rule, of uniform
size. On pricking, coUapses
partiaHy,
Pron*;mnc*Kl crust ronnation,
Lr<ing, thrive to four weeks.
Severe,
Rises suddenly. Remains high
until papules are developed,
when it fjilU e<^)nsiderably.
Riaea again during the develop-
ment of the pUBlulea.
18 very slightly coated. The toiuiU are not enlarged. The i»i;i0ou« tnetnbaf
and of the soft palate and of the pharynx it slightly hypawEuie. On tlie oD
aide of the hard palate and Tery near where it jolm the aoft jpml&te j^m win i
vesiclcfl surrounded hy a distinct red areola. To the left and below th»e ]
minute macules, two of which ha^e almost beeome pepolee. Ton mimt i
difference between a vesicle and a pustule is simply one of degree. On th^ I
ear and on the hack you will notice that these lesions exe purely vesletdiKrJ
so many leucocytes in the vesicles on the skin as are evidemtlj prmmot lo|
on the hard palate, which give the latter a yeUowlah oolor in eont
pearly white color of the dermal lesions.
This case illustrates very well the importanoe of "*^M^g a. ihorongh axS
the throat in children, which I have referred to in a prevlom lecture (Lecttm
828), for unless the throat had been examined the child would bi^ve been iii|il
a cold and would have been allowed to remain in the olinio and t^ti« ^pr^id I
To illustrate still further the effloreeoenoe of varic_^la,
have in the isolating ward of the Children's Hosfiital a cn^
varicella is at its height and has been running its ooiin^ for two
This child (Case 280, Plate YI., Varicella, fiudng page 504), a girl, waai
headache and malaise three days ago in the morning. In tbe aJtemoon an
showed an efflorescence in the throat, but there was also a welUnmrked v^
cence on the back. This efflorescence soon began to come out In crops in i
of the body, on the limbs, behind the ears, and on the aoalp. Tfaero are aka
on the face. Here on the back you will notice a nnmber of l^ions, some
simply macules, and afi^ain a few of the macules have becxKne papules* I
however, the lesions are distinctly vesicular, varying in their eontents to $uch
we soinetimes see the pearly white appearance and again the yellowisb col<
which hu!« become somewhat pustular. In other plaoes the vesdclc^ have
and little crusts have formed in their centres, which axe aomewhAt Indentai.
one of these vefjiclos you see that it collapses and is emptied of its entire coat
that it is unilocular. The vesicle of variola when pricked in this way would
be only partially emptied, showine: that it was multilocular.
THE EXANTHEMATA.
589
uring the ouurae of any of the eruptive dbeases, owing to the probjibilitj that eacten-
cerations will develop under them.
Case 231.
VATfcella. Stage of efClorasceiioei thlnl daf.
*he temporatiire in varicella is in mcKst i^iisc's not high, and m very
uJar, It nsually rises when a crop of lesions of any amsiderable
ser develops, and falls ap^ain at the oiithn*ak» This chart (Chart 12)
CHART 12.
Jfa^s afDisB€MM^
F
J07*
J05°
10+*
ro3«
102*
101**,
100^
99°
970
960
95° 1
1
2 3
4
s
6
7
e
9
10
c
+ 16'^
41. P
40.5**
40.0"
39,4"'
38 a'^
38 3^
M E
11 s i
K 1 X
I X
H U
t B
H i
W X
H K
1 i
J
K
/
y
377"
37 0^
36 5*'
36.1*"
/
\
l\/
V .
/
V
\j
,
11^ ^-^
350**
84
530
PEDIATRICS.
shows the usuiil variations which you niay expei^ tu find iu the tt:-m[«enTj
ni' varitfUa,
I liuvi- :il-«» ln'iv a rhild ^Caso 282), lhn*c yeare of a^, who was bmujrhi :.i:>h-^L
willi I*»)tt** tli>iii-i', ami witli a puniplcgia ari>in^ from u tninsvenfe iiiyL"l;ti> uvi.-*-; ; l-
di>i':tHr. N«»tliiiii: ul»M<»niial was Ibuiid in coniicvtioii with the hiiitjji, lu-art. -.■: 4tJi:ri
rmil ih«- rliild wa^ attarkal with varicolla tin- toiiipi^rHture wu> UMially lUTiuil. ;:: - 1:-
tiim- r<»-«« l'> oT.T'" C. (lUi»° F.), and mraMoiially as high ah 38.3® C. (IUI'= F.;.
Aln»nt «»iH" iinHitli a^i» tlif child lui.'aim* iwth'sji, and his teni j>« Tat uiv p.im: ?«"->. tliL
Oil tin* tt'll<»\viiiij day the ^ylIlJ^t^»!li^ biiruiiK* inort' iiiurkcd, unci thi* t<*ni{»<Tatu^ w*? :. .
ill th«' ivi'iiiiiiT tn Jm' :{y.4° C. (103° F.), On this day tin ettl«ires<.'*'ntv of variivLaiij.i.-^.
on hi-* >kin. Durinic the third day <>t' his Mc-kno:>s hi:» fact* swi'lltnl. and in tlu'rvti:^:-
triiiiMnituri- \va«i lound to U' 41.1° C (UMi° F.). The ves^icular i-ffli-reMvrKr »a- «-:
di'vrl<>{HHl «>ii lii> trunk and face hy this time. Somewhat later it bi'c:inh* univt^al i:-:
a.-sunutl a punili-nt cininu'irr, csjH'cially about the face. During the fuurth. firth. ^d-n
days »)f tin* disia-i' hi> ninjM'p.iture varied in the evening from 3S»° C (102.2® F iivJ'.i'
C. (1UIJ° F.). On tiie seventii day (»f the disease all the s\'niptonis increaBiid m st^rTu^
and the tmipenitun' was found to Iw 41.1° C. (100° F.). On thie$ day si»m»; of ihtTrtLrf
on the face had lieeuiMc ulrtTs. Nothing abnonnal waa found in the lunp«, and nmlliii:
or cft>ts in tin- urin«'. A |>^nas aV»scess developed during the progress of ihi- varii*'.li. T:*
ulcers on th<.' face, a> y<»u mh*, have extendi'd tu »uch a degret; that the child h«? i'.flu.-
bight of one of its eyes. The child is sinking rapidly. The treatment, which b* b«
e>i>entially with stimulants, has failed to keep up its strength, and the Kh:*! tmi3L<i-
connection with the eye has pmved entirely unsucoesefiil.
This child repn'sents a ca.oe of gangrenous varicella.
Hero is the tt»in|H?rature chart (Chart 13) of the case.
CHART 18.
/?a^S of DlSG€LS&
1
1 ^
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2
3
4
5
6
7
a
9
10
11
12 T3
f4
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17Z-
H £
H E
M K
U K
H K
n e|m e
m K
ac
li M
K ■
H m
ME
k K
M X
H £
M ■
a KH ^
K ■
«1
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1
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1
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r^
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409
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/
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1
an
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7
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ee
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Viirirt'lla irniijjni-no«A.
fSnl'i'VjUPiit lii-t-'ry --f th.- rji-.'.i The child continued to prrow weaker, and di»ii»-'i-^
tliirti'-ih ■l.MY fPTii till* tiiiM' wIm-h the first symptoms of the varicella were noticed ^*
jiuto])-v w:i- "I'tiniifil.
THE EXANTHEMATA. 631
■ Treatment. — ^The treatment of varicella is simply symptomatic. The
ciiild should stay in the house^ and its room should be kept at an even tem-
• perature. The diet should be milk. The child should be carefully watched
^ to prevent it from scratching^ as lesions deep enough to produce scars may
k often be obviated in this way. This treatment should be continued until
ri all the constitutional symptoms have passed away and the efflorescence has
^ disappeared. Complete isolation should, if possible, be enforced, as, although
^ the disease is usually insignificant, we can never in the beginning determine
whether or not a rare and severe case is about to develop.
I These rules for treatment are precautionary, and are based on the suppo-
i flition that a child who has had a constitutional disease of this nature must
' be more sensitive to exposure of various kinds. As it is possible in some
. Gises for the kidney to be affected in the later stages of the disease, just as
f it is in scarlet fever, it is well to guard against this complication by the
> protection of the skin from changes of temperature and by the use of milk
> m a diet In a considerable number of cases, especially in young children,
an EDBemia of greater or less d^ree results from ^e disturbance of nutrition
which so often accompanies the disease. In these cases the administration of
BBOcharated carbonate of iron or of tartrate of iron and potash is indicated.
r
Tin-: tliinl iiu'IiiIkt of tho ^roiipof oxanthoinatu \vhi«'h I sh:
is srnrltt livrr, and I have brought yon to tin* s<'arli»t ivvir
Boston City Hospital to-day to show you some illustnitivf c
disease.
Sarh't liver is an aentt* iniN'tious dis<»suie, eharacterizeil
inenhation, sliort pnKlnnnal sta^', on'tlH»mat<iiis oiH<>rt»sivu<v.
desijiianiatitin, and lon^ eonrsi*. Tho niien>-<ir|raiii.sni whieli
has not yet Ihh'ii d(>ternnn(Hl. With the fxtvption of variol
most dangerous of tlie j^ronp. As it (Kvurs s<> luuch nion» i\
rnr\\ life than variola, on aettnuit of its not U'ln^ preveiitahh* l»y
it is to the physician the most im|M>rtant of all the exanthemata,
The e<)m|)lieatit)ns of s<*arh't fever art* so inueli i]i(»n^ seri
sefpiela- so nmeh nioi-e common and ^ravo than thos<' of v:
measles, that its imme<liat<* diapiosia and prompt tn-atment :
neet'ssity in every eonnnnnity where numlx^rs of ehihln^n are .
attaeke<l hy the diseas<*. It should, therefore, rxH-eive the most cs
of every ]>hysieian whos<* ])nietic»e is among ehiltlix»n.
S-arlet lever is the most irn»p;ularof all the exanthemata in i
and in the manifestations which it prcsc^'uts in diflercnt indi>
is usually ej>i(Iemic, returning to the same hn^lities after a novii
It is at times sporadic, and is c«mimonly endemic in lai-pe eitiw.
epidmiics of scarlet fever vary in s<*verity has been clt*arlv show
of tirnc<, >n tliat we cannot ib^eriln* the vinilenc*o of the distmsi
y( :u> to individual susc<'ptil>ility. The s|X)radie! c^ses may Ik? i
maliunauf or of the mildest tyjH'. A mild «ist» may jijive rifio to ;
THE EXANTHEMATA.
533
arlet fever tluring epidemics in comi>arij?oo with the mpid spread of
aeasleSy certain flinieal facts are signifk*ant. The di8<?a^ df>es not seem to
very iofeetious in its t^arly stages. We are thus led to believe that it
|fe during the stage of des<|namatioii that the contafiinm is most likely to l^e
iii^eminated. Measles, on the other liaud^ is known to be highly intklious
its early stages, and for this rcason to spread more qiiiekl}\
As tlie des<^rij»ti(m of actual ciise*> aids the student to romeinl^r im-
>rtant jj^jints in a diseaist^, I shall hi a few words tell you alwiut two
children who have tx^^n under my care, in order to show you the difien^iia*
llietween sc^n-let fever and nie£i>!les a^ regards the stage in which they ai'e
lost likely to Im* iniet^tious and the means by which their eoutagiujii is
IliBually conveyed. Notiee, huwever, that I say usually, for the ocmtagium
of both diseases may be active through their whole etjurse.
A boy (Caie 283) six tgaib old and a girl (Case 234) four years old slept in the same
oni, with their beds touching each other. The boy was tiiken sick May 1, but remained
ISn the same room with his sister during that day and the fullowing ni^ht. He was seen bj
Ijnc early on the morning of May 8, and was then found to have scarlet fever. Hts aieter was
Isaken tti tlie country, and the buy was UtX in charge of a tmint*d nurse. There was absolutely
no communication between the town-hoiiae and the country-house, either by people, elothe»,
lor letter. I myself did not again see the bi»y during bib sickness, having placed him under
ht* charge of another phygieian^
Un Juno 1 I was called to see the girl^ and fotmd that she had scarlet fever. There were
HO other cases of scarlet fever in the vicinity of the country-house where «he had reinainni
I leaving the city.
Th« boy at this time wm desquamating fVeely, and fnur days previoua to the girPa being
ken sick a letter written by him had been sent to her^ and fihe^ after having had it read to
llier} had been allowed to keep it under her pillow.
A careful study of this ca«e led to but one concluBion^ — that the boy during the period
bid deBquamation had infected his ulster at a distance of twenty roileo by enclo«ing the
ontagium of ^arlet fever in an envelope. The girl^ although she had been in the same
Dm with the boy for thirty *sii hours at the beginning of the dii^ease, and although siwcep-
[tihle to the disease, had not contracted it at that time, owing to its very slightly infectioua
[nature in it.s early «tage«. On the other hand, the incubative stage of scarlet fever being
[only a few days^ iAi»d many iuiitanees having prf)ved that the disease li very infectioui during
its period of deM|uatuation, it was evident that the girl had been infected by means of the
[letter.
In the following year, on May 20t I wa-f again called to eee the same hoy. He had been
Lwell in the morning, hut in the afternoon wai> found to have a high pulse and temperature,
Iwith ooryza and lachrymation, so that it was deemed best to send the sister, who had been
in the nunten' vn\y a few h*»ur9 with her brother after he had been taken sick^ to another
Ihou&e^ while the boy waja abi^olutely isolated. Three da^'s later the boy was found to have
sle^. Ten days later the girl was attacked by mea*le*. This case merely emphaeijses
now commonly accepted belief that measles, in contradistinction to scarlet fever, is
tly infectious in the early hour» of the diseaae.
Whetlier the cx>ntagiura of scarlet fever cau be carried by the breath ia,
|I Uiink, somewhat doubtful.
There are, however, ca^es which lead me to believe that scarlet fever may
Ite transmitted at a very early stage i»f the diisease. Ad inj^taiice illustrative
[of this t^ime to my notice not long agt) :
have prov(>d to be the focus of infection for a whole household.
It may occur in animals, and the infection may be transmitted b;
such as dogs and cats, by milk, and by clothing.
There is no known prophylactic against scarlet fever except
which for many reasons should be rigorously enforced. We most
the fact that when the child has passed its tenth year the chances <
contracting the disease are very much lessened. We must also i
that it is especially important to protect children who are leamio
have just learned, to talk. The commonly ooourring and often i
form of otitis which accompanies scarlet fever may not only rendei
deaf, but in a case where the child has not learned to talk it mi
deaf-mutLsm. We should, therefore, under all drcamstances disco
the opinion so often expressed by the laity, and aometimes even
cians, that it is well for children to have these diaeaaes Mrhile they f
on the ground that otherwise they will probably contract diem \
period of life, when the type of the disease may be moie aevi
assertion that the type of the disease is more severe in adult
children is not corroborated by my experience.
Pathology. — The organs primarily afiected in scarlet feve
skill and the throdt The principal complicationa which arise in I
of the discwase are connected with the ear and the oervieal ^amb. *
sequela, and the only one which is at all common^ is nmhritiM,
dU€(m\ comnumly secondary to the nephritis, may occur.
Ijosious of the other organs are somewhat unusual and have u
connection with the scarlet fever. They are generally due part
fever and partly to the septic processes which have aria^i in the
tlie diseases and are represented, as would naturally be
THE EXANTHCIUATA.
535
I
I
Hpttered on the areas of skin affected by the erythema. No e% idenee of
this h)^>enemic oondition, which is so pronounced during life, Ls fbuod after
death.
According to Neumann, microscopic examinations of the skin by means
of hardened sc^ctions of specimens from coses of scarlet fever and measles in
the 6ta|i;e of di'squamation explain in a measure why the former is s^> much
more Hkely to Ix* infectious during its stage of desquamation tlian is the
latter. In ct^ntradLstinetion t(» the patbologicul pnx'csses which are found
in the skin in meiLsk's, and which affect chiefly the bl(KKl- vessels and glands,
a very ditferent picture is presented on examination of sections of skin
taken from scarlet fever. In the latter we find the pathokjgieal process
represented t^sjXK^^'ially by exudative cells, which are ver}" numenius and
closely jiacked togetlier, reaching even up tn tlie horny layer of tlie epidermis.
Occasionally these exudative cells may finally take the place of the epi-
dermal cells, appearing on the fi-ee surface? of the skin, and are gathered
thickly among the exci*etory ducts of the cutane<:ius follicles. You will tluis
readily uodt^rstaud why the tissue proper of tlxe skin and its epidermis
present no marked changes in measles, and why the epidermal cells are far
less likely to carry the amtagiuni than in scarlet fever, where the jxissibility
of eontiigium exists until the des^juaniatiou has entirely ceasetl.
Throat. — The earliest lesions of scarlet fever ajijiear on the mucous
membrane t4' the hard aufl the sof^ palate, Tlib ap{>earance is ver%* similar
to the elIlores(!encx^ which is seen on the skin, except that the minute white
spots do not appear on the congestetl mucous membrane. The pathohigiml
conditions which mxrur in the throat in scarlet fever may either l>e sim|>ly
t?atarrlial, or result in one of the more sevan'c iutlamuuitory conditions aflk't-
ing the tonsils, tlie pharynx, and the larynx.
As is stated by Delafield and Prudden, one of the most marked features
of scarlet fever is the prcH:lisi)osition whk*h it entails t^v the incursi(nj of
pathogenic gcrrns otlier than those which we tR^licve to C4iusc this ilisc^ase.
Thus, in addition to the intlanxmatorj^ lesions pr(xlu<*ed by the scarlet fever
organism an iicutc exudative iuHaumiatiun of the mucfjuw membrane may
occur, and may be associattKl with tliem. This is a]>pareutly caus**d by the
growth of a stiTptococcus which, acf^onling to Welch, in morphological and
biological cliaracter se<?ni8 to Ix* identical with the Hfn'pfocorcuH ptim/cui'n.
In these tuses there may be murh or little tibrinous exudate, and thert^ may
in the early stages, or even through the whole course of the affe<:tion, lie
none at all. The jw^llicle when fornKHl may Ix^ more f»r less adheiTut, ami
sharply ciivums<'rilHHl, or it may tend t«< sjvrrad* The submufxius tissue
may show little change, or much congestion juid ledenia, or it may Ix^ the
seat of suppurative iurtaramation. The entii-e pnx-^ss may Ijc ccmfiued to
the ttiusils. While under these varying conditions the inflammatory prtx-ess
is usually a lix-al one and runn its eours<\ with or without the symptoms of
septicfemia, occasionally tlie sti*e|)toctfx\'us finds ac<*tss to the blood and may
tadncc the lesions of pyemia. On the other hand, it may by inhalation
5:^6 PEDIATRICS.
^aiii airc-ss tn the luiip^ and indiKv varying phases of oimiplicatin^' Ifr-in-h-
piicimioiiia. Tlic staphylcK'otx'Us pyoj^'iies is not infretpicutly a--^;:.:i
with thr >ln'|)t<M*<MtMis in iIh'sc* U^sions, hiit it is not apiuirc?ntly nt' pmuiirrL:
sitrnifii'aiKi*. Sinmlaliii^ vitv closely as it <Ux»s in nmny <-aH> Ixiili t:.:
IcMiil an<l tilt* piicral plirnoniona of diphtlioria, this |i.sc'iKli>-nu'nri'rai:'i«
cM»nditi«>n was fornirrly itmloiindcd with it, but it is now rw<j«rnizfi h> i
distiiu't discaM'.
Thrvv haw Wvn a nuinlxT of extended iiivi*sti||ration.s nia<Ii' <m \\:uiia>
rail*"*! llu* pscndo-incnihranoiis inflaniniatioiis of the thn>at in ?K-arlrt M>r.
liookrr lias rt|M»rt4'd t'lcvcn casi^s of ]>s(Hido-menibrauoiis angina iiw.* lat^!.
ciiniplicatin;; M-arlct fever, and ouv cast* of simj)lo angina without ixanib-i.
in a ianiily thnn' niiinlMTs t»f wlii<*li had sc*arlatina. lii all i\i(^ '"a-^s
as well as in lour s<-arlatinal anginas without pseudo-membraufs. B«-k»r
ionnd sircptiMMM'ci as tho pn^dominant orjninism, and in nono wa< tlieKl'.:'?-
LiH'llltr l)ariniis present. The staphyltMHiec'iis aureus was found in rKv.D
eases witlmut a)>parent inihienee on the st^verity nf the dis^-ase. Xo lii:-
fen'ne<* was <»hserve<l hetwcvn the early and the late pseiido-membran-Jj*
an<rinas as re;^arde<l the haeteria pixsc^nt. Hooker descrilx^s with mu-o
detail the nmrpholo^iuil and Iwieteriologieal charaeteristics of the stivpi-
cH)eei i'nniid. and divides them into gnm])S.
Park, in a series of one hundred and fifty-nine oas<?s, reports ninfttffl
cas<»s of psi'iido-iMeniiiranous inflammation of the throat <x)mplicatinjr ><"trlft
fever. In s<venteen of these cas(»s stn*ptooocci ])i'€Hloiuiiiated, and im»a!}
two wa> the Klehs-Loefller l)a<'illus present. StaphylocixH'i wen* timn'i ii
only a i'rw easrs. Williams has also n'ported eases of this kind, and M'>
ha^ n'pnrt<tl iiin«ty-nine eas<*s of pSi'ndt>-meuil)raiious inflammation (■! li'
thrnat (•niiiplicatiii'r s<'arlrt fever. The Klel)S-LiOi»fH[or bacillus wa- J-'Hn
in twriity-thnt', with a mortality of forty-thn>e |>er c-ent., and wa? ni
found in seventy-six, with a inoi-tality of twenty-oue per ccuL
Finally, wr may eou<'lude that in scarlet fever the mueous niemhraD*' •»!'
the throat is nMuhred |H*euliarly vulnerable to the invasion of |>atlh>:Jri*
p'rms. Where the morbid eon<lition in the throat is represented by i
psendo-mcmhrau*' it will In* fouiul that in the great majority of easv^ it?
prnn's^. a< staled i)y Weh-h, is due to stn»pt(K*<K?ci ; but where diphthtriai?
pn-vahnt and the opportunities aiv iiivorahle for exposure, a lar»^' jiiin:"n
of the p-f'iulo-incmhranou^ eiis<'s may Ik» due to the ldel>s-Txx*ffler liai'ill>.
In :nMiti«»n to the Ir-imis of the throat just deseribeil, the aii'-n-
ornaiii-m (»t' -rniict liver may attack the nitso-pharynx. In this wav. :il^'
hy diirrt (xtcn-ioii tlirouLrh the Kustachian tidK»s, seetmdarv aunil Ksi'HJ?
may Im' prndurrd. The morhid chan<ri^ in the mucous membrane of tbf
naso-pharyiLX whirh tiius take place may n^ult in a thickening of the
ti-sMe>, whirh in mumc ca-es lasts for many months after the scarlet fevt-rl*
run it< coiirH'.
Ear. — Thr pntholnoical nMiditiou of the ear which is most comiu«>ulj'
met with in hwvIvA Wv^y \< w\\ vwwle iutlamniation of the middle ear. This
THE EXAXTHEMATA,
537
I
^
mflaraniatioii is likely to result ia de*?^!^!!^^ of tissue, the formutiim of
adheiiioQB, the c?8tablisfiment of a long-contiouetl suppurative pnx-wvs^ and
an acamipnnyiiitjr necTosi^.
Cervical GHands, — There may be hy{M?r]>la^ia of the eerA'ieiil lymjih
nodes. This ct>nditioD is sometimes aeeoinjiaiiied by iiiflaiiimatory oedema
of the tissues of the nei^k^ whieh may ^> ou to BUppuratirm and even to
gangrene- In thc^se ea*^*s streptoee>m are found in the glands and in the
areas of suppuration. The infeetion is sup^iosed to originate in the tliroat.
The enlarged glands are, ws a rule, indicative of seeondary or mixetl in-
feetion, though it is pjs.*^ible that the slighter forms of enlargement may
be due to reflex irritatii*n with resulting hyiverplasia fj^>m the K-arlet fever
eontagiunu In the severe form the glands are at timw very miieh enlai-getl,
and wlieix" a gaugrenons ]>nKt^s rcsuH.s the blcKxl-vessels may be afli^ted to
i^ueh an extent as to In^ ru[)tuntl.
Kidney. — In sc^arlet fever> bb in a nnmlx^r of other infeetious disea^^es,
thert* are t^c^rtaiu {mis^uis pnMluetKl in the etiurse of the diseai^ whieh are
pmbal>ly solulile in eharaeter. Tlie results of bacteriologieal cultures in
searlet fever have shown that in a number of eases there i^ a general strep-
tixxxx-ns infeetion, the infeetion pi-olmbly cximing from the lesions in the
pharynx. In these ^^asc^s of general infection streptoetxri may l>e eultivattxl
from most 4>f the organs of the lK>dy, theix^ being a geneml septicemia. In
a numlier of these cases extensive lesions may be found in tlie kidneys, and
yet these lesions may b^r no relation whatever tr» the presenee or abs(vn*7e
of streptm-oeei. In like manner, strepto<_'<Kvi may Ix* f<>und in the kidney
without any lesion of the kidney* These lesions are diftiise, and affect Ixjth
kidneys and all jwirts of the kidney. Fprm the best evidence whieh we
have it would sa^m that tlie virus, or whatever it ls whieh pnidmx^ the
lesions in the kidney, is not a living organism, hut is a soluble chemit^l
poison prfKlueeel Iiy the organisms of searlrt fever, or by other organisms,
locates! in some other part of the btxly. This sc^luble poist>n when jvroilueed
elsewhere is taken locally into the blfHid and affa^ts various parts of the
eermomy. In |)ost-mortem examinations of searlet fever certain Ici^ions
will be nstially fijund in the kidneys.
These lesions, ae<x>iTling to Oxineilman, may be divided into two classes,
(1) representfxl by simple degeneration of the epithelinm, and (2) n*}»reseuted
by marked changes in the tissues of the kidney.
In the fird clam of eases the sjluble jmi^^on may only affe<*t the integrity
of the capsular t^pithelial t^^lls of the glomernll The jKrisi-jn may [irtxluce
certain degenerative changes in these, but iKxxl not l»e aiHx>mpanied by any
pi-oliienitinn of cells, or by any wndition \^'tlieh would l^x* eharacteriztxl as
inflammatory. It is more than pi-obable that tin's*' simple degenerative
lesiims are accompanied during life by evidence of albuminuria, and in
case death takes ]»la<^ there may be no macroseopic evideufX' of any lesions
in the kidneys. Careful microscrjpie examimition, however, will show a
isondition of d^eneration in the capsular epithelium of the ^V'tvisws^cwVx.
538 PKDIATRICS.
Associattnl with this there will usually Ix* found cloudy swelling of vanon«
dt'jrn'**?* *>* intensity in the «*lls of the «>nv()lutcil and the smaller crJIemiiy
tuhnh's. The di'jri'neration here? is rart»ly of a fatty character. ClinicalK
in tlie purely <le^enerative ehangt»s there may Ix? only albuminuria with die
])n»s<'uee of iaint hyaline (usts, and here and there a lew leuoixyte*.
In the mvond cfdfw, owing to a greater intensity in the action uiHt
|H)is(>ii, or to some jM>ssible diflerenee in its character, more marked chaD^
may take phuv in the kidney, and may be aecomi)aiiiecl by the dep?[WTJti»>
lesions which are distinctive of the first class. Ditfereut fonns of kriMn«
may (MMur in the stn-ond class, and, according to the predominance of i*
form <»ver the other, may characterize a special form of renal dL'*<is.
Tlu»st' lisions may Ik* dividcil acconling to their anatomical distribution la-'
interKfifidf, when* there is a markeil proliferation of the interstitial tir-*
of the kidney, an<l t/ionwrulary where the lesions are chiefly confined lo lis
glomerulus and its capsule.
In the intei'Hfitidi invin there will Ix? found in the interstitial tt^ut \i-
twcHMi the tubules accunmlations of cells, which are prtjbablv due to a pr-
lilcnition of th(? evils of the capside and of the connective tissue. Tli^r
cells, <ir most of them, an* epithelioid in character, and show ven- few W-
cytes minglcil with them. This form of nephritis should be con^idereJ i-
pur(»]y int(Tstitial, since its lesions are in no way related to tliorjc nf rt
epithelial tissue. Then* is l)oth a genenil and a fiK^al infiltration of coltii
th(» interstitial tissue. The fcM'al infiltration is found princijjally in ttr
cortex (»f the kidney and about the glomeruli, the |a:loiuerulus fre<|mm!v
ap]M"ariiig as a centre from which the infiltration extends into the inteMitu.
tissue iH'tweeu it and the surrounding tubuk^.
This form of nephritis was fii*st deserilx»d by AVagner as the lvm|'L-
oid kidney. The kidney, ma<'roscopically, is sw^ollen ; the caiisule i* t^-ii^
>tripp(Hl from the cortex, and is moist, whitish, and opaque. Usually ilit^
is no evidence of hemorrhage, altli<»ugh in some casi»s |Kunts of punctit'-n.
lieinorrliaL^e may Ik* found in the cortex and in the iuternuxHatc zt>ne.
(;lini(ally, in this form there may Ix* little evidence* of the sevtritv-'f
the le-i(>n>;. Tiure may 1h', how(»ver, albuminuria ct>rTesjx)nding to wlai
is se«'n in the purely degenerative class. The quantity of the uriuv nny
]>e very little diminished, and casts may Ix^ present, as well as a certaLi
nuinl)«'r nf de>«jnamative e|)ithelial cells and leucocytes.
The-.' ioions an* not <'onlin(*<l to sc*arlet. fever, but mav be fouml ii
<li|)htheria. in niea-les, and in other inft*ctiou3 diseases of children but tbfv
are not ennniuin in the inlectious dLseasc*s of adults.
Tiii- niien»se«»])ic seetion, ma<le by Couucilinan (Fig. 90, pa^'c o39\nt*'^
sents a gout! example of these interstitial lesions in scarlatinalDophriiis.
This M-etion wa- taken from a c»'is(M>f pure scarlet fever. There wu*
no amiria and no drojisy. The kidneys were enlarged, whitish and with-
ont hemorrhage. Cultures fn)m this case gave a ^neral infection ^ti
streptococci lu iiW \\u' *.>y^tvv\\<!. v!y.v!^>Y\. \\\vi k\due\\ and I wish vou to DOti':^
THE EXANTHEMATA.
539
especially that the kidneys, notwithstanding the extent of their lesions,
were found to be free from streptococci. The epithelium of the tubules is
somewhat swollen. The tnbnles them^*lvci5 are slightly dilated, and the
epithelium is more granular than norniiiL The interstitial tissue is much
more extensive than uormaL The spaf^es between the tnbulcs are increased
both by cpdenia and by rclhdar infiltration. In the iutcivititial tissue yon
will see bl(x>d-vt*ssels filled with c?ells of the same character as thnso out-^ide.
It is prolmble that nio*«t of the cells outride come from proliferation of the
cells of the blood-vessels. The round spaces in the interstitial tissue repre-
sent blood-vessels.
Fio. 90.
iDtefstttlAl xicpihritb. Bectkm of kidney twm cbUd with scarlet foyer. (Hurtnftck. ocuIat No. D.,
objective No. VHI. Tube eloped.)
The other form of nephritis, called the f/kmimthtr (page 540), is much
more fi'equcntly found in scarlet fever than the interstitial form, and may
^be cousidercd as almost ty|jical of the disease. In this glomerular form
the chief lesion of the disease^ consists essentially in a proliferation of the
capsular epitlielinm combiue<l with hypq>lasia of the connective tissue.
The proliferation of the capsular epithelium leads to the formation of
masses of cells within the capsule between the ^h»merular capillaries and
the capsule. These cells evidently iTsuIt from the proliferation of the
capsular epithelium. As a result of this then^ may Ijc gn»atly increased
pressure on the vessels of the glomerulus, with |>ossibly obliteration of these
I Tessels. The cellular infiltratiyn in the iutei-stitial tissue Ls not so extensive
in the other form (Fig. J>0). Acconijianyiug these changes in the
Iglomerulus there is almost always more or less hemorrhage both in the
tubules and in the interstitial tissue.
540
PEDIATRICS*
Hon' i.^ 11 jsit'C'tioii, made by Coimeilman (Fig* 91 ), of glomerular oep
TbU isectiun was taken from a case of scarlet fever corapliaited
glomerulonephritis. In the centre of the field a glonieruJus is seen, with j
infiltration of alls in the capsular space. The capsular eelk areonli
distinctly epithelioid in character. Cellular proliferation of the oeUs J
Fio, 91.
^jtfS!
t
•^ji»\
%j>j
Capsular glotnemloiKSphH till. Section of kidin?y from child with soarlet fcTer. {HmiUikM
wularNo. II., objei'tivi' No. VilL Ttibe oloi^erl.)
generally the ehanic*ter of thrise in the section of interstitial nephritic I
90) is found, as you set% in tlie intei-stitiul tissue. In the tubule at tlitl
upper corner there is hemorrhage^ and hemorrhage is found in tlie iati
tissue on the right of the {Specimen. In this ea*^ the anuria and droptiy^
extreme.
This form of nephritis may be Ix^st dt^ignated as capsular oloiik
nephriftH, The kidney is swollen and much more hyjieneniie than in
interstitial form* The markings of tlie cortex either are ohHcnred or ttBft
be made out at all» and there an* numerous areas of hemorrhage
hypenemia^ giving the kidney a mottknl a|*pearanoe.
It is this ca|>sular glomerulo-nephritis which gives the most
clinical evidence of the extent of the lesions in the kiduev. In ihk\
dropsy is ahnost always present, the amount of urine is greatly dimini^l^
and in the m<ii*e severe cases there may be complete anuria/ Bl
are found more ftequenlV'^^ m ^W \Mt\\ife lW\i va the interstitial form.
THE RXANTHEMATA.
541
I
diminution in the amount of the urine points to involvement of the glomeru-
lus* Even severe cases of this form may be recovered from. The process
of eell-pn)lifemtioii may cease, tlie cells foniie<l in the capsular space may
dkappear and pass out, and the kidney in afler-yeai's may show tew or no
evidences of the process thiuugh which it has passed. In a certain number of
cases, however, from i\m form oi* nejvliritis a vhn>nh' nephritis is developed.
Cases of this kind have l>eeu reported » notably one by Aufrecht.
In l)oth the interstitial and the capsular glomenilo-nepbritis fatty degen-
eration of the epithelium is not Ibinid to any dcgn.'e. The epithelium is
fretpicntly swollen and granular, and may be hyaline.
Thest^ tw*i forms of nephritis should be separated from eacli other,
although transitions between their lesions are found. Usually they can be
distingnishtd maeroscfJi>ically.
We can, therefore, recognize three pathological conditions of the kidney
in scarlet fever: first, the purely degenerative; second, the acute interstitial ;
and third, the capsular glomerular.
Heart. — The pathological conditions of the heart which an? at times
found in scarlet fever do not difier in their macmsfjopic ai>|>earauce8 from
those met with in other diswtses. Caixliac disease CKxnirring in the coui^se of
scarlet fever may arise in two w^ays : (1) from the general s^-ptic condition
existing during the i)eriod of the height of the temperature and gt»neral
efflorest*enw, and re]>reseute4l usually by an endocarditis ; (2) at a much
later period from a ucjdiritis which has arisen as a com plication, and fol-
lowing w'hich, from the resulting incn^ased blood-prcssui-e, cnlargenjeut of
the heart has been produced, w^hich may be represented by hyjiertrophy or
by dilatation, or by Iwjth.
In cvinnection with this subject, 8illx^rraann has found on examining a
lai^ number of cjases of nephritis during attacks of scarlet fever a detidcil
hyjiertrophy of the heart aunbine^l with dilatation. In some cases l>oth
sides of the heart w-ei^e eipially affected, but usually only the left side was
involvecL In only a few eases was there found a partial fatty d<^neratii>n
of the nvustndar fibi'cs ; the endocardium^ pericanlium, and blo«xl-ves8(*]s
were normal. At^xmling to 8ill>ermanu's oKservations, the cardiat^ affection
was relatwl to the pc^<t-s<?arlatiual nephritis, and not to the scarlet lever
'prooess itself, as the hypertrijphy w^as never found where the child diet! iu
the early weeks of the s^-arlet fever. He calls attcntton to the short i>criod
which intervenwl b^twi^ni the first ap|)earauce of tlie nephritis and the t^ju-
secntive heart hypertrophy, in many eases the time not being much longer
than a wec*k. He als4v notic^ed that in the cases where hyp^'rtrojjhy and
quick dihitati<m ibllowefl the acute nephritis of sv'arlet fever the ag<AS of the
childivn \^cre tlin:^ and a half, four, five, and six years, this iK>st-8carlatinal
canliac cidargement tlms corresponding to the pliysiologi<:-al hypertrophy
wliich I liave referred to in an earlier lecture (Li'cture I\\, page 123).
Scarlet fever may be divided into (1) the benign form and (2) the
malignant form.
such as you set' liciv in my scarli't fever wanl, its it is this cliL-s
will 1h' inort* likely to luw^t with in your pnicticse. Those titses, j
see, either run a simple typiejil course or are aceonijxiiiieil by
and e(»!ni»lieations which make their courst» irregular. The sini
case of the U'luirn form of s<'arlet lever is such as I have already
and is characterizeil by its sudden onset and long duration.
In( THATioN. — T\w Mi\^^. of incuhaticm of scarlet fever is luw
iri-ejrular, hut, as a nde, it is shorter than that of any of the
anthemata. It is usually k»ss than seven days, and quite frexji
only from two to four days.
Symptoms. — Prodromata. — The invasion of the disease
sudden an<l, as a ruk', activi*. The child twls very siek, looks
plains uf sore throat and nausea, and in a large number of ca
continu(»usly. The jndse is rapid. The temperature is high, — :;
10.5° C. (l();i°, 104°, 105° F.). In infants and very young c
the tem|HTature risi»s to 40° or 41.1° C. (104° or 106° F.) eonv
very likely to occur. The hijjher the temix>rature at the beginn
dis*as<' the more active the symptoms, and the shorter the prodroi
the moiv severe will 1k» the casi». An initial tem}>erature of 40*
V.) })oints t<»wanls a seveiv (usi»,
Y(»uu^ children seem to show a less sensitive condition of the t
is met with in older children and in adults. The ap|)earanee of t
lucnihraiK' ol' the throat, although jxThajw not eharacteristie, as
-iinplr nou-iul'crtinus pharynjritis may simulate it quite eloselv,
nrriioii with the ti'cneral symptoms, at least suggi^tive. The nuu
]>nmc of the hard and tlu' soil palate and of the pharj-nx is i
L:v-t«<l. ( )n tlu hard and the soft palate thickly seatterecl overtlu
THE EXANTHEMATA.
643
r
I
of tbe neck and the upper part of the chest, and rapiill y extends all over the
body and extremities, and upward to the face. This characteristic order of
invasion t)f the skin aids ns in distinguishing the effloresc^^ncse of scarlet fever
fn>m that of tlie eomnxoii erytliema whit*h iK-cnrs in such diseases as pneu-
monia, and in cases where certain dnxgs, such as l^elladonna, have affected
the skin and the effloi-eseent^ <'imies out everywhere at once atid In^s an
irregular distributi<ju. It alscj enables us to distiuguisli the diseast^ from
measles, in which tbe efflorescence begins an tlie sides of the neck and on the
face and extends downward. On gently drawing the finger over tlie efHo-
rescence of starlet fever the resulting white mark remains hiuger than L^ the
case with a wmmon erythema. The efflort^'eutx^ oi' searlet fever wmtinues
to extend over the body for two or three days after its first apjxarance.
During this pt*riod the tongue Ls much reddened and its |)ajnllffi aj>[iear
very promineut, wustituting wluit lias Ix^n fallal the *\strawberry tongue.^'
There Ls at times in this sta^ great irritation of the skin.
There may l>e slight deliriiun even in mild eases during the stage of
efflorese^uee. This delirium may be very active and yet not be of serious
impt>rt, provided the tenii>erature remains m<xlerate.
Tlie temiK^rature rises ^vhen the efflort»seenet» appears, and reaches its
maximum at the end of the uutbnak, in uiiwuiidieaUnl cases^ but there is no
CHAET
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Benign and regular form ol scarlet fever.
[decided rise jnst before or fall after the height of the effloresoenoe, as is
I the ca«e in mea-^k^s ; on the e*nitrar%% the tem|)eratnre slowly dmiinishe** until
[the ninth or tenth day from tlie bep:;inning of the pRidromal Hymptnms,
phen it becomes about normal, showing no decided crii^is such as is seen in
[measles, but reprei«enting what is called lysis.
»,>>V- ».••««•> »M^tJ%/ %»^^%M-f. »m-s.-s»m .^ »»•*.- %»^ »J^a »i«»»» ■ ■»■ *»%^**f m^-y^ mw -^ v ^ a. a a>^ aa«^^ «*A **
tioiiatc to the intciisity of the effloresoenoe. This desquamatu
coin|K)so(l of small {Mirticles of cutis, but these soon beoome largn
in the third week from tlie beginning of the disease they fall frc
in large flakes. This form of desquamation is called lamellar.
we have an im|)ortant means of distinguishing scarlet fever fr
for in measles the des<iuamation is almost universally of a 1
character through the whole course of the disease, ivhile the cl
desquamation of scarlet fever is lamellar. This lamellar form oi
tion may at times, in certain individuals, and following the n
inflammations of the skin, ho. represented by large and extensi^
skin. This is well shown in a specimen in the Warren Mus
large .stri]is of skin have crome from the hand of a patient with £
so as almost to form a glove.
Sometimes the desquamation lasts only ten days, but it may i
two or three weeks. It is es])ecially slow in disappearing fironi
and feet, and it may remain between the fingers and toes for a
weeks. Sometimes afler the desquamation has apparently oeas
skin hiis Ixxui smooth and normal for several days it may begin
thus prolong the i)eriod of convalescence.
UuiNK. — The unne is lessened in amount during the prodn
returns to the normal amount in the stage of effloresoenoe, incre
the stajre of des(iuauiation, amounting at times to a polyuria, a
again to the normal amount at the end of this stage. Durinf
of ettlorescvnco, es|)ccially if the temperature is considerably '.
there may a|)iK\ir in the luine a small amount of albumin, bi
a])iK'ars as the temperature subsides, is probably only the insult o
as in many other diseases aceom|>anied by a high temperatuie, ai
THE EXANTHEMATA.
-mr'
Hfe&senod when the Dumber of expert examinatioDs of the uriiie in mild cases
^■bf i^K^rlet fever has iDcreased.
^1 Progxcdsis. — The prognosis of the benign and regular form of scarlet
^K^ver is in almast every case favorable. It is eooipamtively I'are for tlie symj>
^■oms to become sufficiently serious to cause death uuless some complication
^na^^ arisen iu the course of the dlseiuse. The ludividiial who succumlis to
Hjthe simple uncomplicated form of scarlet fever, even when the initial teru-
Bperature is high and the symptoms are severe, as a rule must Iiave Ixi»n
, nn usually vuliieral>le to the toxic eflects of the scarlet fever contagium, or
I must have had a very low degree of vitality at the beginning of the
iliscase.
[ Diagnosis. — The diagnosis of the benign and typical form of scarlet
_. fever is not difficult. Its incubation is decidedly short in ctimparison with
that of any of the other exanthenuita. Iti5 prixlromal stage is short in
oomijarison with that of variola and measles, and longer than the exceed-
ingly Ivrief pnxlrrtmal stage of varicella* The characteristic prmlronml
»gj'nij»toms of sore throat and a general and intense hypenemia i;f the nuicous
membrane, acicompanied by vomitiug and severe constitutional symptoms,
make it etw to ditlerentiate it fr^)m measles, varicella, and variola, none of
I which, as a rule, show these symj>toms.
The punctate erythematous lesions which apjiear in the stage of efflores*
Oence (4* scuirlet fever are rarely met with in any of the other disease of
this group. This effloR^scent^*, beginning on the nef*k and chest and ex-
tending upwai'd anil downward, is distinguished by its ^leculiar distribution
from that of the other members of the gronp.
Tlie lamellar dcsf[Uamation is ver}^ characteristic, and is seldom seen in
*» any of the other exantliemata*
B The complications arising in the ear, and the occurrence of nephritis as a
etjmmon sef[ut4a in scarlet fever, do not to the same degrt^ find their counter-
parts in varicL'lla and mciisles.
Treatment. — As I have often told you in sj>eaking of other diseases,
K> in scarlet fever, having an accnrate knowlixlge of the chief |iatholr»gical
lesit>ns which tx-cur during the course of the disease, you can easily tltHloce
Ihe a}>|>i'i»priate trt^atment. By treatment, you must understand, I do not
tiean simply the use of drugs. On the contrary, I would impress njxin
^ou that in my opinion drugs are employed to entirely tmi great an extent
lin a lai'ge pro|)ortirm of the uneompIicjitfHl cases of the benign tyj>e of
rlet fever. I feel that I can speak with some authority on this point, as
it has l>een my rule for many years to wmpare the results of cases ti\'at<'d
by my collt*agnes with drugs with my own cases treated without drugs, and
prtainly nothing that I have observed io this oonijmrison w^ould indicate
that my patients had suffered from want of treatment. We shonhl have
some definite reason for what we do, and shonltl uc»t be influenced by vague
ideas of what drugs are supposed to be beneficial in certain diseases.
I The ti^eatment of a case of scarlet fever is tliat of a self-limited disease.
1 36
The treatment here in my scarlet tever ward is rendered
than is the inse in private houses by the fact that I am ah
from family prejudices as to how scarlet fever should be treat
be(*ause the patient can at once be put in a room fix>in which all
jmraphornalia have been removed. As, however, your cases in ]
be in their homes, it will be better for me to describe the genei
ment and treatment of scarlet fever outside of hospitals.
At the onset of the disease the child, as a rule, is so profoni
by the scarlet fever oontagium that it wishes to be put to I
The 8ym])toms which from tlieir intensity require treatment
dromal stage of the disease are the vomiting, the sore throaty ai
tcmj)erature.
Tlie vomiting, as a rule, is of such short duration, and is so s
of nervous gastric disturbance caused by the toxic elBect of the
it should 1x3 looked upon as eliminative, and usually does not req
of anything but pieces of cracked ice to be held in the mouth.
The treatment of tlie throat in scarlet fever is to be espeeia
not only to allaying the temporary discomfort of the phaiyngii
to preventing the inflammatory process from eztenfling^ throng
chian tulx's to the membransD tym{)ani and producing^ an otitis
n^ult in a meningitis. This latter complication is rendered poa
close vas(rular connection which exists in infimcy and in childho
the mcMiingeal blood-vessels and the vessels of the tympanum 1
oj)en ]K^tn)-s(iuamo»al suture.
Auotlior ri'ason for systematically treating the throat in a
scarl(»t fJ»vor is derived from the belief that the various
THE EXANTHEMATA.
547
I
I
i
1
I
glyoerm are useful for tliis purpose. A four per cent. solutioD of boric acid
in water can also be used to advantage. The IrK^al treatiueut, however,
shoul4 always be of the mildei^t form, since any aJditioual irritation of the
mucous membrane will render it more vulnerable to the strtptoeoeeus inva-
fiion. If the child knows how to gargle, the disa^mfort which arises usually
from the kire thrt»at during the first day i>r tw^o of the disease may c»ften
be allayeil by simply garbling with nnd water. This pox-eilui-e answei-s a
double purpijse : it not only reduces somewhat the hyperoemie condition of
the nme«jus membrane of tlie upper part r>f the thrt»at and cleanses the
anterior fauces, but also tends to prevent the extension of the pathogenic
organisms w hich would necessarily be favored by a cnjntinuous recumbent
position of the child. If tlie child is unable to gargle, sc»me pieces of ice
may be given t^j it to hold in its mouth, and it should wi-casionally be allowed
to sit up, as when its nourishment is l>eing given.
However desirable this treatment of the throat and nose may be in
scarlet fever, we are but tcM> ofien baffled in our attempts to treat tljcjn
locally, on account of the persistent resistance of the child.
Chlorate of potash, which is so fret^uently used for the treatment of
the throat in scarlet fever, Ls, !n ray opinion, a drug which in this disease it
will be wiser not to allf)w the child to swallow, on axxH:»tmt of its pissible
deleterious action on the kidney, which from the beginning of the disease
to its end is in so sensitive a condition as to be readily affe(*t<xl by any
irritant. Doubtlms in a large number of cases we should nut Im? likely
to cause renal irritation by the small dose^ of chlorate of jMitash w'liieh
are usually given. Children, however, ditler very much in thiir individual
susceptibility to drugs, and we can never tell Ijcfon-hand whether or not
a child is liable to be injured by them* We know that the vegetable
salts of potash are decomposed in the system and eliminated as alkaline
curlMnmtes, thus causing no irritation in the kidney. Nitrate and chlo-
rate of ixrtash, on the other hand, which do not |)art with their oxygen in
the system, are excreted undecorajx)sed by the kidney, and thus act as irri-
tants. Knowing that the tendency during the wiuile tHiurse of the di.s(*ase
is towards a renal hypenemia, we should allow" the child to have plenty of
water to drink.
Unless the child show^s decided signs of suffering frrun a hcightentxl
temperature, I do not use antipyretics in the form of drugs by the mouth,
aa the cases are rare where a tem|M^rature of 38.8° to 39.4° C. (102^^ to
103*^ F,) for a few days will do harm. This is a safe nde to follow in a
disease like scarlet fever, where*, if the chikl happens to he ea-^ily atf<x^ted by
fever, the unfavorable symptoms will apiit^-ar at once and t*an Ik^ attended to.
My opinion is that mere heightening of the temiM>rature without correspond-
ingly severe symptiuns causes much nt^^le^s anxiety. In tyiiii-al rnild cases
of the disease I should, knowing that a lessening oi'the amount uf the urine
in the prodromal stage as a result of the high temjierature is a part of the
r^ular course of the disease, discountenance the administration of diuretics
548 PEDIATRICS.
Im'voihI a plontifiil siijiply of pun* drinking-water. The tempnitnre. al-
tln»uji:li it may canst' seven* initial sympt4)nis, such as oouviilsiour*, a>anilf.
(liH's not have to Ik* direftly trt»ated dnring the prc)cli\>nial tstage. It. k«.
over, eonvnlsions oeenr and continue and the temjx?rature is unusiually lil
such as 40.5° or 41.1° C. (105° or 106° F.), and if it remains at tht beiga
with serious jx^'uenil symptoms, such as delirium, you should eudtavor :<■
i-c^hice it by s|K>njring tlie IkkIv with water, the temperature of which >hi-uli
1k' variiMJ acconling to the s|)ecial ease. To begin with, the temjieratu^
nt' the wati'r shouhl lx» al>out 32.2° C. (90° F.).
I liave meutioneil Ix^foiv that scarlet fever is rare during the first wj
of lite. Tliere an» wrtain obsiTvations which seem to show that nepliritir
is a rare a<'<'<»mpaniment of scarlet fever dnring the first year. We k&'vr
that milk is tlie food which is lejLst irritating to the kidney. It w<.njl
tlK'H'lore, s<*em but rational to make milk the diet in a disease whic?h, likt
scarht lever, i>oiuts out to us by its jwithology that we should as far fc
jH)ssible avoid irritating the ki<lney. It may be merely a eiiincidomf. l-ai
it siHins (»f some significance* that the first year of life should aK) beihe
one whicli is least likely to prt»sent cases of sc*arlatinal nephritis. Fortla?
reaMHi I am in the habit of putting my jwitients with scarlet lever ab^Jutely
on a diet of milk from the Ix'ginning to the end of the disease, or at It*-'
for f«)ur weeks. Perha[)s in this way in a certain number of causes neplirlti-
may Iw wanhnl olV, and if it develops, the patient is already on a diet whiti
is Ix'st suited to the diseas<'.
When the nausea an<l vomiting are present, the cliild, as a rule, tkl*:*-
sick to take any uouri>hment whatever. When the violemv of the ti'vi-;
invji-i«»n has somewhat abatiil, and the diagnosis of scarlet fever ha-* l-^o
madr. nnl(r> .-honld at once Ih» given that the child is to have no il""] lis'
milk. The treatment of scarlet fever with a diet purely of milk has in tij
|)racti<e provcil so eminently satisfactory that it has Ixjcome mv pmtirn
treatment of the <liseas<'. During the initial stage of the disease, and nnn
tlie stoniaeli has reeovere<l its eciuilibrinm, lime water should be added tu t}.:-
milk in the pn)|M)rtinn of one part to ten. Later the alkalinitv of tk* ^]ii^
can be h^seiied, and al'ter the early days of the efflort»soence the milk cw'
in mo^i ea^es be ojven undiluted. The administration of milk alone :?hou."il
l)e <'ontinne(l (ln-«)U*»h tlie stag<'s of efflort^scx'nw and desfjuamation, and until
you are justified in su|)|)osing that a nephritis will not develop in the *}^viJ
ea-e. This in noneral may ])e estimatid at trom f5>ur to five wet*ks fi\)mtlj».
time of the heiiiht of the elllorescemi* and tem|)erature.
DmiuLi the >(aL^e of etHoreseenee then* are seldom any svmptorass vhii.i
HMjuire -peeial treatFuent, in the n^gnlar form of thes disease, except :i con-
siderable irritation ol' the skin which at times arises. This can be allav?J
by the application either of some simple ointment or of a pi>wder of oxitt
of zinc and starch (Prescri|)iiou 5()). The use of the ointment istobem^>ni-
nien<le<l not only lM'can>e it keeps the skin soft and in good condition, but
also becan-^e ihi-; a\)\)Ueati<in reiluces the teniiK»rature somewhat. SwneiiK
THE EXANTHEMATA.
549
I
tbe entire body with water at a tempcTature of 32.2*^ C (90° F.)^ once or
twice daily at'avitliug to tho tHimlort of the patient, is to be recf>mmende<l*
During the stage of desfjuainatioo the application of a simple ointment
to the whole btRiy is desirable lx>th for the puqxise of softening the dis-
int^rated epithelium and lessening the duration of tliis n-tage, and also
to prevent the spread of the contagium by means of the loosened t^cales.
The child shimld l)e kept in bed nntil the desquamation Iuls alnii>st
entirely ceased. This will cover a iw?riirtl of imm four tt» five weeks. By
the end of the fourth week, if the destjuamation has completely disappeared,
the diet can gradually be increased by the addition of sonp and bread. It is
well to kce[) the child in the house for tivc or six weeks, and i^till longer
if the weather Ls cold or damp.
The urim should Ije frequently tested for albumin during the first three
i, and afterwards when the child is first allowed to get up, ailer t^dch
ige in diet, and afer gt>ing out. If any albumin is detected, the child
should lie immwliately put back to bed and on a diet of milk tintil
the albumin has disappeared. Remember that the mikl ciises are the very
ones in whicli a nephritis is liable to occur, and therefore w^e should watch
them vigilantly until they are out of danger, which is usually in the fifth or
sixth week.
Isoi.ATiON AND DISINFECTION. — The disease biding eminently infectirnis,
the patient with its nin-se should be isolateil to as great a degree as circum-
Btances will permit. An upper room should be chosen preferably. It has
been observ^ed in crowded parts of larp^ cities that scarlet fever in teuement-
houses is not so likely to sj^read when the first cases art* in the top iYH>m9
of tlie tenements. In a number of instances in ray practice I have had
one child of a numerous family strictly isoIat<Vl in the upper stor^^ of the
housc^ and the other children have remaine*! in tbe house w^ithout ctintract-
ing the disease.
The intcnsit}' of the lesions of the skin and the invf^lvement of large
surfaces indicate tliat the air of the rcK>m should be; kej)t at an ecpiable tem-
perature, in order that the function of the disabled skin should be taxetl
as little as possible and that the internal organs should not have Ux> great
compensatory WT»rk fon^ up<ju them. The tempcratuR* should be kept
at aknit 20° C^ (68^ F.).
A disease which renders necjessary confinement to the room for weeks
demands a room with good ventilation and jilentifu! sunlight. Therefore a
room on the sunny side of the house, having an o{>en fireplace, should \)e
chosen.
The room should ho free from all cotton or woollen materials except
such as c^Ji be dcstnjytHl by fire at the end of the dL«.ease. The blankets,
sheets, towels, and clothes can, of tH>ur8e, be disinfected, but it will save
much ultbnate trouble to remove tlie f*arpet and the curtauis and replace
them with pieces of old cari>et and sheets. The pictures, and in fa*;'t every*
thing worth preserving, had better be removed. TW looia oaxv \afe xsvaA.^
xue utj(x'uuii» are u} ix reueivixi in u vvoBtsi one-quarcer mil
cent, solution of carbolic acid.
After the child is entirely well it is to be thoroughly va
a solution of corrosive sublimate 1-2000^ and then immediately
so as to avoid irritation of the skin. The child is tii«n to
another room to be wiped and put into fresh clothes, whid
have not been in the scarlet fever room. The mattress is to 1
canvas wet with a corrosive sublimate solution 1^600, and sen
house to be disinfected, if possible by steam. I usually advifl
never to have it brought back again. In place of the matti
better to use old blankets, which, if in sufficient number, are
and at the end of the sickness can be thoroughly boiled awH
fected. The iLseless articles which have been in the room dori
noss should l)e burned in the open fireplace.
The room must next be disinfected. This is a very diffict
do absolutely, but tlierc are several methods whic^ are fiir bett
usually rccrommended disinfection by sulphur which h«w been i
used for this purix)sc during the past century. I mention salpl
infectant merely to tell you that it was proved by Koch as long i
to be entirely unreliable.
If there is pa|)er on the walls, it should be scraped off and i
burned. The floor should then be washed with, a solution of ooi
liinatc 1-500, followed by soap water. The ceilings, the walls, a]
work, and the furniture are to be thoroughly rubbed with hm
wiixnl with the corrosive sublimate solution 1-500. E^maroh
that broad is the best means for removing infectious mi^tCT^^^ ft
of this kind. The micro-organisms adhere witii great tenacity ti
which, with anv eruml)s that break off and fidl to the flnnr mi
THE EXA^'THEMATA,
551
thiiik« serve to show you the eharacteri&tics of the benign type of scai*let
L fever without variation from the regular tj'jie and without complicationa :
A boy fauf ftnd on^-half years old wa* noticed by me on November 6^ whcQ I waa
Taccinatini^ his sister, an infant, to be quite aick. Beaidfts ib« infant the hoy's two brolhersj
one tW(» tind a balf years old and the other six, were in the room with him. The mother
supposed that the boy had an attack of indi^e^^tion. He hud be^n vomiting quite frequently
And had no appetite, Hi« pulse was 120. Mii* tumpiniture win* 38.3^*0. (lOF F.). He
had no headache und no sore throat, but he had the iippeumnee somewhat characteristic of
acuHet fever well marked nn the hurd and the iioft palal<-\ He was placed in an upper room
of the houae and completely isolated with a trained nurse. Thv vomiting continued until
evenings when it stopped and did not return*
On November 7 he was reported to have had h restless night. His throttt was found to
l>e very much reddened and to feel a little j*orG, His pulse was 135, Hib temperature was
S8.8® 0. (101° F,). He had had a natural movement of the^bowel*. His ap{>etite wa«
poor.
AH unnooeBsary articles wore immediately removed from the room, and he was confined
to his bed. He was placed on a diet of milk and given us much water an he wUhed to
drink. The efflurescence of scarlet fever very Ff>oii appeared on hid cbeet.
On Novembers the effloreHceoce had spread all over his body. He wa« reported to
have filept well and to have vomited his milk but once. His pulse wan 125, and his tem-
perature wag 37,7° C* (1(H>° F.). He was sptmged twice daily with water at a temperature
of 82,2° C, (90° F.), and as the skin was somewhat irritable the itching waK allayed with
inunctions of vjiseline. Tho temp*^rature of the room was kept at 20° C. (68* F.)-
On NovemlH?r 9 the efflorescence had spread to the limbs, and was also present to a
alight degrtie on the face. At 6 a.m. the puke was 120, the temperature 36.6** C. (B8** F.).
At (\ P.M. the temprature wa« 87.2** C. (99° F,), and the puUe was 120« He had a little
more ftp(:»ctite, hi* skin was leas reddened, and hia throat was not »o *ore*
On November 11 the efflore*icence began tcp fade, flrst on the chest. On November 13
the ttmiperature l>ecame normal* and desquamation began, first on the chest. On November
25 the dHsquamation had almost cea:!4ed, and the \wy wi»s allowed t<i get up and play about
the nvmi for an hour. On Deoeml>er 1, the deM]Uiimation having a]mo«t ceas^ for several
days, he began to de^cjuamate freely again. Un Deeeinber 8 the desquamation ceased. He
wiis disinfected and then sent down-etaire among the rest of the children. He went out of
doors December 25.
No albumin was detected in hi* urine during tlie whole course of the disease. He
resumed bis u?.uh1 diet on December 10,
Nime of the other children contracted the disease, although they remained in the house
"while their brother was sick.
I shall now ^liow you in this IkhI a typit^al ease of the l^eni^u form of
fieartet tever with tlie dbtinrtive efflores4:?ence of the (lipase on the ehest,
neck, and faee.
The boy (Case 288, Plate VI I., Scarlet Fever) h ten years old. He is said lo have
been expofed to scarlet fever eight diiys agr^ He whu tuktm sick, with sore thront, vomit-
ing, a quickened pulse, and heighlened temperature^ l\mv days ago. Three days later ihh
effl'trescence appeared, first on his neck and cht^st, and later it spread downward over the
trunk and extremities and upward to the face The eflliorescence is, as you see, in the form
of a punctate erythema. You will notice that the degree of redness is much changed
according as the skin is protected by the warmth of the bedclotbes or is exposed for a
greater or less time to the temperature of the room.
There is, therefore, no definite c*)lor or degree of red color which is characteristic of
icarlet fever, a« it is liable to vary fr*>m many ^•auseii The vomiting ceased three davs ago.
The boy has been at times slighlly delirious for the past two days, but to-day the tempem-
Variations in thk Hknign Form. — Jn the benign lurm
ft'vcr \vc nijiy luivt* j^rt'iit variatu)iLS fn>m the typical nianiie^tati
dist*as<' wliu'li I haw just (h^Tilx^l to you.
A hritrhtrncd tom|HTatun» in the evening sometimes continues
w«»«'k alter th(» elHon»scx»n(v has faded, witliout the existence of anv
al)le cause: this tKrurrencv should always be looked U|M>n with
After a rapid increa^^i* of teni|)t»rature at the beginning of the di;
s<nnetinu*s ensues a condition of eoinplete apyrexia^ while all
synij)t<»nis continue to deveiop in the usual manner. When the tc
remains heijrhtenetl at the end of the |K'ri(Kl of efflorescence and
int<» the ihtIikI nf des<juaniation, es|XK»ially when there is no local
wlien', we slinuM susjH'K't that a nephritis may be developing.
tenijMTature after liavinj^ Inn'ome normal rises again, we should su
coinplicatiniis as otitis and suppuration of the subcutaneous tis;;
neck, or that the heart is involvtMl.
Hehipses may take j)la(v in scarlet fever. In some of the^
the etll«»rc'^ceiic«* has disaj)|H*an'd it may return in the second or tl
<lurin^ tlie >tap' nf destjuamation, and even after the desquan
endiil. The symptoms of these (u^^es art* sometimes more severe
in tlie tirst attack, but in most of the re]K)rted cases of relajiee
lever the fir>t atta<'k has Ihhmi a mild one. Such cases oc<*ur
older children rather than in younjj^er, and must be sharjdv di?
iVniii the cnscs where a fresh infe<'ti<m lias taken place and which i
icri/cd as a sc<'ond attack of the disease. Thomas reports a case
ll'Vcr complicated hy varic<'lla, in which on the twenty-fifth d
•-carlct fcvtr a relapse occurnMl, and on the twenty-sixth dav
attack of vari<'«'lla dcvelo|M'd.
( '♦•rt'ilii I'fKi'-; t\\' «Mn*1i«t l«»\'i>r hnv<» lv»nn w^t-w-kW-^a/l iw% •••.UI^.U :-.
THE EXANTHEMATA.
658
The efflorescence may last only Uventy-four hours, or it may last fourteen
[days. We must remember that we are not to dejiend upon the efflorej^cenee
in making nur diagnosis in scarlet fever, as it may be so evanescent a« to be
^^ecareely recognizable.
B Conviils^ions occurring at the onset of the disea^ are not, as a riiley
^■Mdieative of a fatal issue, but when they occur later they are usually of
^RmouB impcirt*
P The occurrence of scarlet fever in surgical cages is of no special sig-
nificance Ijcyoud the apimrcntly greater susceptibility of patients with ojien
wounds to eontraet the disease, \Ve should Ijear in oiind the suggest iou of
Osier, that in tiie majority of these surgi^-al cases thus far nx^inktl theefflo-
»re8cence has probably been the red rash of st^pticaemia, and that the reported
cases have l>i*c*)me rare siuec the gradual disappearance of septicemia as a
cxjmplieatiou of surgical operations. Atkiusoo also suggests that in many
cases these rashes may have been due to the quinine whicJi was given to the
patient.
A variation may arise frf»m the oixJinary scarlatinal inflammation of the
mucous membrane of the throat becoming more severe tlian usual and re-
sultiug in exudation. The larv^nx in some cases may also present unusual
8ympt«>ms, such as aphonia, and serioiLs symptoms caused by a a>ncurrent
opdematous condition of thi- glottis may arise and eveu pn>duce a fatal issue.
I have in this next bed a case which represents certain variations from
the typical symptoms which occur in the throat and nose» and which are
very mild in their ehanu^ter :
TbiA boy (Case 2S9)^ tbree years old, was attacked four days ago. Tbe invasion of tbd
I was characteriE^ by drowsiness, loss of Appetite, maltdM?, ^Uj^bt tmuseaf a quick-
d pulse, a tempemture of 89.1** C. {102.5'* P.), and intense sore throat.
On the s^k^ond day of the disease the temperature continued to rise* and in the latter
part iff the day a piinetiform erythema appeart'd on the neck, and later on the face siid hands,
■in^ the next iiipht he was very restless, sleeping only five or ten minutes at a time, and
plaininj^ of hn tbr<>at, of headaehe, and of being very thinsty. His breathing was rather
On tbe morning of the third day the recsord showed that in tbe piubt twenty-four
I he* bad taken only 120 e.c. (4 ounces) of milk ; he had had no movement of the br:»wels
and had passed 300 c.c, (10 ount^) of iinne. His pulse wa^ 134* his tempemture 89.4** C.
(108** F.), and hh respirations 34. In the evening the puUe w«8 134, temperature 89,fl*
C- (108.5** F.), and rp^piration^ 80. His throat eotitinued to l»e painfVjl. Tbe whole thntat
\ reddened, and the ton^ila were enlarged. There was a thick muoopurulent di^churge
the nose. The glands of tbe neck on each «ide were enlarged. There was dm^ider-
irritation of tbe iikin during the davt which was retieved by the occasional use of a
tion containing carbolic acid 4 c.c, (1 drachm) to wat4*r 478 c.c. (1 pint).
This morning he wa* reported to have hnd n very restless night, to have taken 420 e.c.
(14 ounces) nf milk in the twenty^four hourn^ la have had one movement of the bowels,
i to have passed 600 c.c. (20 ounces) of urine in the twenty-four hours ; the temperature
I 88.6** C. (101,5" F.), pulse 128, and rt-fipirutions 28 Tbe child is very irritable and rest*
Tou nee lhnt lh»'re is a constant copious muco purulent discbaiiefe fmm the nose, and
flbat he coughs quite (W»qucntly, The glands on each nide of the neck are still considerably
swollen^ The f^cnrhttinal efflorescence ha^ invsded the entire liody, has extended over tha
Hnibs, and is accompanied by conddemble irritation. On examining the tlirr>at you will see
; its entire mucous membmne is verv much i^dened and that the tonsils are swollen.
^niiri-*) uf l)r«»iniil«» of j-inia during iho night. The efflorescence was l>egin
Till' tlin»iit wtts iiDt M> Kort', uiid there was no appearance of any uewly-devt
coiidiiions in it.
On iho Mxth day of the disease the temperature in the morning was 37.7
and in the evening 39.6° C. (101.8° F.) ; 800 c.c. (10 ounces) of milk had 1
till* pn'vious twenty-four haxin and 916 c.c. (80) ounces) of urine had been p
wa> d«'ri»l»'d improvement in the throat and nose.
Th«> hactt'ridloixieul n'port stated that in the culture made from the exi
liad U'vn tuken fr<>m the throat the K lebs-Loeffler bacillus could not be found
On thf MVt-nth day of the disease the temperature in the morning was 3
F.) and in the evening JJ8.5° C. (101.5° F.). Although the appearance of tl
ini])r«>v(il, tlh' patient was very fretful, and the voice was quite hoarse.
On the «'it:hth day the ehild had become much more hoarse, and was ui
eKi.tpt in a whi<p«T. The discharge from the nose had ceased. The temp«
m..niiiii: \va- :57.4° C. {*Ml'}° F.) and in the evening 88.2® C. (100.8** F.).
On thf f..ll.»wing day, the ninth fn>m the invasion of the disease, the ch
hriirlii'T ; hi- app«'tit«' n'tiirned, so that he took 1200 c.c. (40 ounces) of milk i
f.lur licur-. an(i In- pa^-trd 840 e.c. (28 ounces) of urine. The swelling of the
ni'ok had almost disappeared, and the thn>at showed no evidence of irritation.
Frnm tliis linn." th«* tempenitun* continued to vary from 87.5** C. (99.6° F.'
iMi: to :i7.7° ('. ( UHP F.) in the evening until the thirteenth dav, when it be<
I)i*-({uainati<>n ht-^an on the eighth day and continued until the twentieth da
syniptoiii^ aro...c, and there was no disturbance in connectii»n with the kidnej. '
hi." voiei- <»n the nin»'l«'«;nth day.
In t\w lHMii»rn form of scarlet fever certain cases are at time
in wliich tlic liitrh tcmjHTature, or the especial vulnerability of t
the scarlet liver eonta^inni, <»aus(wthe symptoms to vary oonside
tlie typiejil lorni and to 1h' unusually grave. As an instance of ti
<as( .s I will report to you one which was seen by me in consul
TH£ EXAJfTU£MATA.
565
i dty it extended all over the body and was of an intent character. On tLe alxlh dAj
; ct>m(.tlicittiuii of pain in tUu wrUtd begaO} but it disappeared in twenty^four hours under
hv »d ministration of ealicylic acid. At thb time aUo there waa considerable swelling on
he left *ide of the neck, which gPttdually disappeared in four or five days. Wh**n the
rer waa at iu height there was considerable cyanosis, with quickened resplmtion. The
uke at this time was weak and difficult to count. From time to time during the attuek
intifebrin was given for the reetleMnestt and brc>mide of soda was uccasioniiily used. Tine-
lure of digitalis was given when the puh*i vfas quick and weak and cyAnosis was present,
lit the treatment which was most depended upon was by bathing.
The methcxl of bathing for tht? purpot^e of reducing tho temperature was that of
ilacing the child In a tub of water. Whenever the temperature rtrached 40,6^ C\ (1U6* F,)
he child was placed on a pillow in the butb, and was kept there until tht* temperature was
luced three or four degrees. The time r^^qui^ed to accomplish this was usually from
Dne to one and a half hours. While the child wtm in tbu bath ftimularit>i and milk werv
;iven to it. The temperature of the water was about tl^iut of the child^ and was gradu-
ally PL'duct'd to about 82.1** C. (90.5° F.)- During the first four days the child was dlher
deIirioui» ur in a comatose condition, and when in the bath would pass its urine and fwcal
L dbcharges involuntarily.
llie high temperature continued until the sirth day from the banning of the prodromal
, aymptoms, when it fell decidedly, from which time the baths were omitted, and the tem-
etatun? continued to fall by lysis until it reached the normal degree on the sixteen ih
ay from the invasion of the disease. After this the child hud no unusual symptoma,
Und made a rapid recoTeiy. There were no complications. The desquamation took the
sual course.
Here is the chart (Chart 15) of this case. The broken lines show the degree to which
I temperature was reduced by the baths.
CHART 15.
/^ai/S €^fD£3C^^m
F
1
2
3
4
5
6
7
8
9
10
II
12
13
14
IS
16
17
18
19
20.
21
c
1 107"
106**
KH^
103'
I0l*»
ttmtp
98*
97"
96'
95'
^'lE
M V
m t
V s
n c
PI ■
j{ K
M C
"*
M e
KS
M t
a«
M a^
H K
M K
J>l K
II M
TTk
U K
STE
416**
4LI'»
40.3-
40.0-
39.4"
3fl,ff>
37.2"
37 0»
16. r
35,5"
y
7
^
/
i
/
f —
1
I
1
y"
1
1
\
1
i
/
i/
ly
>
y
T
V
r
/
/
/
1
/
/
^
\/
V
i-
H-,.
--
1—
...
*'
.-,
--
-,,
,--
--
^.
_^
V
c.
V"
^
^
^s
^
Si
Tozlc iTiiiptoniii and hl^b temppratttre In acartet ferer treat«d by batlis.
ICOMPLICATIONS AKD THEIR TREATMENT. — Most of the Cinmplu'atioilfl
Woioh arijse in scarlet fi?vcr an^ due prubably to the a*^ion of stn^pt^xi'occi,
^either Isolated or associEtcd with other micro-organ bm^, Thew micro-
irgauisnis pnxiuoe serious sjrmptoms, which are often tc\lU>>«<pA' \vn iV^jv^\^
exiMaiion aiUH'Tinj^ mo mucous meiuDrane oi tne entire bmx'aJ
tlm)at, evidently |)nKiu«Kl by stn*i)to<t)cci. This complication a
to the severity of* the st^arlet fever, and is a ooniinon si>urc*e of
the ear aiul of intW-tion of the eervkml glands. In addition t(
this <'hiss you will at tinu^s meet with a nienibrauoii.s cvindi
mucous uiciuhraue (if the throat, the pathological losion:^ of w
1h' ditVereutiatetl fn>m those of di])htLeria. This membranoi
is <'aus4il l)v tlie acti(»n of strt^ptoeocK'i, and the dia^ios^is l*
uicmhraues au<l those which are produced by the Klel>s-Loef
caiuiot Ix! made excvpt by means of bacteriological examinat
more severe iuflaunuatory conditions of the throat are not e«»n:
exjM'rieu<*<' outside of hosjutals, but have been observed a numi
in our scarK't fever and d i pi it her ia wards at the City Hospita
cases of strej)t<K'<>(rus inviisiou the entire thrt»at may be ver>' mi
the tonsils euhu'tred, aud the nib^>-pharynx afFected to such a degr
to occhidc the uares. It is niH'cssarv to make a bacteriological i
of thcM* lesions which have U'cn calk»d i>seudo-membranes, if we w
niiue iu the early days of the disease whether or not we are de£
case of diphtlH'ria. After the first three or four days in most ea
u>iially so uiarkcd a clinical diflerence between the progress of
where the Klcbs-LiH'nier bacillus is present and that where the (
simply secondary to a streptocoix'lis invasi(m, that we are not loi
as to our dia^n()sis, even without the dec;isive proof bv culture.
wlicre tlie Klehs-Loeffler bacillus is present the continued incr
Mverity of the sympt<»ms and the n'sulting exhaustion of the eh
thjit \vr arc dealing with this niicn)-orjranism. We must not 1
misled by this p'ueral rule of dittm»ntial diagnosis, for there
c;iM'< in whirii it is imoossible to diften»ntiate l>c»t\vf^n n ai-w*o.rx4^,^
THE EXANTHEMATA,
657
inf^ a comparatively short csourse, there is not sin'h a need for stimnlantfi
[an Ih iiidieatA-'il where diphtheria ib present In young chilrlren it is often
ipo6sibIe to treat the throat locally, and I have usually found that my
lehief reliance in tiding over the severe stage of the dLseaisO is the admin*
jistratifm of sufficient fo<jd, and of r^timolants when they are indicated by the
Igvneral o>ndition of the ebild. It is to be remembered, of ooun?e, that the
llin»at in j^carlet fever may l>e attacked by the Kleb^-Locffler bacillus and
tlie dis€>iLse brought to a fatal issue by a c<:*mplii^ting diphtheria. When
Idiplitlieria is i*re8ent, the treatment should be the same as lor a primary case
)f diphtheria ; and this I shall refer to in a later lecture (Lecture XLIL,
ige 828).
In the more severe forms of inflammation in the thnmt the inflammatory
proeessfi may go on to abscess, as in the pharynx, but the most common pla*^
in the tonsil or in its neigh borh(Xid. The?<e abscesses miLst be tarr^fully
l%i'atch*xl for^ and when dete^tiJ o|ient\l with antiseptic precautions as soon as
■liible. We sliall by this trt^^tnient often shorten tlie course of the disease,
'and thus save loss of strt^ngth and vitality on the part of the patient.
As an example of one of the more severe lesions occurring as a com-
>lication in the throat in scarlet fever, I shall report to you a case which
cnrred in my pi*actice.
A boy (Case 241), two and a bttlf y^ars old, wm seized on December 4 witb diarrbcsa,
smiting, and wre tbr«>at. On Deoetober 5 tbe tonsib were found to be enlarged and the
rhole throat much rvr-ddeniHl. The eilofeeoeiico of scarlet fever appean?d on tlie cbestt and
be child seamed dull and sick. The temperature vrm 40** C {104^ F) and the pul*e 150,
On December 6 both ^idee of the neck were much swollen, and the t^jnaiU were much
|«nUj%'ed,
On December 7 there was considerable muoo-purulenl dtwbarge from the nuse^ and the
empemture was SO.T** C, (103,0" F.). The child wa» not io dull, and the effloreacence wu
r^U unirki*d over the whole body.
On DweraberS the diarrhoea continued, and the temperatun? and pulse remained about
tie Aarne, The child took milk r^^gularty, but refuiied to have any appUcatJonA made to ili
Uroat or n<-Mie,
On December 10 there was no e^iipccial change in the general symptoms, except thai
he diarrhoea wm ie^ and the throat and m^e were nittjer ^ore, Ther<» was a peculiar
ayith-white exudation around the mouth nnd throat which could be eaaily remoTed. The
Eieck on Intlh «ide« waA swollen and hard. Tht' pul«« wu^ rather weak, 140« and gtimulanti
en? given every two hours.
On December 11 there were le«» bardne?.^ and swelling of the neck^ and Icaa diiicharge
the nose, the pulse was 150» the temperature was 89 A^ C, {1t>8** F*), and the cfflo-
nco was fading.
On December 12 there was much exudation from the mouth, but the child took mow
nl1k« and d<'«<|Uiunatiou had begun.
On Dtv.nnber 18 the temperature was S8.8«C. (102*» F.) and the pulie 150. Tbe child
itd a trn^at dealf was very reallesa, and complained of pain in the joints, but the neck was
\ swollen.
On Ileeember 14 the child vomited twici^ during the night. On December 15 tbo
llUe was 186 and the tempeiature m 3** C, (101*" F.), On December 18 the temperature
97 7^ C. (100^ F), and there was a profUse dow of saliva: the breathing sounded aa
hmigh Ujc throat and posterior nares were con«iden»bly <»ecbiH*H|.
On DeecmlKT 2<l the pulse, which had been decidedly weak, became stronger; its ral«
r^r^H PEDIATRICS.
wii- uIm.ui 1:.<), and tht- tonijwrutun.' whs 37.2« 0. (99® F.)- The child ^l;-: -.\
liriu'liiiT, uiul tin" thn-ut wji> h^jj tnmblfuoiiie. The pains in the leg?, h-.-wtv-r, ^7^..•
Oil I).oiiiImt hi th.- piiN.' wiij. 148 and th.- U'ni}HTatun? 36.6® C. (98*> F.-. Tiat ^-
firi^idi-niMi' di.-rliurg«' fVnin tlic iioso, and llirix? was uii efflure^poexict^ of htfrj»»,s vu :i.- _>
and tan*.
On Drci'inlMT *SA l»i>th tonsils won- fnuiid to Ix* much €*n1ur|;ed and «'f a iiK-vy ^.-i- .:.
Tlif ii'iiiptratiin' tnMii tlii> tina* n-muint'd iioniial, and the child rapidly imp v-i ji.
Din-mluT lis, wln-n it oompluiiH'd of pain in tho \vt\ ear: (>oino hours lat*T. jitrtovj':.:
llif iiitiiiltnina tyinpani tonk plur*- luid thi-n* was a >li^ht luuco-puruli.-nt diM.ljur;^'c.
On Di-riMnlHT 'JJ* ImiiIi i an. wen* t;ci)tly irn^at(>d with lukewarm water. Tp :: 'li
tinn- thf urine lisid >h<i\Mi no abnonnal n»iiditioiif but on this day it was f'-uo^i :•<■•'":::: i
faint tra -f alltiirnin, and tin* sp^-i-itir j^ravity wa.* 1013.5. The sr*dim>'nt was v.m j:
(•••n-i-t'il of "mall naiml nMial opithidiuiii, mucous cast"^, and an i.ic<*usi« mul hy.i'..!-. :.■-
n}.n-"iiiiini: a rondition of hy[)«'R«'niia. Fn)iii this time the child rapidly M'-'^vr :.:.
ti'inp» ratup" n-niaint-d normal, the ^wi'lliiin and hardness of the neck i-niip-ly li'sji"!.'--
tlif alidimin and ra-t-* ili-appeannl fn»ni the urine, and the ears rvcoven.-d wiili- u: :-^.-
ini: drat'iit— », liut i\tr ovit a year thi-n* was evidenee of dec^ided thickening of tb-.' lir-t---
the na- '-pharynx. TIh'D- was no ."uhsetjuent paralysis.
In I hi" i-a'-i^ thf rhild n-»i-te<l all attempts at tn^atnient 80 sirenuoU:*ly l\nl ::•
WM" d<>ni' liiyoiid the ailmini>tration of milk and brandy. A hacterioli>t:ii.-ui •.xan.i-i. i
<if llji' •xudalf in tin- thmat wa^* not obtained, so that th»* KK'bs-L« Heftier Uui:. :• ■■: '■
iidt hi- ililinii<Iy txtliidrd a- a raUM-. hut the sul>se<)uent I'oursu of the di>e.is<f -fi --^i ■ ;
in all pr"l»ahilit\ tiipiitin'ria iiad ii<»t beiMi pn*.'»ent. It then.*fon* n*pn?'S»*nT'i von- w»^ ■
lypiial iMiir"!'. uninlhuMn-ed by ilnii^s and ."pwial trr*atnicnt, of one uf th<r !!;■■?!: -t"'"
ft»rni> i»f -larli-t ffVi-r with a mmjdication in the throat.
Cervical Glands. — The jj:liin(ls of the nvek are more or lesc^ euLin.>i
arntnlinir to tlic severity of tht» infi'C'tion. This eulargoineiit niaviu-t-
rMM'< Im' <o onat as to cause much swt'llin^ ami dLstorticui of tht' fair t-"
link. '1'Ih' >\v(HinLr cxt<'iMls at tinu's uiuUt tho ehiu fnun out- tar t-*-
otlnr a- a nia-- of ci-lhilitis. The tissiu»sof the ucvk uiiiler the^t' omtliTi-:*
may, a- I have ah^ady dcscriUil to yon in s|M»akm^ of the |>athnI(tjrv<»:TU
<li-raM', <up|niratc. and this <*on<litioii, even if it d<x*s imt pnKhKV a rs'i.
rc-iilt from iranorciic, may trivatly pndonji: the |K*ri(xl of ct^uvakscviKr.
While tlic ohmds arc cnhir^tl and tender, the application of hot h'liQ'C-
tatinii< n.-nally oivcs much n'licf, as d(H»s also in iiKMUe c-asi-s an ict? fxil'^--
Imv 1 thi- I am not in tlic hal)it of making any external applii*ati<iii.
Ear. — The niiddh- car is so ch^sely eonnei'teil by means of the Ei^*>
chian tulM- with tlic iiaM»-pharynx that aunil c^>ni plications are ox(T?i^li^' '
cniiiiiinii where na-o-j)harvnir<'al irritation exists. I shall, tliereft»rP. i '■
s|»eal< i)\' the c(»m|>lieations which arise in the ear durinii: the omr*"'
si-arlrt (ever.
The <ym|)toms which indicat<' that a secHnidary infection of tho '■a* :*
takiuLT |)laee are not always clear, as they may ditFer much in their maniir
tation-. We -h..iihl therctl>rc wat<'li with the jrrc»atest s*>licitude and fxriU-'^^
with the o-rcate-t ear*- the ear (hiring the eoiirstM)f scarlet fever. The W"-
toiM- may Im- aetive mihI rc|»rcH*ntcd l)v annil ]>aiu and great r^tle^B^
< )ii the (.tli«i' haml. tlier«' may Ik- no apjian-nt jKiin, esjKXMallv in intani?a.i-'
yomio- <hildren, w Im arc often miahle to indiwite the location of thepaiit'y
THE EXANTHEMATA.
559
which they are affected. In theee cases the symptoms may be merely a
Bomnoleot (Njodition and occaiiional atUicks of fretiiilneaB,
According to Pn)iessor C, J. Blake, whose advice tn me regaHin^ thc*te
cam^ hai* pnjvcd invaluable, as 6*_m)0 tis an aural complication it* dettvted
t the treatment of the naa>-pharyiix should be begun. The nosrc and uil^j-
pharynx .shonld be kept as clean a^ [M>Ksible, The ear BhoukI l)e ^entlv
inflated by means of a Pulitzer bag. Pain should be comljatjcd by the
mstillation of a solution of atropine in glycerin and water into tlie ear (Vrv-
scripdori 70) and by the application of dry warmth. In addition to this, an
opiate shoukl, if iTtjuired, be given internally.
MeMc,
R Atrupinjfi nulpbatis .
Olywrini,
Prescription 70.
Gmnuna.
0 06 B Atmpine sulphntis . ..... gr. i;
[ Glycfriiii,
Aq. dc«LiL ........ *A 8 ' 75 Aq. d«-'i»til , . Aft ji.
Sig. — Three or four drops to be warmed and dropped into the enr once every thre«
IP
1 eoJ
Booi
Fae
The omf^^tiou should be control hxl oa far a.s jxis'^ilile hv the internal
at! ministration of bromide of jmtassium in small and imjuentlv re|K^ated
doses. If tlK^e measures fail to ^\ve relief, and if there m an iBcrease of
inflammation in the middle €*ar^ fks shown by marked swelling and conger-
tioD, espirially td' the su|)tTior p<r>8terior portion of the membmna tyinpaui,
OP by a bulging of the niembraue» which is seen to be pressed outwani by
the fluid in the tympanum, pai-uecntei^i.s with tlie knife shotdd 1m^ jH^rfornuxJ,
always with antiseptic precautions and under gtM»d illumination. In the
early stages of congestion a cr€\s<'entic incisifiu carnal along the superior
posterior Imrder of the membrana tymjiaui tlu*ough the congested region,
and res^uhi ng in free hemorrhage, will orten cut short an acute pnHVi?8.
A tm^ incision in the most prominent |Kiition of a bulging membnuia
tj^mpani, by giving a vent to the et>ntained pus, may result in **i>eedy rc*lief
from l>otb pain and fever, and justifiably forestall the eftbi-t whioh natuif
is milking to f»btain this ivlief. In the acute cvmgestive stage, after inrisioii
f the membrana tympani drainage- wicks made of dry abeorbent eotti>n
should !)e applietl, and c-ovcrtHl at their outer end with a jiad of alisorL'fit
otJtton filling the tvmeha. Thi^^ wieks should be n-newed a.s otlten as txrtli
the wick and the eotton jiad Ixntmie saturated. The dressing should lie
kept strictly a.st^ptic. .\fter tlie paracentesis of the membrana tynipaui, in
BUppurative ea-^^s the ear should l>e syringed tW^fpieutly with a wcjik, warm
eolution of bii'arl>onate of stxla, then earefully driixl by means i>f alisiirlicnt
itton, and, after the first few days, dressed by tlie insutllatir»n of |)ow-
dere<l Ix^raric acid, while vaseline may he applied to the canal and (t^>ncha
to guanl against the exoiriation of tJie skin.
The after-treatment of tlie middle ear in these ceases where there is no
perforation of the membrana tymiwmi should consist in gentle inflation by
r>60 PEDIATRICS.
In^•aIl^ <»t' tin* air-<lnu('lie us«h1 in iM»conlanco with the evidence afibnltd k
lii'ariii«!:-t<'>t> and hv tlio ohjtH-tive examinations. In ea>es where thvrt L«
]M>rti>ratioii of tlie inrinl)j;aiia tympani with ccmtinued suppurative di-K.-liar^
thiHoiiirh ('Itaiisiii^ slioiild Ik* enii)loy<'d. If under this treatment impn.'Vtr
iiirnt dnos imt soon tiikr phicc?, the ])atient should be referred to an aurk.
I liavi' aht-ady reirrntl to the im{)ortaiice of detecting at oiii^aiv»>
j»Ii«ati«»ii ot* tlu' ear durintr the j>rogn».ss of a case of scarlet fever aiKi ic-
lucdiattly trratin^ it. Childnni art* so often rendered di»af by the m-rli-i
j>nM-«'><<'s re>uhin^ from thi» sejirlet lever conta^iuiu that it bi-ivmns j
|)«>-itiv<' (hity lor the attendiiijr physician to watch the ear a-* earetUlviL
thfs*' ca^es a< he would wateh the ht»art in a oa^se of rheumatism. Iaa>ili-
tinii to the daiif^er ari>in^ from a ehn»nie disturlmnce of the tissues oiiiK
4iu\ ycMi imi.-t earefiilly l<M»k ll»r any evidence of the rapid extoiMim *.:
HH-niidary inftrtion from the nas(»-pharvnx to the middle ear, and tbtHir
tliroiiL^li th<* iH'tn)-s<juam(»sal suture to the cerebral meninges, a rJeritsv:
<'niiipliiations whieh usually pr(»vt»s fatal.
1 pHcntly saw a eax* in (H)nsultation with Dr. Forster which illu>tni^!
thr danpr »»f not tnatiu^ jn'omjitly and thoroughly the ajmplitatiun vJ
otiti> in <'aM*< of H-arlet fever.
A rliiltl i(':i-»' L'll') two arid » half y«'ttrs old had Ijccn attacked with scarlet lVv-r<::
l:ittr with :i f.-jnplicitiiiix |iunilfiii niitis. When I saw the child it was lyiiii: inaiU*.-::
stupor, :i|ijt.ir-riily imhici-il l»y |in*— iin* on the cerebral blof»d- vessels of an unu-Udl.y liV-
«<'ii'«ti f I'M- in tlh' iiii«l«ll«' ♦•nr thnnii^h the }K'tri.>-8(|uainosal suture. In thi.- cb-'rir
lur-- ha-l i.iki :i jilm-j- iji Imih iih'inlirana' tyinpuiii, and the pus was flriwiiii; in l.tn,''" 'jua-''-
ti.- iV-iii il:- • M'TiimI m"atii<. A ran'l'u) examination by Pn ift'jisor J O. (inrn ':.:^--
I:.\\'\.!-. !i..jf ilir jnr!'"rati"ii' ol* tlie imMnliRinje tynipaiii wt-re v«'rv mimiti-. :ir:i '.-■
I- iv!.::,| «Tii|...!- \\;,.« ti.'i nli. ■%•.■.! until a fn-t' o|M»ninir was iinule in mich tvnijvir.iin: a;: :!.-
.■Mir>' ii.il.l;- 'MP tli'-r-'iiL^iIy >.yiiiiir''d <>nt. Althouijh tin* syiuj»t«»ms of i«r\-'J? 'Kr>
r.:i.\. ,1 |,v til.-... pr. ..■.■,} 11 r.'-. ^rrnud-.xry inf.-etion of the cerebral iiifiiiii£re«; had alrv-ady lii-.:
j-lii-.-. :ii..l ill.- l...y .Mil>^'<ni«-iiily (li«»l nf an acute punileiit nieniiitjitiss.
'1 ill- . .>. w.in."^ u- il.ai \vf -Ih.uM not ho niisletl by the idesi that a simple H'it f ;o
iV-iii lii'- :iiii;. ;.• i> M.<'--Mrily sulli«'i«'nt to j^ntvijh* a pr«»p«T exit for collection.- "f }-i>j:.'"
iiii.|.i:.' .:i:-. :i' .1 !li:tt. in.l.-' tli«' la-f i- in the hands of ail expert aurist. ccrehral pn-rrun ■
pn:'j!-!it !:.. !.'i.:i!i« i- lik-ly to -M-.-ur at any tinu*. It also repn'scnt* a cla.<? of oa-^: :
wiii. li 1 -!i:i;i :•.:". r a-:iiii wImii -p.-akiht; of meningitis, and illustratei> one of the 5*.v.-Ld;.7
I'.-ni.- ■ I" i!i .! .li-.M--.
KiiiiKiy. — 1 liavc sjiokiu smuewhat at lonjrth in the earlier part "^
tlii- h'tiirr ••nnci'niiiij^- thr alhumiiniria which is present in the ditfrnt:
-t;ij«- Mr-.-ml.t fcvrr, mimI .mI-o of the dillerent forms of nephritis which ma^
«>«-.iii-. W liMi I lic.|»r I li:ivr iiii])nsse(l ujKm you is the great imiH-trtancf't
<1< t«rtiii- l.y iiuan^ of tn-ijiiPiit analyses of the urine the lx*ginnin<^ of Ar
tin- iniMt r ti»rm> of rmal <li>tnrl>ain'<' or the more severe forms of iieirfiriii*-
ii«ii:illy ivj»n-('iitr«| l»y tliat wliirh is calleil capsular glomenilo-nephriti*.
If '•Mi-diilly \v;it«-h«'(l \n]\ \\u' ajipearaiK'c of alhumin will almoist alvE^"-
juvcnlr thr clinirnl -ym|»ti»Mi-, and by a still more rigid enforcement of tk
nilc'^ whirh 1 h.Mvr l.-iid <h»\vii as practically governing the treatment tli^
flirt I nr «l''Vr\«>\>\\\v\\\ vA' w \\e\>\\\\\\^ wvav be prevented or at least renderai
THE EXANTHEMATA,
561
Hmuch less) prcmotinred* It is quite fmiuently tho ease that a suspicion is
H first amused of tlie presence of a nephritLs either bv vooiitiug or by cedema
W^ of tilt* taeo, especially about the eyes, and commonly cjct^urring during the
*' perii*d of desfpiamatiou, from the eighteeutli to the twenty- lourtli day,
P Under these circnmstanoes the urine will Ije found to be diniini.^hed in
quantity and to «>ntain albumin. The daily amount of the urine may be
reduitd as low as 100 ex\ (3 J ounces), or even lower. The niicros<x»pic
[examiuation of the urine dt>es not differ materially from that which results
fn>m the other forms of nephritLs in their early s^tiiges, but later you may
[possibly tind that fatty cmsts are less nomerous in the nephritis of scarlet
^ver, because there is less fatty degenei*ation in the renal e|>it helium. The
lier in the course of the disease the symptoms of nephritis apj:iear, the
severe, as a rule, will be its tyi)e. The extent of the albnminuria
lis of less consequence than the total qyantity of the lu^ine, A rapid and
lexteDsive diminution of the urine is ominous, as it indicates ttie accumu-
lation of nitrogenous waste in the blood and the danger of a resulting
.. uneniia. The albumin cnxnirring early in the disease is more ajit to Ije
M in large quantities than when it appears first in the thirtl or fourth week.
H Hfematuria is frt^tpiently present in this form of nephritis, but ordinarily
■ of itself ad*ls little to the gravity of the disease. The oxlema of the face
* may l)e tbllowed by a rapid involvement of the ankles and legs and at times
may IxHMme general. During the course of a general cedema the dc^uama-
tirm is apt to cease, returning on its disapi>earanee. The redema may last
^ for months or may pass away quickly ; it may lie entirely alisent, but in
■sueh eases the nephritis is almost invariably of a light grade.
H At times during the presence of a general axlcma serrius effusions into
Vthe pleura may occur. (Juieiua of the lungs and brain, though rather
rare, may also take place. Instead of a slow development beginning witli
a*dema of the face we may have an acute attack, ushered in by fever,
vomiting, ht^adache, cetlcma* amblyopia, coma, and ctjuvulsions.
Relapses may occur many weeks after an attack of scarlatinal nephritis,
we should watch the cast^ with the greatest ean^ for several montlis.
nephritis of s<!arlet lever, aldiough it may last for months, has a ten-
dency in children ultimately to disappear, on account of their wonderful
lrecuj)crative |xnvers. It is also rare for the renal disease following scarlet
Ifever to become chronic.
Retinitis and amaurosis at times occur during the progress of the
nephritis in scarlet fever. In these eases of amaurosis it has been noticed
[that, although the loss of sight may be complete, almost always where
emia and amaurosis are coincident there are iimnd no jx^n^eptilile eliange
the retina, no congestion of the papillie, no increase of intraKranial
pressure, and no intense cedema of the lirain. The sight, under these cir-
pumstauees, may be recovered completely.
The alterations in the glomenili already 8[)oken of not only cause
fwuria and the unemia, but also obstruct the renal arteries, bs very
r>G2 PEDIATRICS.
iM^arly all the n-iial bbxMl has to jwisri through the plomenili. Wr f:!
in (|iiit4' a ]ai*p* nunilMT of (^ast^s of c-a{)siihir glonieriil<»-iiephrin> a rj^j
hyiMTtn^phy of tin* left vfiitru'lo. This aircliac* o>iii]>]i<-;itii*n i« u-t : ■.
(•oiiUiuinhHl with thr ciuKH'anlitis \vhi<*h I have already sjn-ktn : t
siMiuuhiry to tlic s«'arli't fever, aiul which is sup|K>siH.l to U- i-aiwil isii.
s|MN-iiil ]v»is<iii <»r l»y the stn'ptiM-^Kvi whirh I have aln^ady (KxtiUaI a- 1*::;:
pn-M'iit ill thr «lis«'asi*. It is, in fact, not tlie dirt^-t result <»f t^ r-ark'
fever, l«it i-^ siM'ondary to tlie nephritis, and L<, in tills s<»nse, unian t
the s<*arlet fever. W(» then»ion' do not find tliis a(*ut4' c-ardiae hyprrrfi-
in tlie t'arlitr sta'r^'s of searlet fever, but when a raitosular jrlonionihHkphr>
is i»ne<' estal^li'^hi'd it may take plaee in so short a |x*ri<Hl ;is a wnk. iLt
raj >i< 1 hy]Mrtri»phy h:is usually lKH?n ol)S('r\'ed in children lx*tw«'n tin- 1^
of thn-^' and six years, which is of some si|rniHcance in explainiiii! whyi
hy|Mrtn»phy shniild take phwv so easily. If you will rvctxU what I faa>
alnady told y<ni in my hvture on deveh>i)nient (Ixx^ture IV.. paiiv li.
yi»u will understand that iK'tww'n the ajrt*» of three and eijrht years a fi^
ol«»^ieal hyjMTtn^jihy of the heart exi.<ts, j)os.<ibly caiL^Hxl by a ivutiaiLS^
of tlir a«»rti<' narn>win«r iu the nei^hlxtrluHxl of the duc-tus arterio^ib. i&:
that tlir lnart will Ih' nmre nwlily affeetiMl by increased blrMKl-prv«»ur:i:
that ivj^r. This t«'iideney to ehanj^e in the eanliac muscles Ls als<» aix-tunu-!
by thf rapid ^^n»wth ^A' the orjran at this ]ieri«Kl of life. Besides tliei-jnii*
hy|Mrtn»phy we may, at times, have an aeiite dilatation of the heart in->
e;is<s. This i> a s<Tii»us eompliejiticm, which must Ix; guarded ainiiiH-ni
wIk'Ii it o»riir< must U' n'<'<»iriiiz<d at once. These wirdiac (Miupli^Ti.',-
vrry tnijiinitly n'^-ovrr eomph'tely, as it is seldom that anv t-xki-i"'
(•haii;:i- in tlif iiiiiMlr«i tA' tin* heart take place.
Altliniiirh thr .M-i'iirn-int' ot' su^ir in tlu* urine* during the course nt' •<•::-■
\\'\iv i- vny rarr, yet it i< well to examine the urine for this elenieui in '*^
ot" -rarli't ti MP. r»y takinir this pro<'aution it will sometimes^ Ik* p-^i--'
t4» c\ plain -»iru' ^tlurwi-*' ol)s<'iire syin|>tonii« which mav ari.se.
'■•I-
Zi- ■:. ■! r.:i'ii}.. ru'. p pTi- Till' ciiM^ fCiiM' 243) of a b*:iy, four years old. yivr c-
■ 1 : ■ ■■I' '. . ^^ ! ■■ ^^:'' :ittMi k.-.l wiili -i-urh't fovor and diphtheria on Jamwrt iT. 7:-
r.A A .- : _•' '-.'. •■■Mil :i!..l -r.nhially >iil.-iiil«'d. but on the thirt«-enth d.i\ :>■:'-
■ '.:.. . ■ .: ! a::' - ;/. .1 with M-nrli-t tV'v«T an otitis externa apiH-un-d. mx^n^*.---
"'■■•■ ^ ■ .: ■ - :i' : 'v t!i. r.iy'ui iliv.-l..piiu'iit of cpdomu and asi'iio. r:-. :■
..!■•■■ ■■j.!.::::^ l.v 1"'iiii: l»->>«-Mril in quantity and hy c-ontainir..' i -■■■--
: '• i : r:.' :■■ u- .ti-t- and MnmU'iirpusoles. After a fi-w ilav- li ' "
11- - . ; : • - ! .— ■; ■■:!. :.t..1 tli»' pali.nt wa> tr<-ati*.l with hot baths and ii>j-Ai. :•
\.: ■■ :!i- :i].i..iit.' iiiipr..viHl ronsid^'rahly. the ohildV MnwirTli i ■ •■ ■
!:■:.■ ■ I :•. 1.. .i .lii!i:i- tli«- wli.'lr of Marvh. Karly in April, ..n :«ti"-i^"^ •
. - ■ •:■ ! • '■•■.\- |.:.r:i:y'.i'. ..f thf riu'ht U-ir, which Vo<in iias-*ii -T?" A' --•
li- .■ !:. ■ H .- . ■■ ■ • : ..r- •:!i.iri in th- urino. He then bo{;an tt» sshi^w .in i:.^'-
:..:; ■ ;. ^ : >Mi ■:. ..f ili.urim^on the lOth of April>hi.w.^iriJ:::
M""-": --.N-. .-1 :■'•■'• : •■■■:-tainr.l a (■..ii-iderable amount of susrar. Ti-:"-
.■•:'.■• : ^r> \"^-:\y-:.-nr li.-iir- was :!omowhat dwr**a#»Hi, ' Thv ,i|-l'-
:i- • • -• Aa- : i n..li.'.al.ly iiirreasod. and nothinir clrf »>■: ">
Ns;i> li.-. A ..V Ns .- v'.A^^^l .u a diet of meat, milk, eggii, and ivd wii-^'--
t
THE £XANTHBMATA.
563
^ny the SOth of April there was only one per cent, of sugar m the urine, and by lUe middle
^hf May only one-founh of cme per c<»nt. From this time the child jD)pn.>ved iti ftnmgtb
BWtid was allowed to have a niix($d diet By the middle of June th(? urino was fuund to
^ tie fkve firom eugar and albumin^ and the child became aa strong and aa well as over.
H I have already told you that very little treatment beyond hygienic
^Bueasurei^ is needed for the mild una>ra plicated cases of scarlet fever.
"Tills can hnnlly be .said of the au^es that are comjvljcated with se\*en3
fornirt of nephritis, lor in these we must ai't promptly and with grt^at
judgment.
We shtmld be can^ful about using diureties which might irritiito the
kidney, At^*tate of [wjtiish is one of the safer dinreticN in tins eom|»lieation.
Bin the lighter easc^ a lemonatle made with bitartrate of pota^^h wnll be taken
" well^ ami will often quickly increase the quantity of the urine» reducv the
crdcma, diminish tlie albymin, and cause a radical change for the better.
' Tills lcnic>nade may bt* made by using 4 c,c. (1 dra<*hm) of bitartrate of
I potash to 47^ c.c. (1 pint) of Ixiiling water inUy which a lemon cut in thin
slices hiis be€*n dropped. This quantity a little swettent^l may 1m» drunk in
twenty-four hours by a child five years old.
In severe cases with general oedema and thrt^tening unemia cathartit^
are rather more certain in their actitm than diaphtiivtics and diuretics, and
are especially intlicateil where, as is usually the aiM.% constipation is prc^mt.
Podophyllin in dosi^s of 0.006 gramme {^^^ grain) may be given to a child
I five years ok!, and rt^jM^teil a numlx*r of times* It usiially acts quickly.
The compiund jalap jxiwder in d<»s<:^ of (X»]— 0.6 gramme (5-10 grains) may
also l>e given where a rapid and fkHndini derivati^m by tlie intestine is
indicated.
Having provided for the projx^r mt>vement of the Uiwels, if the skin is
hot and dry, and unemic symjitoms, usually rc^presented by anuria, som-
nolence, amblyopia, and headache, art* prt*s4nit, the hot pack, either Met
or dry% should l>e res<»rttd to, I pn*fer in these* cases to have tlie child
wrapfjid in a blanket and placid directly in a tub containing water at a
temi>crature of 40.5*^-43.3° C. (105°-110^ F.). The child should be kept
in the water fiftc^en or twenty minutes, and even longer if necessan% and
Bhould then Im* taken fn»m the wet blanket, envt4«i|Mjd in hot, dry blankets,
aod kept in them until the skin has become moist and rearlion has tdken
place. While the child is in the bath, milk itin U- giwn to it, and stimulants
if they are indicate<l by a weak or an intermittent pulsi\
■ In addition to this treatment, muriate of pihx^qune in doses of 0.003
gramme (^ grain) should be given by the mouth to a child of two years,
and subentaneously, if dt^sinxl, to a child five yearn of age. In these
cases of threatening uraemia, convulsions sometimes appear quite suddenly.
B Under tht^* cinumstan<M^ enematii of hydrate of c»hIoral, 0.3-0.6 gramme
H(6-10 grains) diss^tlvnl in water, are of value in controlling tJiese ner%'ous
H phenomena. I myself prt^fer to use a combination of bRimide of |M>tash
Hmid hydrate of chloral, such m you see in tliis prescription (Prescrii^tion 7l\*.
504 PEDIATRIOS.
pRESC'KimOX 71.
Mrfric. Apothecary.
Grmmiua.
B Chi- -nil. h\anii 7 o B Chloral hydrut j
I»iit:i>-ii l»n»iii 16 J 0 Potas&ii broui p.
A.). .l»Mil 00,0 Aq. deBtil [-
M. M.
Sitr .- .TTo c.r. (1 (IniohiiO in 30 o.o. fl ounce) of warm water : t'^ bf civen by^vi
iiiul npiatnl ill IimIT an Jmiir if ih'iiIimI
Wlu'H' tlir iisciti's is extn»nus (laracentesis alxloniinis is nftenof gw
valiK', nt»t only in n'lii'vin^ tlie pressure, but alsM> in increasing theactimx
the «liim'ti<\ which, |)i'rha|)s, I h* ion' was ni^t acting fiix.»ly. Digitalis ti
vahiahh' n-nuily ('S|KH*ially adapted to the treatment of the nephriiu
srarlrt tivcr and t<» that <»f tlie <*anliao changes which result from ii B?
the adininistration of this drug the flow of urine is increa^sed. ItblK^i
pvrn in thr f'oi in of a freshly prt'pared infusion, in teasptxMiful doses evq
lonr hnnis to a child five years old. Diiiretin, 0.3 gramme (o gnun=;,4
soIv«il in wat<r an<l given two or three times in the twenty-four liiMiK.la
pri»v<il of <'onsid(Tal)U' value in my easc»rt, and is ap|>arently liannle*.
1 s|K'ak of siMiial ages, sueh as five years or two years, men^Iy itaziii
hy whii'li ynn cjin judge what the pn){KT doses should be at theotkrair:^.
In a<lditi(Ui to tln^s*' more (*ommon cximplications of scarlet JWrf
innnlH'r of s<i'i>n<lary inftvtious are at times met with. Thus, ca^ ■
purpuni Inllowing or eomplieating si»arlet fever have bet»n repcmed. »
arc usually fatal.
An lii-wU' inflammation of the joints, usually the larger ones, i? mt infr
(juiiitly nut with during the eoursi* of scarlet fever. This acute -va-*"!:
i^ at tirnts appan-ntly cither due to or cl(K*«tdy ci>nneeted with rhninuii:*!!
and may In- aecnmpanicil by en<Ioearditis and jx^riearditis. The latter -ii-
cas4- is, howcvi'r. rarely met with uidess in the later stages of scark't tv-
in cases where nephritis has developiKl. These rheumatic castas are iir^
contnilliKl by the admini>tration of salicylic acid. As a nde, thovaivE'
of long duration, and if ctlnsion takes plai-e in the joints it is son.niN 'I-*'
not Ix-cnine purulent, and d<Ks not give an especially serious pn)gn«vb.
In (^uun-etinn with tlusi' casts, either uncomplicated or where tlielwu
i- al-n jitVeet^Hl, chorea has sometimes arisen as a complication.
A mniM' severe form of synovitis, ap|)areutly caused by sensLs, mavit
occur during tiie courn' of scarlet fever. The effiision in the joint? in tij^
ea>cs may become purulent and lead to serious and jiermaneut dLsorzani^
tiou iA' tile ti>-uc- and oft«'n to <h'ath from general septic infection.
i»<-idcs tlie-c acute inflammations of the joints a chronic pPCKVS? ^
times ari-c^. apjM'ariug, as a rule, wry late in tlie disease or subsequent t
it by many montii-. This inHammation is tulx>reular in character andafe
witii e>|)<M'iai frc.jUcuey the hip and kne(\ Although tubercular, itjwm?*
Im' a late re-ult ot' the original toxic eiVvd of the micro-organisms of '^
si'condarily conueeteil with the scarlet fever contagium.
THE EXAXTU£1IATA.
566
' A caae which I saw in consultntioti with Dr. Miller, of PFovidence, reproiCDU 90 well
ae of the milder forms of whul wu* proltahly cap^tulur gl<>merult»-nephritb, and the eflect
|of re#t ill the trfiutmeot of the diijeiiise, that 1 ehttll rt'port it to you.
A girl (Ciifte 244), Ave year* old, was attacked by scarlet fever of the betugn form and
I very mild in its chanoter. After the usual prodromal symptoms the efflorescence appeared
nd run its course, and de^^uiimaticm became eetabli^hed. At th« end of the sccoud week,
land while the des^^uumatiMfi wa^ Ktill pn>ecnt| the child seemed so well that it wa« allowed to
I be dn*^ed mid about it^ n^um. It wa^ aUo allowed to have its usual food, which included a
Iconsidrrahle anmuut **t moat.
On Januiiry 4 tho child was very irritable during the day^ and passed her urine invot-
[nntarily in the forenoon. During the afternoon «he was feverish, and parsed frtM^tently
|0ioall amounts of urine. That night she slept welli but on awaking on the morning of
lanuary 5 she seemed dull, and was i^aid to be feverish and to have little appetite.
On January 6 the record Btated that ehe had passed only 90 c.c. (3 ounces) of urine
in the twenty-tour hours. She seemed tired and languid, and there was an oedematous condi*
f lion of the eyes and upper part of the face. She had one normal movement of the bowels.
On January 7 the total amount of urine passed in the twenty-four hours waM 480 c.e.
Lucea). She wslh ^iven infusion of digitalis and cream of tartar water on this day, and
[ on a diet of milk.
On January 8 she seemed better, and passed 480 c.c. (16 ounces) of urine in the twenty-
Ifbur houre. She was then allowed to have an increase in her diet, consisting of broth and
I'vanouji kind A of soups. An exAminalion of the urine (Analysis 61) by Professor £. B.
rood on thiii day gave the following result :
ANALYSIS ei.
Color * Rathtvr pale.
Reaction . Acid.
tTrf.»pba.^irj . , . . . Diminished.
[Ind<»iyl ...... liicrt^ased.
lUrea Dimini^ihed.
fTFric acid , Increased.
LIhumin Considerable tmoe.
[Sugar Absent.
[ Bile-pigments . . . Absent.
Sjiecifle gravity . . . 1009.
Chlorides , * . . . Almost absent.
Earthy pht-tsphatt!* , Diminii*hed.
Alkaline phosphates , Diminished.
Sediment Slight in amount; conNi*t»'<l chiefly of normiil blot H]*^lobulea, a
few renal cells, and a few hyaline, fibrinous, bliK>dt and epi-
thelial casts. The blo<:>d-globules and the casts were nonnal
in appearance.
In regard to this examination Professor Wood remarks that the important features
the urine were its dilution, the preat diminution in the normal salts, esp«»cially in the
Jofidos, the considerable trace of albumin, and the blood and casts. Tho normal character
' the blood-globules and the comparatively small number of the oasts seemed to show that
ily a small portion of the kidney was afiected. At the time of the great diminution in
fie quHotity <>f the urine the tubules were probably n«*arly completely blocked up. The
ow fpf^'iflc gmvity and the ^reat diminution of the urea and chlorides seem to indirnti* that
|t would neeti but little additional Irritation U* produce a marked nephritis. The present
Jttion *e«mis t»> be one of a mild nephritis.
The geneml Bymptoinp* presented by the child and the diaturbanee of the kidney shown
the examination of the urine made me advise tlmt she should be kept in bed in a warm
om and placed on a diet ejiclusively of milk. A warm bath was to be gtven onoe otIvIm
I'll tiaitliarv ll mt* inin* WIU* inxjixs u:uciiibi«vuR| auu Bu^ was lau^uiu.
liMi^i-, ntif ii>iv«' ilfjit'tioiis fnun the bowels, and complained of a burning s
Unit lit tin* tiiiH* of the inov«>ment(<. The total quantity of urine was ^
On thin dHv s)i«> wiu< tiimlly p<*r8uaded to take milk, and no other food w
On jHimiiry 12 tho child ewnied brighter and the face was not so n
t"tul uriinuiit of iirin«^ in the twenty-four hours increased to &40 c.c. I
uii:ily>i'* (AnulvKirt 62) made by Pn>fc«>or Wood gave the following resu
ANALYSIS 62.
(.'ninr Nornml.
Kruction Acid.
rniphji'in Diminished.
Iii(i«»xyl Incn^ased.
Insi Slitjhtly diminished.
l>ic arid IncnMistnl.
AH'Uiniii A slit;ht trace, and less than on January 8.
Sui;jir Absent.
Hilt'-pii^nuMits .... Absent.
S|)«'ritii' 1,'nivity . . . 1014.
('lil.»ridr< Almost absent.
Karthy })li«»-}»hatf-. . Diminished.
Alkalinr plm^pliati's . Dimini.shed.
St'diiiMiit Cunsidenible in amount, and consisting o
blo<Hl-globules, a few renal cells, an occi
blo«Ki cast, and an occasional small epithe
Tills >p«'(iin«'r> '•howrd tliat inij>rovement had taken place in the con
siiic' tli«' pnvinii* rxaniiiiatinn. as the albumin had lessened in quanti
imn-ax-d.
Oil .Taimai-v \'-\ tli'- t«»tal quantity of urine hud increased tn 141
Tlx- <liil'l .-•■••iimmI very wrll. and was n»ported to have slept quietlv all i
<.rth'' uriiM' -li..u."d tlu' >p<'citic' icnivity to bo 1011. The chlorides, thoug
THE EXANTHEMATA.
567
CJOIOT
ANALYSIS 08.
Reiiftion , ,
. , , Acid.
Upophaein
Indoxyl .
Vn*H
. . . Nuniml.
Vtivncid .
. Normal .
Albumin .
Chloride* . , ,
Very Bligbiest powible trace.
. . . Nomiftl.
£ftrtby phijD^phfttes . . Normal.
Alkaline phosphates . Normal.
Specific gnivity . , . 1017.
Sediment Slight, and coDBisting of a very few normal Wwd-globulee*
Slight exoew of mn&il round cflls and of colb like those
fK»m the neck of the bladder.
Although a very prolonged »ettit:b was mad^ for caAUi^ none were found. Profeisor
IToocI con*kid(tred that at this date the kidneys hud practically rc*covered» m they weredotng
prfectly norniiil work. The hlood probably came from the neigbborhood of the urothm,
I there WHS irrit^itiuti in thjit loeality.
In April the child wa^ allowed Uy have, besides her dietof niilkf some broth and bread and
liter, and m May ^he wae given meat. She wiij> kept in bed until the latter part of Marcb.
During the course of her dckness various attempts wore made to incre*4«e her diet more
lickly and to allow her to be dressed and about tbt? roomi hut each time wb*;n this was
Erne she showed Rymptoma which pointed towards the presence of a renal complimtiun,
^b aa a fiweiling of the eyea and face and a iw of temperaturei with resulting tuiuis«a
Id loM of appetite.
This eaf?e jihows how eureful we must be for many week^ and even months to control
lA tempemture of the room, the amount of exercise, and the kind of food^ where a nephritb
p0 complicated a caae of scarlet fever. It also showii how entire recovery may take plaoo
ftn where the renal irritation b pronounced and unusually prolonged.
This table (Table 94) gives the record of the total amouot of urine
ia each tM^enty-lbur hours for ninety -two days.
TABLE 94.
8
9
10
11
12
13
II
1-
M
IT
18
11)
2(»
90
im
m)
90
240
300
M»)
1410
1545
1440
mo
915
UWrn
im»5
1140
1020
Ouncet.
8
16
16
S
8
10
18
47
48
ai
mi
81
80
mi
86)
Ui
m
84
Days.
21 .
22 .
28 .
24 .
25 .
26 .
27 .
28 .
29 .
80 .
81 ,
82 ,
88 .
84 .
85 .
86 .
87 .
8g .
89 .
40 .
ac
Oanoea.
86,5
28*
900
80
Hr20
84
1125
87i
1020
84
1185
89)
975
82)
12B0
42
990
83
ll.Vi
88)
1280
41
1280
41
1125
87)
1185
89)
1185
89)
l<i,M>
85
Hi<)5
88)
990
88
1020
84
1290
^
I
5<J8
PEDIATRICS.
Piiyv
41
4-2
4)
41
4".
4';
47
4S
4'.»
;.i
:.4
♦'.1
•;4
1170
121. -I
icrJO
1110
1(H».5
14'J5
i:u)r»
irJO
12:iO
1125
11 r>r)
1080
1<K».',
1080
1200
1*15
1215
i:wr>
124.")
lO'.Ki
1040
10^
••75
(♦:]5
1050
TABLE 'J4.—(hHfinuefL
Days.
07 . .
68 . .
69 . .
70 . .
71 . .
72 . .
73 . .
41 4
34'
37
36^
47J
43J
37i
41
87J
38^
36}
33^
36}
40
80}
40}
44}
41}
36}
35
35
32}
31}
33
35
74
75
76
77
78
79
80
81
82
88
84
85
86
87
88
89
00
91
92
C.C.
. 9C0
. 1275
. 1230
. 1140
. 1275
. 11»5
. 1230
. 1380
. 1275
. 1260
. 1230
. 1215
. 1230
. 1140
. 1280
. 1305
. 1280
. 1170
. 1200
. 970
. 785
. 1235
. 930
. 885
. 885
. 1065
-V
L»
41
41
4S
*^?
4:
4:
*^
4;
38
41
^
4;*
&
4»
*:
-*!
Ui
■51
t
Thi- tal»lr (T:il)lc IK')) shows tho nxH)nl of the total amount ut* a:k
t'W l»y tlir cliiM ill cacli twciity-ionr hours during thirtv-tme clav?. M:'
« r t\(lii-ivr (li«'t (hiring tlies^' (hiys, ami although, as I havt* db-^:
told ynii, in tlir iM'iiimiinj^ of hiT si<'kiu»ss she disliked and rrfiisiil K' :..■--
milk, -lie \v:i>, nrvrrthcKss, |K'rsua(l«l to tiike it, and finallv did so wi:
n-i>taiMv. 'I'lic tal)l(' is instructive a>< showing the amount of milk ^ hi-
i> >iitli«i('iit inv nourisluncnt lor a child of this age.
TABLE 05.
.,
.... »;:;<i
. 1 lln
:: i:.::n
1 1 no
.". 1 no
•; . Utn
1 no
s
.... rj<;(»
!'» . .
11 ... .
1'-' . . . .
.... ]'y,()
.... rj»;o
.... \'2>\n
I'l . . .
U
l". ....
.... 1110
.... l:^'.o
... i:i:»n
1'' i;i.-.o
ounri-s.
L>1
4H
51
4K
48
4H
48
4l>
42
42
42
42
48
45
4.->
45
iHiyn.
17 .
18 .
10 .
20 .
21 .
22 .
2.S .
24 .
20
27
2R
29
.SO
31
C.C.
L>r:*-
1260
4-:
ir,20
M
1440
^^
1580
■Vi
1580
.=il
1580
:.i
1680
M
1620
.4
1020
M
1620
X
1620
M
1620
•4
1620
M
1620
M
4'a>e 245.
1,— Bcfofu treatiui^L
ScArtet tevvT. Nepliriti* : eoUrg^tnent of tbe beut.
THE EXAKTHEMATA,
569
This boy (Case 245, I,, faciiig {lage 568) whom you aee here in the?
iivalesoent ward is an illustrative ca.se of scarlet fever coniplitated by a
t>bable capsular gl(>merul<i-nephritis and a resulting caitiiac enlargement.
Me ifl seven yetre old, and cvntcrod the hospital on July 28. His mother U living &nd
ill, and state* that hb futber died of Brii^ht^e di*va«e. The child U «ald to have heen well
(til eighteen montbH agu, when he had an aiLack of scarlet fever, raild in form and not
eoom panted by any severt; symptoms. In the latter part of the attack bU temperature ruset
nd he began to have dyspnoea and dro{)gy. Since that lime he haa been alowly but steiidily
t>wing worse. At you ^ee, he ha;& extensive cedema uf the fucet che^t^ arms, aMornen,
I legs. He ie somewhat eyanotict and his breathing: is ^> much atf^cted that he h unable
lie down, the orthopncea compelling him to be supported in a serai-recumbent poeltion.
I closer eiaminatiim you gee that there ia a ^U^hi puffineiui al»out lK»lb eyea, that there is
ellow tinge of the ecinjuneti%^», and thtit the lips and tongue are cyatiolic. The extreuii-
are cold to the touoh^ and their skin pits readily on pressure* The skin of the whole
y is dry and hur^h tmd in certain portions is etivered with fine scales. On the inner side
the left leg and on the outer *ide of the right leg are some old scars, ap|iarently re»uUing
u previous scaritJcation performed for the reduction of the anasarca, hi mldition to
lie (pdeinatous condition of the walls of the abdonjen, a disstinct fluctuution is found on pal-
iiliou, showing thut there is tluid in the abdominiil cavity. An examination of the luuga
Ibows that there k dulnegs over both bases behind^ and over the»e urea^ of duliiet^^ na well
over the whole front of the chest, fine moist rale^ can be heard, indicating an OHiematoua
idiUon of the lungs. On examining the heairt, 1 And that it* impulse is moat distinct
the sixth interspace a little outside of the manimury line. The nrfia of cardiAC dulness
ids fKnn the second rib on the left to 2.5 cm. (I inch) t*> the right of the itemum, in
BPea eorreeponding to the third intewpace and fourth rib. The dulness then extends to
left ecroes the sternum to a point 2.5 cm. (I inch) ouL^iide of the miimmary line and as
as the frixlh interspace, corresponding to the cardiac impulse. A loud systolic murmur
ikn be heard over the regi<m of the cardiuc impulse, and is transmitted so that it can be
iard in every part of the thorax. The total amount of urine in twenty-four hour^ has
iried fti>m 900 to lO&O c,c. (30-35 ounce*). An analysis (Analysis 6i) of the urine gives
ke following results:
ANALYSIS 64.
Color Barker than normal.
Specific gravity , 1013.
Reaction . . , , Acid.
tJrophiein . . . Diminished.
Indicjin , , Increased.
Chloridt« . , . Diminished.
Albumin , . . y^ per cent.
Sugar Absent
Sediment . . Very slight and floeculcnt. Microscopic examination shows numerous
short hyaline and granular ca*ts of medium diameter and fKTa»»ion-
ftllyof ttmall diameter; an excels of renal epithelium j consldemble
abnormal bh»od; an occasional white corpuscle ; one or two bt«Mjd-
cast8, many hyaline and gninular cahU^ with one or more renal oella
adherent ; occasional fiitty renal cells and casts with a few fat^ln»pi
adherent
i entering the hoepital yesterday he had a slight diarrhoea. You see that to-day he is
i to lie down with comfort, on account of the dyp^ncpa arising fW>m an accunntlation
' fluid in the abdomen. The legs are also very much swollen and ledematous . Hi« face ii
newhat puffy. The cyanoiU is so marked and tlie child is in so much dintrv^ that it is
dent that immediate relief should be given not only to the general symptunis. but also to
n Il« II lilt. 1 •■ »^» <. lit- i<<« kia< ii<-.7|fiv«*i «■> *Tirt«i\A »*\» aaaa^trwa (.ra^ fcxr a^AaAVk^ •• v«-.aaaaa»<.
thif (.'Diiilitinii (if the kidiH'v und heart which may have existed at an earli
pc»^^>ihl(• that (iuriii<; the .stui;o of etHoreitfoncu an endocarditis such as might
curlier >yii)}itoii)s of scurlet fover may have been present and may have been
pulholoixii-iil h'sioii of th«' vulves. Thu history of the case, however, states
«»f thv >iarlrt fi-vtT was a mild one in iU early stages, and that whatevei
folliiwi'd ari>M' at a lut«'r stage <»f the ditjease, during desquamation. It would
th»'n-r«»n.'. that tin- >yiiiptimis <»f <edemu and cyanosis which appear in this la
di>«'a.-i> WIT' i>aus(><l )»y a disturlmnce of th(; kidney. As I have already V*
<Niiupli(jitioM i^ ifiMfst cuiiiiiion in tho later stages of scarlet fever. The phy.-sic
niaili* wlh'ii tlwM-hild entered the hospit^il showed that there was a coinplicati
n'pn-i'MiJ-il l»y <'anliae I'Mlargeineiit and a mitral systolic murmur. The exai
uriiM' >h'>\v> u> that it !.•« pn>l>able that then* are organic changes in the kidn
the In -art, althoui^h wt* cannot >ay detinitcly that such conditions as we find ii
Hut b«Mu pnnhht'd l»y acanlia<' lesion followed by passive congestion of th»- 1>
fi>n-. :iltii>>iii;]i wc caiMmt decide without a |)oHt-morteni examination whetb
and heart are allected. we can at least suj>|)ose that the following sequence oi
has re-ii)i(<l and ha> pr<Khic<Mi the pn'sent clinical symptoms.
The rhild had -earlet fever in a mild and apparently unc«>m plicated form \
the .-tairi- "f dt-tjuarnati"M. During the latter part of this stage a loe-ion
prc.-uinaMv of the ««Mp^ular clomerular fonn, occurred, and, owinc^ to the ii
pr»--\in' wliieh tlnally n-^siilted fn»iii the changes in the kidney, hyportri.>ph
j)p'-uiii.ihly f«»ll<.w»'d l»y «lilatati«>n. appeartni. If 1 have correctly read ih
l«-i'»ii«. uf have, then, cardiac ♦'idurgement sec<)ndary to a renal disease and
nriirinal -laih't l*i'Vi-r jMiitagiuiu.
Till- pr.'i^riM^i^ in tlii- ca-e is very unfavorable. Although we know that i
tati"ii of th" h'-.-irt may h*- i-ntin-ly rec«»ven"d fnmi, yet as long as this ci.»ndit
i- «l:iiiL"r (if Midih'M death ln»ni canliac failun*. When* the cardiiic diliitati<
ext<'ii-ivi' di-cM-.' ..f ihi- kidrn-y, e-^peirially in the form which we most oomnii
in -.Mih t f.-Mi-. .jip-iilar i;l«)Mjenili>-nephritis, the chances are that this fa
phu-.- |..f..r.- til'- n' phriti^ ha-' l)e.'n n-covennl fr»)m when a patient has l»een i
a «liL:r««' a- i- th«' c.-i-'- with thi-* hoy.
Thf t r.Mt iMi-iil ^liiiiilil I l.w.Jnto nmi 6t% no not t/i tnv «-VkA -m...-.^lA. ..r «
THE EXANTHEMATA.
671
I He wftg Me to lie down witb oomfort, slept well^ hU app«?l.ite retumedi and at one time be
could evt*n be moved about the ward in a wheel-chair, Some wc3ek.4 later tlie cardiac »ymp-
tonifi returned, and he again began to have cedema and ascites, cv anosU and urtbopnu^A. The
urine, as yuu ^ee in the table (Table 96), varied c«jn8idcrHbly, but at no time did it Ehow the
^reat le«isening which m fuund in case^ uf threaieniiig unciiiia. The frymptorii^ were^ iudeed,
mostly those of a crippled heart At one time the temperature, without any asfiigtiahle
t caitiJie, rofte to 41.1* C. ^106* F,), and somewhat later it became subnormal. On September
I 4 the a»cite« had increa«ed to such a degree that paracentesis of the abdomen had to be again
I performed,
i)n September 8 the fladema IncreaAed, and the urine wa& reduced to 450 c.c. (16 oudcca).
Diureiiri was given in doeeaof 0 6 gramme (10 grains), which increased the flow of uiine
to 12^ c.c. (41 ounces). The diuretin given id these dose^ once or twice a day for some
iinie cutjiiuued to act eui-tceBsfuDy.
In Qctol>er the action of the heart grew itill weaker, the cedema of the lung« increaied,
and, although there had been a general impruvemcntY the child grew prc^gressively weaker
during November. Early in December be was attacked with vomiting, had a weak and
mpid {iuUe^ gradually failed in ttrength, and on the 2ldt of December died suddenly. No
i AtttOpey was obtained.
The total amount of urine in tliifi case, meatured dally from July 29 to September !&»
I m fultowB :
TABLE m,
.{Jkftal amount (^f urirn passed in UDtnty'four Kouru during thirfy'4m§da^9 m a eate of acartii
/ever eomplieated by nephritit and refulHnff in eardiac diiatatiofi.]
Date. Ce,
July 29 1440
July SO 1230
July 81 . .
August 1 .
August 2 .
Augiiat 8 .
August 4
August 5
August 6 ,
August 7
Augufit 8
August $»
AugiHt 10.
AugUMt 11 .
810
............ 810
. ... flOO
.600
, . 1820
91MJ
680
.... 510
610
S40
1020
lt)20
August 12. , 720
Anglic IS. , . . , . 1020
Augu**t 14. , ti^O
August 22 ft40
AugUKt23. , .9110
August 28. , m)
Aut^UHt 29. . . TT^O
AuguHtSn. , . . , 48U
August 81 . . , 600
. .840
... 480
, . . .... 900
. 540
450
i2sa
660
.... 750
Snptimiber 1 .
September 2 .
SeptemWr 3 .
8eptemb4?r 4 .
Septemlior 7 ,
September 10
September 14
September 15
)
ounces*
48
41
27
27
80
20
44
33
21
17
17
28
84
84
24
84
28
28
88
20
25
16
20
28
16
80
18
15
41
22
25
TRE EXANTHEMATA.
LECTURE XXVI.
THE EXANTHEMATA.— iConduded.)
MEA8LKS.--RtrBKLLA.
MEASLES (Rubeola). — Mea^sles is one of the most t-ommon diseases of
ildhood,aiiJ tias lx*eu koowTi fi>r many (jenturies. It is an acute infB^tiotm
dii^ease, evidently caused l>y a siK'citie micro-ortranism. It is cliaraeterized
}y laehryniatioii, photophobia, coryza, cough, a papular effloresoeDce, and
\ slight tlesipiamation. The miem-oi-ganisni whicli produces measles has
lot yet been determined. It is Hiipjiosed to find its vehicle in the tears, and
the 8iK^rPtion of the throat and nost^ and p(.>^ibly to exist in the blrx)d.
t^ tenacity for cl(>thing, thus eontinuing as a fret^h S(3uroe of infection, b
ild in comparison with that of scarlet tever. It is very infectious, and
I some <xmimuniti*>s is at times exceetlingly fatal. This was the ease in
le epidemic of 1873 in the Fiji Islands, where it had not owurred for a
Dg time ; it spread rapidly, and mnstxl two thousand detitlis, of which
ixty-seven jier cent were in clnldiTn under five years of age. The high
mortality in measles is, as a rule, nt^t auised by the measles itself, but by its
implications. The epidemics of measles, as I have already told you in
mparing the dl«?ease witli scarlet fever, spn^^id rapidly and ai»}>ear to have
^n element of i>eriodic^ity. This has Iw'en well exemplified heix? in Boston,
in tlie cn>wclfJ districts at the North End, where in certain yeai's large
■itimbers of children are afl'cct*^!, and where in the snc^ceeding years the
dts^U'^e ajipears f^nly sporadidilly. Mi»asles t*an cx-cnr thr*x* or four timers in
e same individual : this recurrence was one of the peculiar features of the
lidemic in Boston in 1880. It may attack young infants, but is rare
ider six months. After the sixth month, and especially during the first
ear, the susceptibility to the disease Is incrt^*4ed, and we aieet with tlie
test numlxTof cases between the first and the fifth year. The suscx»j>-
ibility t<j measles appears to lessen as pnlx^rty is a|ipniat*hed. It is sonu^
hat mvQ in adult life, though the fac^ of its attacking large numbers of
mlults was also a {KH'ulianty of the epidemic of 1880 in Boston.
Measles is an extremely infections disease, the contagium apparently
ing innn one individual to another after a ver\' sljort exj)osure, and often
ithout any direct contact, a^ l)y transmis^sifin through cli>thing or by the
ids. It is most infectious in the beginning of the attack, and the infec-
ion may be transmitte<l thi-ee or four days before the efflorescence apjx^rs
the skin. There stx^ms to W nuich less liability for the transraissioir
the disease during the stage of d*^*jnamation than is the case in some
af the otlier exanthemata, such as starlet fever and variola, the meana of
574 PEDIATRICS.
traiisniis>ioii <t»rns|)oii(lin«r nion* to that of varic"ella. In sjx»akingrr.l'«4tira
t'cvcT I liavr alnady rt'tcTHMl to the i-ase (Case 234, {>agc 533i of ihr* ioi
^irl wliti, altlinu«rl» <'X|His<tl to the scrarlet fever inft^etion in the liesimij
of tin* (lis4as*'. (lid in»t <'<)iitr*ict it, but iu the follciwiii^ yi-ar, when i.xpi>e:
lor a slinrt<T tinn- to the contu^iuni of lut'asli's, \va.s imniediatdy infr^lf^^f
that di-^ra-M'. The fi)nowiiiji: castas which I shall re|K)rt to you will beinta-
ostii)^ and instructive a^ example's of how the trausniission of the (iiintadia
of M-arlct llvrr <aii U' prevc'iitul hy treatment, and will also illiL-iraii tk
lii^h ilept'e of the inf(rtion in the early stages of measles.
A Imiv ((*iw 1247) will! was in my wurd at the Children *8 Ufjspital wu iit*i&c£^i m
srarlft ft-viT.
I hud liiiii n-iiii>vc<i til the contaf^ious ward and placed under th*? i-aiv of a 5«!&
nuivi'. wljt» h:ul ••nl»T« to carry nut tin* Ill0^l pniiho untiseptic truatniont. Thedi.-*^:!'*:-
till- u\M>r \v«>n> that >h«' ^ll(»uld apply un nintmont to the child, ruhhin:; it iiiio '»k -l:
tiiuri'iiixltlv tn>iM th«' hciid to the ftH*t twic(> daily. The child was also tit \yf h«th«d:w
daily wiih a sulutitui ••!* rt»rr«)sivf ^ul>linlatt', 1 to 10,000. The nurve was c«uti'«r»».'ii/.'
all"\v li«T rl"tln- to t<»urh tli«* lx>yV IkhI.
DuriiiL: thf r-arly -tai^r nf thin b«»y'i* desquamation a second boy (Casr 24*'. ti
iMiiipiril tlif lii'd ill tln' iri'Moml ward nrxt to'thebed fiv>ni which the fin^t b«n iui t»?i
riiM"V<il, wa- attaik«'d with H>n' thritat, vomiting, and fever. I had already p»id laj "Js
I'-T ih.' (lay. aiiil my hi'U>o otfiivr, thinking the case was prohably onu of ecif.rt ^!
i«»iitrart»d rp'iii havini: Ihm-ii in ^uch vUtue proximity to the bed fn>in which tk-^M^*
wa- laki-n, Iia<l tli*- '••■(■■•ml lM>y n-inovcd t<i the contagious ward and plai-t-d in^hcsov
n">in with thf tlr-t l»«»y. On the fnllnwing morning I found that the i^t-tnnl I- yii--^*
hav.' M-arh-i ffViT, hut ha«l nicMshw. I immediately had the secvmd Iw Km:r*l*
:iri"tli»r n-rn, ari<l In- wa>i <-an't'ully watclH-il for a wwrk, tsupjK>sinf; that havinir pi'-t-.--
r.i'.:lit with tli" tir-t \>*>\ . wlm wa- in th«* nnM*t inft*ctious 8ta£:o of M.'arh*t ffver. L- i.T-'
h.f. . . ..i.!r:(. t'.l -.jirl'-t f.-v.T. A Wfi-k pit>«sctl, and he evidently had f->«if.^''i infiii-; '■
th.- >i ■i!'!' t t'.'\' r (-..ritairiiiiM.
'!"• II ■i.i\' l:it»r th«- l««'y wh«» hud scarh't fj'vcr was attacked with meafh-*. | -1*^.1' -'.■
I .i.trai t' '1 'liiritiLT tin- iiiL'hi fn»in ihr hoy wh<» was his rooni-niato in the earlv sU^^-i^
:ilt;i' k «'f lii«:i-l»-.
TIk-i- f\v.« « :i-.- MppanMitly .-IhJW — Hrst, that pcarlot fever, even during its ni'>«: :r"V-
ti.ii- -In-'-.' .Ill !••■ |inv«'Mt»"(l frdni .-pn-adini^ hy thon>ugh and constant disiinft-cti-'n: w^
that III' :i-l<-- 1- lii-hl\ r.iiitaj^ious in its early stages.
l*Arin»Ln<;v. — Mryond tin* morl ml conditions whieh apjK?ar od the jkw
mimI Mil tli»' iimroii- mriul>rane of the throat, there is no esiKH*iallv eharii*?"
i-ti«' p.-iiliol^Liy «)!' iiM-a-Ns.
NnmiMmi li;i- -tmli^Hl the pathohijry of the skin in measles hv int^ia?-'
-|H ciiiirii- wliicli wn-r lianh'iie<l in a dilute solution of ehniniie and ^■
cMlnird with r:iniiiiir. Iiji'inatoxylin, an<l piero-carmine. The iiatlK»lo*-
r|i:iii<j<- \\( ic tMiMid tn Ik» ahnost entin*ly eonfincd to the elands of the jki
:iinl t<» tin* l»l(.(Ml-vr--.('U. Alxjut the walls of the blood -vessels, priihipi-^
in tin- ii|»|Mr I;i\< r- of tin- ciiti-, wen* found eollecrtions of mund ci^U^i*-
ii) rrnwilrd iiiM—r- -iirrnimd(Kl the hM>j>s of the blcxxl-ves^'ls even in '-^
|)a|»ill:j'. Tin- M l-v« — rl^ tln*nisrlves were dilated and full of W>«^
Thr cnjk nt" tlii' -\\ c'li -i: IjmmI^. m- Well as the exeretorj" duets, were envel»>|^
ill arciinnilatioii- nj" mimd ('clN, wliih' the neighboring tissues were filW
THE EXANTHEMATA.
576
ith these cells. These coUoctions of cells were always Mtuated outeide
.1 of Uie walls of die plaiids. TLe sebaw-ous glands presented like changes.
The Ijair-tollicles shovvi'd roimdi^^l prfjtul)e!*aiut^ wliich t'ori-fspoiided to the
iut*i of insi'ilioii of the erec*tinvs pilwrmi), ami which were pnibably caused
(2 by oontractioo of these muHcIe^. In the raiiseles themselves there were to
^ be found, lx»tween the cx^Ils pn)|jer of tlie muscular tissue, .^"attered round
^ cells, wbk'h showed tlie jKirticipatinn of the muiseular tissue in tlie inflamma-
tory prot'ess. The htnr-follielt^s, in the same manner as the sweat-gUiuds,
were seen to be sLirrounditl in their entire length bv rollc(^ion8 of roinid
Is, whi«^"h were more numcT(>us iu the li>wer than in the n{>j.>er part of the
in. We tliri'eiore mmp that in measles the pathologieid pnx*es.s in the sl{in
ects chiefly tlie blood-vessels and glands, while the tissue pn»j)er of the
ikin, iLs well as of the epithelium, presents no marked ehan^*s.
From tlie fact that in mea^^les the pathological pnjeesses of the disease
situated more jMrtieiilarly an>uud the bloo<l- vessels aitd cutaneous glands,
it may b«^ assnuKnl that the infeetious material nf the malady, whatever its
ture, is eliminati^l from the system thn)Ugh these channels.
In addition to the ptithologit^l lesions which occur in the umx^mpU-
catc^l eases of measles, thert* is almost always associated witli the catarrhal
eondition of the muauig membrane of the upper air-passagts a r^itarrh of
the larger bronelii. One of the most common t*oru|>lications of measles is
pneumonia ; this is usually a broncho-pneunKinia^ lobar |)neumonia Ijeing
com| m ni t i vel y rare.
In some i-ases an iuilammation of the smaller bronchi axt^mjMinied by
>ulmonar>' collapse occurs. The bronchial glands are apt to U^ swiillen if
seetjudary iutktion is a sc*vei*e one. Aecc»rtling to Osier, a swelling of
Peyer*s glands is not unct>uunon, and may be aeeompiiie^i by a hyj»era!mic
•'^ CM)ndition of the mucous membrane of the gasti'o-enteric tract*
Although a secfmdary infetli^m of the ear has l>eeji tNjnsidenxl rather
istinctive of scarlet fever, thl-s ctmiplication hm in my exjierlcuce arisen
quite frequently in meask^s. When the ear is affected in measles tJjere
is a ci»ngestion of the middle ear. When the onset of the i*relimiuarv
Ofmgestiou occurs in connection witli the inflammation of the nasal and
liasiv pharyngeal mucous membrane, it w^msists of a simple, general, acute
ngestion of the middle €*ar, aceompaniiKl in the Ix^ginning with serous
xuilation, and later with a rapid thickening id* the membrana tym|iaui in
wmnection with thi- inception of the suppurative piiut^ss. ^\'hen, on the
ler hand, the prt^iminarv ccmgestion is coincident with or follows tlie
orescence on tlie fa<^, tlie (^ingestion is primarily in the iipjicr jRirtions of
he membrana tynipani as the result of a susfR-nsion of vanj-motor inhibi-
ion. Under these <x»nditions thei'e is a civngestion of the mauubriat plexus,
of tlie su[>cTif>r and pi»sterior [M^rtitins <»f the membnina tympani, an<l of the
itirrt^jRmding portions of tlie inner luad i»f the external auditory canals.
In mldition to this more common etkudition, a general ciingestion of the
ibnuia tympani is foimd during the stage of efllorescienee, and is likely
576 PEDIATRICS.
to Ik* iiion* s<'von* in its-tyiK? than that which occurs during the pp.Jra
stap' nl* nuu*<U's.
The iiiHainniation nt'the middle ear accunipauyini^ meask^ Lsminvli!^
to \in\r iH'hiiifl siK-h tn>]>hio changes &» thiekeuiug of the tym|iaDi(' mt;03C
mcnihrane with the formation of adhesions tlian is scarlet lever.
During an attack of meiu<li»s, and subsequent to it, the tissue? sb>T u
isiKsial viihierahility to intW'tion by the bacilliLS of tuben?le. The mfe
cidar inf'e^'tinii may U* n»|)resc»nt«l hy the lesions of a geuend milar
tiiU'ii'iilosis or hy thos4» of esi)CH.'ial tissues, such as of the <irmcal a
l)n>nrliial ghuids, the Joints, the ear, and, most commonly of all, tbr \ui
In the latt4T instaniv the lesions aiv usually those of a tuberculous bp>Li
]>iif'umnnia.
iNriitATioN. — The time of the incubation of measles may van* t*?
mu<li, and may <N»ver a iKTitxl of two or three weeks ; the usual time, b."
ever, is t4'M days.
Symitoms. — Prodromata. — ^The pmdnimal stage varies in lenLtLte
ntkniiiug ten <lays as the usual time tor the stage of inculcation, the |>r
drnnial stage may U' considennl to last from two to three days, and inr^a
ca-c> fojir <lays. In this stagt* wa have in typical cases of the disea?e*7Tq
toins <li>tinctivc of mcasK*s. The invasion is charaeterizHl hy j^x^
<-atarrhal (-oiiilitinns att*e<'ting the nose (eoryza), the eye (lachiymatim'.t
the threat and upjMT air- passagi^s (cough). In the first twenty-lour k:
thc tcni|HTaturc rises to ;58° or ;«)° C. (100.4° or 102.2° F.), and ottai!
to'"-' ( \ I in t*^ F.). The height of the temi)eratiire on the first evenim »-
fair iiMlicatinii as \n the st'verity of the cimiing disease. Thus, a t» niir"
tun* nf In..") < '. ( inr)'M'\) indicat<^ a seven* <*ase. An important p'irt
Im' iinticrd nM^anliiiL: the ])nKlr(mial sympttmis is that after the tip?t twrn:
linir hniir- there i< in a large niunlHT of cases a remission iu the tomivraTi::
Nvhieh giM.. down, iM'i'haps, to iMJ)"^ or 37° C. (99.0° or 98.6- F.1,3:
nin:iin< <lo\\ n f'nr alniut twenty-four hours, when it again rises. The 0x1:
<nryzn,:uMl hiehryin:iti(»n, ^vhieh apjH^ar early in the prcnlromal stai^^An^
al»at<', Imt lather iiien-ase, <hiring this remission of the temix^ratuK'. Ti
is ail impnitant point to rememlxT, as the child who seems tjuite nVk i
ln-«- it- ai)prtit<' while the t<'m]x*rature is high during the inva^io'
tlir «li-«aH-. >r<-m- l»right<'r and lias a n^turn of ap))etite on the seix'nd i
wImii tlir triiip.M'atm-e is l(»wer. This iKK-'uliarity of the prodmmal -Ta?
nitr i-l.a.lin;:- Ix.th tn the pan^nts and to the physician, who, hfcau^t:
cliiM apjM-a]-- .-•» imieh U'tter, are led to Ixdieve that one of the infaii'
(li-ra-e< i- not <lrvrlopinir. In infants and young children the pn^ln
-ta«^e mav hr^iii with a convulsion, hut this is unusual, and if itiKX-nisn
not. as a rnlr, paitimlarly seven\ an<l d(H»s not necessarily make the pri
n<»-i- niniv Liia\«'. Ibadaehe in the pnxlromal stage is quite fw^off'
v^.initiiiL! i- rather rare. 'I'he tongue is usually furred, and the m\x><
nirnihraiw •»(' thr thmat towards tlie end of the second dav and beforeil
crtloreM'cwvH' \vA> v\\>\wwYvA vA\ vW^ ^V.\\\^ d\c\\va a condition which U^^
THE EXANTHEMATA.
577
hw
nimilar to that which is about to ap^^ear on the skin* These lesiooB^ which
kre eftpec^ially pronounced on the soft and the hard palate^ are repretsaited by
mapule^ or maouk's of a dark*red and later purplish-r<?d color, of different
mxe^, and mnsiderably larger than the punctate macules which I Imve
ldesc!ribt*d in sfieakiug of the throat in scarlet fever. These papules may
wometinioH Im* Ibund t4> have eoalei^ced in mune partB of the fauces. The
mii(*tiU8 membrane Ix^twc^n the le^sions Is comparatively normal in color,
tliough tliei'e may be a sliglit hypenemia of the entire tliroat. This hy[K»r-
however, is not nearly so inteniiie at? is m^n in the throat in scarlet
rer< After tlie remit<j?iion of the temjxu'atnre, which I have already
[descril)od as taking place on the second day, the temperature on the third or
ifourtli day agaui rkea.
Efflorescence. — At the end of the third day or at the bt^inning
[of the fcmrth day — that is, the thirteenth or f(»urtei'nth day fn>m the time
when infection took place — an efflorescence appears on the skin. The efflo-
*noe iLsimlly reaeho^ ite maximum in ab4iut thirty-sLx hours, this lieing
more coui^tant number than the other figures which I have given you ;
that is, it Ia aliout the fift*»euth day from the date of infection* The stage
of incubation ]a nither more cf>nstant than the stages oi' prodrome ami efflo-
irescenct*, the latter two varying a.s to their length, but together amounting
[to five or f^ix days.
I When the efflorescence apf>eai^ on the ^skin itcon^isits commonly of gmall
rmaculcs; or papuk^s f)n a slightly nddcn^d l:»ase, which first ap|K^ar on the
feee^ As the diti<;»a,se progr(*Rses» these* li'sifULs extend to the nwk and cht^t,
and In the latter lm*ality are, especially in the Ix'ginning, of a delicate pink
color, the fVirm of distribution in some cases being crcscentic* The efflores-
cence then rapidly extends to the rest of the bxly and to the esctremities*
[It is usually more pronounced on the face, where the papules are apt to
[lOoalesee, and where an cedematous 4m >r»ditirin of the tis'^ui^s, i^^jiecially artjund
|i)ie eyes and nose, usually cxM-urs. The eyes ari* swollen and fmrtially
MbiH d, and the conjunctivae are rKhleued. Phot^iphobia at this time Is pro-
nounced. The efilorescence may also appear on the w?alp. The cfflorcstx»nce
reniaios well marked for fn>m one to two days, and while it is at its height
the temjwnituri' rc^aches its maximum^ and remains high for two or three
M^m, oorr^fMinding to the intensity of tlie eflloreecenoe* It then rapklly
l:fidl8, and reaches the normal p^iint in abcuit two days more, — that is, there
rsppears to l)e ofVen a distinct crisis in the disea^^. During the |jeriod
of efflore^'enoe, when the tem|)€*rature is j^itill raised and the efBorftscemx^ is
at its maximum, it is usual to have, in addition to th<* symptrmis of cough,
cjoryxa, and lachrymation, a sliglit disturbance of the intestines, represented
by small, frequent, hx>ee dischai^^, apjiarently arising from irritation of
[the ret'tum and descending ci>lon. This condition is seldom a s«tioiis one,
and no t^pecial attention ntxxl l>e {>aid to it unless it should continue for
laome da>^, or at^er the maximum uf the temperature and effloreesoenoe has
l})eeu poAsed for a day or two.
L S7
r>78 PEDIATRICS.
DFisiirAMATioN. — The di»s<jUttnmtion is usually furfuracotms in cha»-
t4T,— that is, tht* ri»itholiuiii is cast oft* in fine tlakcvi, and is thus dbny
^iiislicd tnnii the hii-^* laiiu>lhir iluki*s <Krfurrinj; duriug the peri-J ..!
(h'xHiaiiiatinii in s<*arlct frvor. The d('S(|uamation Ix'gius in the*»nli^rii
\vhi<h thr ri!lon's<*tn<*t* <*anie ont, — namely, first on the face and lattr <»a ti
elirst. The iurt'iiraet'ous rharaeter of the detM^uamation is esjui-ially &. ti'>
ahh* <»n tlir >i(hs of the nosi*. The disea^ usually ruus its entirtciKir?^ b
thni' WK'ks.
PncKJN'osis. — The pn)jrnosis of measles, a^ a rule, is gr»<Kl, hut tii?
d<|MiMU ahnn-t entin'ly njioii whether the dLseasi^e id free from or at-v^-
j)auif<l hy <MMn plications.
l)iA<iNo<is. — In order that you shonld understand how difficult it ?udp-
time-* i»* to dia^rnnsticate nieasK's, you must recognize tliat it b one of 'i^
nio^t variahlc dinit-^'s with which we have to dc^l. Durini; epidemics ii
uiidouhtiil nica^h's (»iis(s arist* wiiieii differ materially from the disrtwasi:
apjK'ars in its ty|»i<*al form, yet these easels, by pnxlucinf]^ the typical imz
othrr indivi<lnal>, prove that they an» all i5Siused by the same omtairini
In like maimer certain epidemits may Ikj ehanurterizcxl by irregular f-rst
of tlir di-«a^e, and, as true niciisles can <K.t*ur a numlx^r of timi»s in thesiif
individual, tlie i-e<'otrnition of a s|>onulie isise Ls otteii impos^sihle. i^ fc
iiiUrv di-ea-es of th<' skin, we shonld recognize measles not bv aiiv]'iini'>
lar drrmal h-ion, hnt by the |H»cnliaritit*s of the pnxlronial svm[iti»niv'i:r
«:vneral eoin-H- and hwation of the efflor<»scence, the time of the maxlLia
<»f tin* eilj.nrse^nee and t<'ni|HTature, and the i-hsiracter of the de-inn:ii:K:V i
'I'll. >, M pro<lr..mal >taij:e (»f thi*ec or four days, eharaotoriz(^l l»v rj:;ir lJ
sympi'.m- n[' tlie ryes, nose, and ujifXT air-j>assj4res, and a papular ti-
re-criK'r MpiMMiiiiL:- firM on the fac<*, ditleiviitiate the dist»a*H* at en<.r:'ri
vari«»la, varierlla, and scarlet fever.
Tkma TMr.NT. — The tn*atinent of meash^ is essentially svm])t<'!iui:
Tiirn* is no known means of prcMlucing ininiunitv from the dixu** ":"-
>hnrtrnlii- it< eoiir-e. It is a self-liniit<'d dLsc^ase, and the tr^'atment -li-r-i
Im- diivricd to proteetinir the orjrans which are most likelv to l)e attarkiii l";
eomplirntiuii-. IirariiiLi- in nn'nd that the eye, the nost\ and the thn»;it i*^
all'trird in thr pindiomnl ^tair<', that later the skin is in a ver\' ?< i>i--'lTf
eMii<liti..ii. .-mmI th.Mt tlie luny: is InHpicntly the si»at of some e«>mplicaii"L. ^■
>liniiM (jiivi-i <.iir tfr.Mtmrnt e<pe<'ially to the protection of these or^^aa-.
riir •Jiild -In mid Kr |»lae<il in a hmmu kept at an equable temp'ranift.
•Jn -Jl.l ('. («;s -71) F.), and well ventilateil. The rcnmi sliod-H^
d.M'keiird. and tin- eyes should Ik' protects! from light durinjr tho ^^W^
enuisr <il" tlir di-r.'isr. Tnless tliis pHH'jiutiou LS taken, the eves an' "^^
MiMMiisly Mtlictrd li»r many months after the measles itself has disappw^'^
Thr rjiil.j -liniild l)r lopt ill ImmI uutil tlic tcnijK^ratiire has been norma! fe
a i'rw ihiys. thr «n|..irM-.'n(v has faded entirely, and the desquamation!^
alm«»-t erM-i-d.
The (\\i'\ i\\\v\\\,i: \Vvv' \haVA vA' \Vw WvsrUt of the temperature should bt
THE EXANTHEMATA,
579
[>up, milk, and bread. Later, whexi the temjK^rature is normal and desqua-
ation has begun^ the child can gradually have its diet inci-eased, until
l>y the thii-d wet*k fwm the l>egmiiing of the attack it is having its usual
.Ibod,
The* ctmgh, which b verj' troubletsome at times, does not, as a rule, require
oy special trt^atment, as it will of itself in nit^st cases pa.^s oif in a few
ays. While it c<3ntinues it vslu lx» tnuiti^nl with some simple mixtur(% such
camphorated tiucture of opium in c<jld water in doses of 0-iM),6 e,c,
(5-10 minims), to allay the irritation in the thmat.
For the irritation of the nose I liave iound that atomizing the nares
ith some simple i^efined oil, such as oleum |X'trolatum allium, is useliil.
iring tlie invasion of the dist^ase, however, these catarrhal symptoms
exceedingly difficult to control hy any treatment whatever.
As at times thei^ is great irritation of the skin during the period of
lorescence, this [xtwder (Prescription 56, page 466) should be applied
liickly to the entire b<Kly and limbs. In place of the powder some simple
lointmeut, such as j)etrolatum, may prove to be more soothing.
CHART 17,
D^i/s of Disease
F
M
2
3
4
5
e
7
8
9
JO
c
107''
I06O
104°
103*
I02'»
I0l**l
100*
99P
15?
M e
M K
M K
H R
,N E
M 1
M K
K R
M R
M R
4M 6^ 1
41 P^
40.5*
40-0«
39.4*
36 8°
, J
/
s/
V
f
1
'
-^
3e.3*»
37.7«
37 2*
37 0°
36 e**
16 I''
J
/
T
L.
_,,
.__.
—
...
—
Li'
35 5'
35 0''
p^
^
a
^
=
^
TfpUaa
UlL'tL-'lo.
tA»* rule, the rhild should ho kept in an equable temperature for at lea^t
I weeks, and at the end t>f that time, if the dcs([uamatiou hus ivased, it
Entay he allowed to go out of its room, and in plea^^nt weather out of tJie
thonse a few days later* For several months, however, it should ^\e carefully
prote<'ted from sudden changes of atmosphere, a^* the catarrh of the air-
jMissagi'S is so likely to Umve Uiem in an extremely aensitive condition that
very slight irritation may cause its reourrenoeu
6S0 PEDIATRICS.
Ucl'nn' till' rhild IS allowwl U\ leave its nxiin it should be th.»n.ii2iLT
hatluti t*n»ni ln;ul \n iinit in hot water. Although the c*»nta«rinm ut'iu^a-.-
\\ii< imt the .siiiie tenacity lor elothin^ as the ccjuta^ia of variMla d
siarh't Irver. y<t the PMini slionhl Ih» thj»nnighly di.siiiliK'ted after thriij':
lia> li'ft it. This can U* <lnne in the same way tliat I have desoriM t- } s
ill <|M'akinir nf >earK't fever ; hut the extreme prtvaiitions taken in tht-kts
<li-«raM' art' nnt ituisitleiiKl nt-^-^ssiirv for the prevention of the extend H':
nna^Ir-. If the i-arjM't had not \HKm n^moved when the ehild war put b:o
tli<' PMiiin. it (-:iii Im* taken from tlie house and thoroughly elfan>4il Irfi^ h
is l>rMU;rl,t l)a«k. The iNMlelothcs and everj-thing that can Ix^ wu-ImI -ii-a:
Ik- thnroij.^rlily lM»iIiil. The nMini should 1k» eleans<*d and the wincliM* shnii
U' alluwtHJ to rnnain o]>en for sc»vend days, as fresh air is one • i* tbf Ik
inran- of <r.idiratin«r the miero-orpuiisms eoniieeted with the exaiitlif-nui-
Thi-i rliart Chart 17, |)ajrc» 579) shows the tenijierature a* it u.^oi:''
(MTjirs ill till' tyi)i<al and repdar form of mea-^les.
pH'tJur siMakinir imy further of mea<U's I will show you herx- ii; ri
isoln tiller \\;inl at th<' C'hihln'u's Hospital a uisi* whieh illustrat«-s -^t nlji
typiral picdin' nt'the n'jrnlar form of ineask»s that it will be v»*rv iii-triKr>:
ll)r ymi \n rxainiiir it.
Ill" ■.■.ill ■(':i-- L'l'.*!, -ix y<*rtrs nld, aftor oxp<>:5uro t<» nioa*lf> fourt'.-":i tls-i:
• I wiili !;iilir\ maii-ifj. »urvza, oniirh. aiifl ti tfiiipt>rutuix' of .lii.4^ (.'. >V '■' F
Oil th»' HTniiil duy fnnii ih<* lie^iiiniii{v «if the invu.*:-.. ' ■.
t.ni|Mrjitiin- fill tn ;J7.7<* C. { ICK)° F.), but yr^rol.;.- i: *-
Mu'aiii, Mini t'»-iljiy. Ji.- y«»u s»-i- ]iy tin* fhart, i* 4o- C. l-i :
L.if-r \i>t«'nlay uIUtjuhiji an i'tHor«.».-.o«'iiri». jiupulMr ::. ■ I •'- '
Mpp'-ar. .1 fji tin- facM-, ami. a> y«»ii m.m*. h:i!» now »;\l- : i-: '
ii. .Iv ami tlh»ni\. Tin* di-i-asf i.* imw at ii* h-i;::ii. V .
till- -\v.»ll«-ri ri>riiliti'>n ttf tho «'yi*s, ik»:*«'. ami •■mir" :"= ■ ■
til'- .'XtriiiH' photopholiiH fn»iu which thi* ihiM i- - -"J * -"
til'- pn-i-m f f.in.-ul«'raM<f lachryinutinii. a v..:it:M.:i.. •" '
(Ifv r..ni:h. ami tin' ^'xt^'ll^ive coryza. Yi»u wil'. nU- ■ -r-
h'W th. papiilr- hav<* coah*>L'<'d <»n the face, ami an- fa- 1'^'
1^ f — I ( .'It than till' \vi4i1ly fii*purati-d l«>sioii2( f»n th** rh".-t.
> i Wli.M y.Mi havf niu.v »»«vii a case of thi> kind v-ai wi: -
% hav any .litliculty ill niakiiii^ yc»ur diagrnM> in i4 ty^i.:.i -■
I M "^ m.-a«-l.-> at th«' lu-ijjlit of th«? Mtau^e of ot!l..r.H»Mi.-»..
i 1 ^ I M I l)is mxt ImiI is u lM»y ( Pluto VII., Cxl— ioi). f:.. iij i^:'
la 1 '•■'•1'. "iirlit yiars ..M. who is at the hoii^ht nf th- ••* :-►•
M. ^ — . — _^ _jj .,r ;ii, attack «>f nn'a>li*>«.
^ ' • ■ "^ \ ' "l" H- \va- si'iz.-d with the Uaiial prodnnnal sytij-T"- '
y .-■'i-li. ••■•i-y/.a. ami larhryinati«»n five day.-* nsris un-l t-i3;Lf
111.- .iiil'.-r.-iit Mair«'> «»f th«- typical lesions of iiu-a.-lH* -•:-.>-■:
'■;. : ;■• i ■ '.' ■; V 11 will i:..ti.-«- hnw tln'cniijunctivjif aro rt'ddern?ii. ami h-V: '.-■'•
n -■ ■:'i'-i -I- '•• -■•\-II.'i. :.lih..ii--li tlii- >w«'lliiiir is not i?<» intense as in th»> cas" i-f :>!■••
..;irl (■.!-• 'jr.' ulr-rn 1 fia\.' jii-i .•.l)..wn yoii. Tlic offlon^scence in this t-nsv h*- r/ '
vry lapil . ..r- . !.. ._■ i...,ino ..,, il... i;,,-.. in .... intrns*. a form that tht? d»is*iiianiili--. U-
ah-ily I.;.:., .ip.i. :iiti,..!i-.;li tin- . ill-.n- wo. ..n th«' oh«*st is in a much earliiT ?tAi?: ■■■■■*
V. :■ j.'... M T'.- ).:.j.'r:. - Ml .1 i:ia.-iil.- Iiav. a- you so<', coaleisced on the che^^k* aiA-:'
^\lli:. '.■:■> -'.I :.|.|.-.i: :,- i-.rj.-. .[..ply PMLh-mHl l.-sinns on the forehead. On therhir*'-
Ti'.-.k y.-vi \^\V. '.>..\\.. \\.. -w.-.v- -A w-TwvA >V\\\ \\v\*->ix\\\ss, like white blotches, their Ntr-i*"'
THE EXANTHEMATA.
581
►
jetermined by the clusten of papules. On the «id^ of the nose ytm ten a sUgbt de^uutnt-
n, which hisiA tho furfiiniceous churaot^r that I have alri'aU^ described to yoxi as typical
' iii6Bftle6« You will notice that on the che«t the papules and maculed are much fttiialler
I dze, are of a much lighter colur^ and in some places have assumed a cn^iscentic shape.
Thi* cft8«* repreftenu the typical efBon?^com-e of roeaile^, and up to this time haa not
howD evidence of any complication. Both thii* boy and the )?irl (Case 249 1 havn ri*ceived
no druga directly Car the meai^le*, but have Iwen kt'pt in a diirk room to protect the eye^,
and have been erurrounded by an equable temperuture. Their t<jod hati lH.*en milk, broth,
and bnMftd.
In this next bed h a boy (Caie 251), three and a half years old, who is convnlefici^nt
an attack of measleis. He was expoeed tfi measles^ on tbe 2d of the month, and
his ftrst pniMlromal symptomB on the !2th. These prodromal 6ymptom« continued on
12Mi, lath, 14th, and I5th, making the prodromal stage four day8. On the 16th a
lar etfloresoenoe appeared on his face, and desquamation began on the Slst of the
fionth,
I merely show him to you as representing the UHual time, ten days, in the incubation
meik^le^, the rather prolonged prodromal peril wl of four days, tbe ap|>eariitice of the
enco on the &ce about the tilV-^entb day from the time of infection and lasting four
a, and the desquamation beginning five days from the flr«t appearance of the efflo-
Variations in Type. — I have? already refem'tl to the mi}>nrtant fact
ling the diagnosis tif mraslt^si, that diiriiig cpidemii^ and iti h|M»n»di*?
the di^^ase variety iiiiidi in it^^ tvjie, aiKl presents great variations it* its
prodnioml stiigt\ in its dermal lesioiift, in itB desquamation, and iu it8 entire
course. I wi.>h eH{>w'ialIy to impress this a[>on you, as it is thniugh a laek
of appnx-iation of tlds fat^t tliat the diagn<»sis of other distiises, such as
nib'lla and various forms of erythema, is mntinnally being made where, in
faet, the disc»a*4e rt*present8 one of the more unusual forms i»f measles. If
Utesc* variatitins in mi^asles were Ix^tter uuderstoodj we should not find the
disease rnlx*lla so often diagnosticated.
At times the stage of inenlwttioii of meashi« varies considembly. It may
even W extench-d frf>m the usual ten days to twenty-one days,
lnst<;^d of tlie usual prtKlromal stage, certain tuses during epidemics of
undoubted measles show tew, if any, pnxlnjmal symptoms.
In thii next bed ia a boy (Case 252), •even and on^Mjuarter years old, who wa* attacked
[ with thp pn^mmftl Fymptom* of measlet on the 9tb of the month. These symptoma were
m heii^htened temperatun^ of hIhiuI 88,8* V, (102** F ), a quickeneil pulae, cough, and eoryaa.
On the lOtb, 11th, and 1 2th tlie cbikl felt p«*rf<fH'tly wtdl, hiid a go<:»d appetite and an alnin«t
Uonnnt ienii^H'mlUftt. On tho ft»Uowin^ day, fhi^ 13tb, he wjw found to have the papular
I efflort*!*cenc'e of meit^tles on his face, and a tenip«*ralur»-» of 88* C. (10(),6* F.) ID the moniiiig
^and MS* C. (102* F,) in the erening. It ha« b«'<"n a very mild ca«?^ and, tm you sec, it
DW deM4UiimHtinfi^ KH|rHtly,
X f^hiiw hin) ttf you lui representing one of the many vurtation« which ari»e in measleti
[ the TanatiMn in thtM eiise conMiBtini^ in the child bcTirijO^ pt^rfectly well during the Ijut three
I days of the prodromal r^tai^s and thujB showing prodromal lymptomt only during the flrtt
ltWcnt3'-foijr hour^ of the invasion.
Tn addition to Uie usual eatarrhal symptoms which I have des<TilM>d, in
^Bonie ctise« tliere are vomiting and sore tlimat, Aj^in, instead of a iH>n-
ible elevation of the tem|>eniture, it may be a'arcely aWwit iVw \kWt\scB^.
M'nt«il l)y iiiiniit*' vt'sichs or niilia, characttTizing tlie form ca
Any nl' tlirM' lonns may Ix* confluent, but not usually anyw!
tin* l:i<H'. TlicH' is anotlicr lorni of offlort^sci>iK?e which occm
is rail', and isot'a nion* siTious nature than the cH»ninion Ijeniir
you will nuH't with onlinarily. This is called the hemorrh
nant tin in, and is rcprrsi'nteil on the skin bv ^$nlall capillarv
It is ot'trn rapidly fatal, and at times appears to be part
hrniorrhairir <liathr>is n^presiMitiHl by epistaxis, luematuria, am
from nthrr lo<:diti(»s. The temjx'rature in this form is not tvp
not remit in the i)r(Hlromal stajjts thus depriving us of an ini]
of diagnosis ; but a <loubt its to the nature of the disease does
as th( othrr symptoms soon Ix'i'ome pnmiincnt. The more
coiirsi' of this form the lM'tt<T the pn)gn<>sis, for if fatal it is U:
so. It may 1h' (■om|)lieat<Kl by a malignant broncho-pueuinon
The elUonst'eni'e, In'sides diftering in it8 form, mav va
deirn'<' in its intensity. Thus, we may have ever>'' grade
macule, from the smallest to the lar^»st, and varj^ing from sn
to a litdit j>iid< <*<»Ior. In like manner, although the arran^
ellloirxcnre, (*s|M'<'iaIly on the elu^t, Ls somewhat crescenti
epidriiiic- of nndoubtiKl measles this ereseentic shape is often
st<':i<l ol' the rtllonsc^'nc*' first apjwarinjr on the face and then
th<' tln»ra\ and rxtrrmities, we may find in undoubted measles
lirst on thr chrst or some otiier part of the Ixxly ; or tb<
may aj)jHar (Hi tlu' face Jind tiiomx simultaneou.sly. We mav
in certain caso the etllonscHiKX* ai)pears first on the alxlom
thJLilis, and yet the j>n'sence of other typiml and imdoubted ca
in tlie vicinity or in the same house assures us that we are
THE EXANTHEMATA.
683
[qneiitly been nok'd where the post-aural and cervical glaods were en-
I largt'd.
Tiu're Is a form of mc^sk'8, tailed tlio nx'urrent» which k cLisi^ly allied
to rela|>sing tbvcr. The main ehanKitcrLstic of tJiL? form is the high fever*
[The tempomturc will ti4jmctimes Ije raisiHxl for five or six days, will then
become noraial for scvcd or ei^lit days, and will thca rise again with a re-
cjurrence of the 8ymptoni^» Thii? is a verj" umisual form^ and one which
needii merc4y to be mentioned here* It if* acei>nipanied by the general
juymptonis connected with the noi*e, eye, and bronchi which are met with
in the typical form of mea^ileH*
Rehipnert have Ix^n re[iorted to occur in measles, but they must be very
I tmcommon. I have never met w^th such casen.
In i*eviewing the picture;? which 1 have endea voiced to give you of tbeee
variatinus, it miii^t l:>e evident to you that, although iii the large proportion
of teases measles runs so tj^pical a course that the diagnosis is very easily
made, yet :^urh great variations in ty{>e are always liable to CRX-nr that
, we should be extremely earetul not to make a diagnosis of certain other
I diseases, such as rubt^Ua, except under unustial circumstances. This is
imjK)rtant, becraose we know that during cpidcmit^ of well-markctl measles
all these great variations a^ to incuhatinn, pnxlrome, efflorestt^nce, des<pm-
mation, arid the cntii*e course uot infriYpii^utly arise*
A ca*<^ which oot*nrred in my w^ards at the City Hospital during an
epidemic of metisk^ which t<K>k place in that institutkai illustmt*'s how
^grejitly the symptoms and api»earau<xr of the dis4^'asc may vary. The cases
€»eeurring in tlie hospital were almost without exwption of the typical form,
in which no mistake could be made as to the* diagnosis of m(*asle8.
A girl (Cufie 253) who was in th« hospitali and who wils exp<js«d U^ iMrot'tioti Truin
[ the pAtienU with meaalegf ftfter feeling perffctly w*«U un the pivvioua daj, wii* found in the
Diomitt^ to have ««1ig:ht coryxa, cough, and it piipuhir i.'fflore8c»?nc»' not enntluent evi*n on
the fttoe, amall in Aze^ light pink in co\ot^ and not crescentic. While the effiofeflc«nc«
I laiiUHl the ap|M?iiit" waa fiomewhat k^s^ned, and the terap'ratun" wa* kIm»uI 87 5*' C. (V»9.6*
F.), At the end of twenty-four hours the efflorescence hud ahn(3«t fiided^ und in u few duys
[the generul fyn)pt4jm« paAsed away, the patient '9 appetite had r^lurntxl, the tem}>oraturo
I had U*come normal, and she Beemed purfwtly well.
If tht!» ca^e had been met with a^ a f^poradic one it would have hc«ii impoeuhle to
I make the diagDOsia of nieaalei, and fr<>rn it^ mild nature it wmild have been tuppoeed to
^Iw «onie slight fornt of diaeaaey ftuch wa rubella.
T have met with cases of this tyj>e quite frerjuently, l>oth durinsr epi-
i demies and HfH>nuliealiy ; tlmr i^ause is always obseure, and in theru the
[diagnosis l)et^veeu measles, ndx'Ua, and papular erythema is otlen im[HissibIa
Iti this next bed ia a little girl (Case 254) who Is canvileteing from moMlaa and ia
•lightly desquamating^ The nn^ord states that she was ntU<>keil with eoiighf coryjui.,
l»C!hryruHti«>n, a temperature of 89,4* C* (H)«8* F), a puUe of 120. and respirations slightly
quickened. On the sec^^nd day of tlie attack the^ lyroptoms abated somewhat, mnd the
^temp*!ratuR' fell to 88,8® C. (101** P,)- Ou the following day the temperatare rote to
IV C. (108.6"* F.) In the momicig, and in the evening to 40.6« C. (10(^ F.V ^^ ^^
584
PEDIATRICS.
linn- »ii ••tllon'siM'iuM', pHpulur in churact»rr, appcHntl on the face, and by the fi-urrlds^:^
hpnutl mpiilly li» tin- I-kIv uikI liinhs* On this day the tempemiun;* iVll i<k:iS*=C. :?
V.) lowaril- tl.f jni.liil.- ..f th*- day, and by oviMiinj; to 38.6° C (101. o*> ¥.\. UMnrLr.-
ifii: i.t' th«- tiflli »lay ih»' U'iii|K*nitiin' was 37® C. ('JS.o** F.) in the moniinsr ami ?T.V'.
('.»ti..')0 F.) in th»' fvrniiii;. Thf ii'injMTatun.' was then normal for two da}?. ■■<:: ..c •>
rii^htli day thf cliild wa> I'mind In havo a U-iii{>cmtuiv cit'ST.T** C (100° F. i.iind t/vrOr
Ithiiniiii; t'f pain in xh*- \vl\ rar. A marked cHingctition t»f both niombrana' lutifnu rlj
i-W'jiUx xTiiii-. »'tVii».i.in wa*« all thai was d«'ltrt»'d. The toni|H'nUurc'. after tliu-tu:;:::^; t?:
:J»;.«; t.. :;7.7' C. il»S° ti» 1(M»° F.) tor two or thn**; days, fell to the normal, aud :i' ..'ts;*
ti"n ••!' tin- i'ar> -iili>id«'<l. Durini: th«' tinu' when the ears were affei^ted ibt -}- s-"
vt-ry >»ii>iti\i- t«> lii^ht. an»l thfn; was i-onsidiTable eonjunetivitU, of which thr -/aiU .rt-
l>lainrd iTPJiily. Tin- i-«»uirh was alnt wn' troublesome, and was evidently caller.: I: ji
irritation •>t'tlii' ]nur<iu« Miirnlmine of the throat, ai* at no time was any bnjDchiul irraL i
di-t.-.t.-d.
It i.- t.i 1.1' n«»ii('»«l in !lii> i-an' that iho conpwtion of the membranie tymr^iLi 't\ryi
a> I hav»' aliiMilx ili-i-riln'il. riiirinv: a jH-ritKl closely f<»llowing the efflorcfk.'eiici' ol ;bv 'jue
lli-n- i' tin- rliart (Chart IH) which ropretjenta the temperature duriiii; lh*-iij^"'
invasion and itllnn-'^i'i-nit' in this case, and also the accompanying mild Ci>ngeati->L<::U:
iininbrana* twnpani which is so common in measles.
CHART 18.
J)a€/s ofJ)is^as&
F
1
2
3
4
5
6
7
8
9
10
\i
E2
13
(^
C
107''
m^
103^-
102°
lOl'l
100°
99^
98^
97^
96**
95j
n K
■■ «
11 I
H S
X E
M<
M 1
M R
H E
a »
n K
H C
H K
M K
At) A^
4,.,.
4a.(F
B
ffi
r
or
fis<
er
\ce
/
f
\
\
\
/
y
\
r«
r^i
-s^
f€>r
1
/
^
^e^
i^t3
37 P
37,2**
37 CP
/
/
1
Y
y
/ .
/
^
'"
liTiT:
^^
I'i^
="
=
^
^
=
35 0^
1-- u iih I .iiiL'. >tii
.11 of ni.mt.mnnp tympanl during f<ta«ce of efflorwcvnce.
(•nMi'i.hATiuNs AND SK<^rET..^:.— TlioFt* aix? quite a number of cinniJi-
cations ami sr.,iul:i' \vlii<'li may (Kviir in the eourse of measles. TIk- o-^
roiiiinnn of tin- >vv\nn< mus an' jHTttissLs pneumonia, and tulvrculo^b.
'rii«' lirM-iiarnr.1 .li^rasr s«vnis to have an intimate conneetion withm^a^K
and Its o,viinviHy in tin- course of m<'ashs mulers the prognosis ni.»reffnft
1 hi' hn.ii.-hiti-. whicli is so (•«)inmon an aec»ompaniment of measltsS'iiH-
tiinc^. Mp|M-;n- in m m.Mv scv.-iv form, attarkin^r the smaller bronchi a?ir-£
a> tho<c nf inrJinin >i/.r, and may result in a broncho-pneumonia, whii
is iniicli luuve cvuwuwAx vv- -A v^^\\\\^\\v^\^\v^\\v^i' «vQa&lea than is lobar pneiimoii
THE EXANTHEMATA*
68»
She broncho-pneumooia does not, however, appear to be more severe when
[ arises as a complicatioa of measles than when it occurs separately &om
^t di.sea^. Broncho- pneumonia aa a complication of meaj^les may occur
sry early in the conri^* c^f the disease, even during the stage of inva&ion ;
It it occm*s most commonly towarcLs the end of the second week.
When, therefore, after the efflnrescence has faded and the fever has
fcbsidfd, the teni|>erature again rise8 without evident^e of local irritiitioii in
le throat, ear, or glandii, we should suspect that a broneho-pueunionia 1-4
tveloping.
The additional symptoms of quickened respiration and the movement
; the ala? na^i will render still more probable the supjxjsition that thii^ e«jni-
icatioD is arising, even though nothing abnormal m detected in tlie lung
lelf. Thij* ab^enc^ of abnormal physical signs in the lung in the early
Bge of broucJio-pneumonia Ls r|uite common, and I shall defer a further
tecriptioD of them, as well as of the di^iease iteelf^ until a later letiure
^t^ture XLTX,, page 962). In infanta the temperature of tuljcnindous
ronehti-pueumuuia d(M:'S not seem to ditier very much frtim that of ordinarv
nn- tuberculous broneho-pneumonia.
The congestion of the larger bronchi, which appears to be almi»st a
irt of measles, may become subacute and chronic, instciid of, as in usually
case, passing off soon after the maximum of the tem|^*rature and efflo*
leurisy may oocur 10 tlie course of measles, but is not so common as
ieumi»nia.
Among the rarer cf>mplications of measles are empyema, endocarditis,
[carditis, and raembrtinous laryngitis.
Catarrhal laryngitis and tracheitis are not infrequent aocompaniments
the acute stage of measles. CEdema of the glottis is rare, but has been
Hown to occur.
When an otitis oc(*urs as a wimpliration of measles it is charai'terized by
sympt4inis which I have already described (page 575). In treatuig this
implication the nose and na^o-pharynx should be kept as clear as f¥>ssible.
She ear sliould 1)6% as in the cases which 1 have aln^siflv <h"^rribed in speak-
fcg of the tn'utUH-nt of the c^r in scarlet fever, gi^ntlv mflat^il by meati^ of
Politser bag, and the atrojiine solution (PrescTiption 70, i^age 559), to-
ether with tlry warmth, slmuld Ije used.
A case wliitli nime undtr my observation illustrates so well this aural
^plication occurring in measles that I sliall ref)ort it to you.
A girl (Cose 255), one jrear and Msven montlit old, prQviotisljr well, wa« fttUck^d on
ftreh 0 with conrza, cough, Ijichrvnintlon, n hetj^htcniHl tf>m|>erAture, quickened respinu
pnfr, and a quick puW. An e(l)on'§c*enc(* <>r mt^a^lew iippi*nnyi un the face an Uie fv)U(»wing
Ijp And the child fdt «)ck, ooughpd c«mtinuou»U% tind hud » hoano voioe. The ni9pir»-
\*«n*MJ fnim 86 U* 40, th^ pnU^^ frf»rn 170 U* 180, Th?? 4kiii w»0 hot and dry, and
throat wa« lotnewhat n*tld«*nod. In the afternoon ilip tempemture in the axilla waa
id to have riien %o 40 2** C, (1CH,8<* F). Sh*^ vninii«l and had a conTulaion. Th*
FCMia ijrniptoma paiuod uff in a A«w houiv, ftve p^nvptmlioa followed ^ and the oiMSb^
i;iu-«-ii jHTi'TJiiii'ii *u im* nil-Ill I'luiui i>iiipaiii. ^xn nin^ii ne nifrt* wm.-
IVmiii tlMf.ir iIh* t«iii|>.TJitun' f«'ll t«» 3H.H° C. (101® F.), the rc^^piratioii!;
iioniial. th«- :il:i- iiti.-i (M'ummI ti» IMovl^ iiml the rhild fell into a quiet ^]
il:i\ ihf <tll..n'H-fnfi' wus jirmiouMM'tl all i»viT the l>iKly, face, and oxtn'
linn- \\v im-'i^lff. rsiii it- ii-uiil ouiirr, and wiia followed by desquami
p'l t>\»T\ .
TIh- aiip.il «nniplicuti«»n. linwfvcr, proved to l>c vory intractable, ar
canMullv in-ai-il liv l*n»r«'^>'»r Hlak«'. liistrd fnr many month:*. Tht-
innnl.rana lyiupaiii di*l fmt roinplotfly heal for over a year, but the c
ill rninpN'lr n««»vrry wiib"iil any disturbuiifft of hearing.
In :ul(Iitinii to tl)fM'«)njuiictivitis Avhii'li is a cf>niuion acx
iiir:i-lr^. ami wliirli, as a riil<\ r<Hinir(»s no troatinont lx\v<m(
of iIm' «vr< Iroin li^lit, the iiiHamniatorv pnxx^ss may exten
ti--iH- iA* tilt' oyr and c:!!!?^* other grave k'rfioiis, suoh a
<'oujmHtiviti<, keratitis, and iriti.s. Tlu'st* complications sli
at (»nrr l»y a skilKnl (KMilist.
TnlMit/ has calhil att<'ntion to the (h»Ieterious influene
n'mlrriiiLT murr ai-tivc any snlraente or ehnmic aftectious ol
may have cxi-ittKl previous to the <lis(.»ase.
In a nunilHT of* <*as<'s an a(Mit<^ swelling; of the thyixnd [
|)la<'<' duriii;r the cojirse o I* n leash's. This swelling of tlie thv
even can-*' niarktii <lys|)no»a by pressiirt*, hut it usually disa)]
thn-r day-. In some rast-s, however, a formation of pus h
tnll..\\rd l.y destruction of* a part of the gland. In intractal
kiiiil it iia- iM-rii timnd that the external applieaticMi of iodini
Kiilai'i^ed e<rvi<'al «ilan<ls an* not so c*ommon in measic
tl'V<r. hilt tiirv iriMv n^wnr uut] uuw nvoii i^rr^v#» fi^ni^i^o A«r»>M
THE EXA.NTHEMATA.
587
The most commoD sequela of measles is tuberculosis. This may occur
^ either a** a general miliary tuberculosis or as tuberculous disease of any
Kof the or^iB or the jdints. TulxTeulous diisease ol* the j()iiiti? eeeiiis to
^show a ^4pecial predLiipiKsitioii to follow attacks of measlei^. It is noticeable
that where a patient with a tuberculous joint ha.s an attack of uieask^
rthe prrKjess in the joint is apt to be<x>me temixjrarily more active, and the
fprognt»8i!^ i.s eonse<iuently more g^rave. The oi^n which in mea^k^ is
I mot^ commouly atfec^teJ by tuIxTc^ulot^Ls ib the lung, and the mrjst i^mimon
I form of tuberculosis of the lung is a tubenulous broncho-pneumonia. You
mu8t remember, however, that a tulx^rcoUKsiK of the lung may oilen ix-cur a^
a ftet|uela of measles where puennHmia han not been preeent. In infants the
U<*mi>eratupe of tuberculosis, as has been obser\^ed by Holt, does not seem
to dirter ver\' much from that of an ordinary bi-*ineho-pneumiinia. In
reganl to the relation which exists between meask^?^ and tuberculosis, we
eh(»uld appreciate the danp^r, which seems to be a serious one, that the micro-
orpmisra of measles will render active an old and rpiiescent tuliercnlar
nidus, whether it be in the broucliial or the cervical glands or elsewhere.
I have here a case to show you which represents the infection of a patient
with measles by the Imcillus tuberculosis.
This girl (Ciiee 266), six jvvin old, wm always well until About one year ago, when she
tllJid All tittuek of ixiL'tuiles. Allbuugh there was no acut^^ pulmonjiry affection followlti^ the
' Rttnck of iiir'aKlffi^, fihe heiE^Hri to M utfc'ettHl with sti^ht dy^pncBa and a cxtugh about one
I month nfift the mciisU^M hiid c^nded. Sinco then these symptoms have increased^ and «he
I hiM lutely hud gwelliiiii; ot the feet and hoA compluined of a genexnl malai«e. 8he has
\mi considembly in weight nod streni^th. *-)d physical ezajnioation dulnesa h fnund
[ mi the apiccfl of both lunga, and over the dull areas coanw and flue moij*t rales. Nothing
: abnomiHl is found in connection with the heart or kidneys. The tenipeniture varies fW>m
t7.7* lo JiS.S"* C\ (100° to 102** P.), the respiration* frT>fn 30 to 60, and the pnlse from 120
lo ISO. An examination of the sputun) iihow^ the baeilkift* tubercle to be prej»cnt. This ia
[ evidently a caae of pulmonary tuberculoeia following an attack of measles.
Another seqnfla, though a rare onej is poralysid. C^iaes thus oomplicatiHl
have shown mostly a paraplt'^ia, and, according to Osier, frequently ("an lie
classified as po«8t-fel>rile |>iilyneuritiH, although it is poesihlc that eome of
them may be dne to a mpidly a8<?eading rayelitis.
A very rare scfjuela of meai^le^ ia the di^^eat^ noma (i^ncruni oris). I
have here in one of the isolating nx»ms a case whicli illuiitratcs the secjuence
to measles of broncho-pneumonia and noma.
Thif child, a girl (CaM 267), four yeare old, had a aevure attftdc of whociptn)^-«ough.
^ Wh^n the whooping-eough had laRtPd six wt»^k8, fh« waa attacked with measles. Toward*
thetnd of the swond week uf the tneaak« the child wti altaoked with a l»ninohc»-pneunionia.
[ ThU pneumonia was not of an unusually ficvem ty|ie, but it lasted for five or nx we*'kB und
I left the child in a very weakened and debilitateil condition, iHiring the pneumonia the child
[iraa not well cared for, and thii complication anise, for which she ha« entered the hcj^pitHt
At [ fthflll refer to thi« case later (page 793) i when upeaking of di*ea8€« of tlic mouth,
II ahall »how it to you now merely aa a caa© of noma which I ain having actively treated,
[but in which the pr>t(ftnjfli« is very unfaTorable. When noma ooeura m a i'nniplir«iion f»f
ivlei and pneumonia it b generally fatal.
iiitiin* invt'stiL^itioii, until tlu* sjKX^ial min-o-tu'jLraiiisin \vliu*h
that wliifli |>nMlucrs inrii^h's can ho scpanitfKl l>ac*t<'riol<»«rH*si
rnltv which arises in iliiVci-cntiatintr rulK'Ila fniin the other
chis> i> <'hifHy in tlistinjrnishinj; it ihmi nica»iles. Wo cannot
cal «:i-i(»i* nilM'Ha in sncli a way as to cmiblo lis to dia^nosti
ill :i -pnr.ulir «:is«'. On tlic other hand, this can bo done so i
otlicr «x:mtli<in:ita that \vc c;m at onc<' diajjnosticato a sjK.irai
(lisca.H-. liulKlhi is dcscrilM'tl in nianv ways hv <il>sorvors in
tics, Init i*i n>ually s|M>lxcn of as essentially a highly inflvtio
an incuhati^Mi of two or thi*cc wn'ks. with slight or no j^nxln
a sliL^htly rjii-<<| trnijMTatnrc, acn-omnanicd by mild catarrhal
often l»y son' throat and swcllinj^ of the cer\'uail and |K>st-ai
Tlu' rlUon-^rriKM* is ronunonlv descrilK*d as ])a|>ular or in
ol* liuht izr;idc, ol'tm i-vancsit'nt, and seldom showinj:^ auv
( 'onii)Iir;itinii> or M'(juclaj lollowinj^ ridK-lIa aro said to bo i
you will U'lir in mind what I have told you concerning the ^
o<rnr r«»iiniiniily durinjr cpidi'inics of nndoubtiH.1 moartlos,
oiirr tlini thi^ dr^rri|)ti(Mi of rnU'Ila Ls one which niav be a
mild rM-(> <»t' MK'a.-Irs. As, however, epidemics arise in whi<
tcri-ti«Mlly mild ^ymjitoms occnir in many cases, and as tin
likr <MM'>, it i> j>rol)al)lc that in the fnturc a micro-organisu
niU'lla iiiMv Ih' found.
Iw':iiiii^ th«-i' facts in mind, we can mercdy say, ro^rdii
it-^ iiin-uo-Is r;mn«»t Im* made in a sixn-adic case, that the pn.
and th.Mt th<' trcatmnit is the same iis that of a mild ca.*^ of
It in:i\' Orl'li:Mi<< mI<I \'<iii tii c'lrrv in vmii* niiTi«lLL< *v««-..^>. ^1^^
THE EXA^'THEMATA.
089
statemeQts are merely approxiiiiate, but in thk way the diagiKxsig of
dbe&i§es is much simplitied and their charajt^terl^tioi are made more
ftromioeut.
TABLE 97,
Variola.
Varicella.
Scarlet Fever.
M<wlo>,
Hubelta.
Acubation . ,
12 days.
17 days.
4 days.
10 days.
21 daya.
^rudromata . .
8day»»
A Ibw boun.
2 day*.
8 days.
A few houn.
fflopeftcence .
Macules.
Papules.
Vft&ieles.
Pustules*
VedcloB.
Erytheiim,
Papules.
Papule*.
Nmiuatiiatton .
Small erusti.
Lamellar.
Furftiraceou*.
Implieiiiionit
pfHd BoqUL'lw,
Larynjc.
Lungs.
Kidney.
Ear.
HearL
Bye.
Lung.
Tuberc'Uloftis.
Although what I have sho'WTi you in this table is far from definit<\ and
ight, were ooe of the diseases to be dia^DO'^ticated, be very misleading, yet
hv differential diagnosis between all thes<^ diseai^s I think you will find it
rahiable IxHmiise of it8 Himplieity.
In addition to the leading pointi* which I have indicated in the table,
tie genera! <ymptoni:^ and tfie tem|»eniture of the\se dji?ea^es pnn'ide us with
tcelh*nt material by whieh to diAtirigiiish one fn>m the other.
The sli>w progressive devehjpment of variola is very distinct from the
ite, rapid eour:*e of all the others. Tlie vc^miting and sore thn»at of
rlet fevcT are us^ually quite distinH from the coryza, lai;hrymation, and
DUgh of mwi^le^. In variola the rise* of teni|M»rature dmring the prtnlronial
its d*x*idal les84"ning at tlie time i>f the ap|>earan<-'*j of the etHores-
and itt^ gradual ris** again during the i^tagt* of suppuration, are
rerj' di?*tiiKt frimi the sudden ri-^^ of tempc^niture in scarlet fever during
pnxlnmial st^^e and up to the height of the effloresoenoe. In like
aer the tern |>erat ore in mea**les differs from that of the other diseases
its sudden ri.s? on the first day of the pr<xln>nial stage*, in it>* lessemng
the second day, and in its ri**e on the third day and np to the height
|f the effloi'eseence. The manner of the decline of the temfK-ratiire diflers
variola, in scarlet fever, and in measles. While in variola it is slow
prolonged, in scarlet fever it is rather rapid, although it declines by
lysis, and in measlei* the fall is often by crisis. In contradistinction to
riola, scarlet fever, and measlw, varicella and rubella differ marke<lly
the al)^*cnc^ of a prodromal stage, in their short duration, and in their
ent and moderate tejnprature^
DIVISION XI.
DISEASES OF THE NERVOUS SYSTEM, AND THE
MYOPATHIES.
LECTURE x::x:v^ii.
INTRODUCTION.
To-HA Y, ^ntlcnicn, we sliall begin to study a class of disea^(^ which s
tlu' in(»>t (litlirult to uiKleivtand of any that are met Avith in early life. Tfei
(liHiciiIty exists neeessarily from the complex organism of the part? affecH.
and on acc«nint ol' the im|K)i*tant rdU which the nervous system play* in if.
ilina-cs whieli ocimh' in human beings during the process of their de\V.i^r
iiK'nt. We are inneh moi\; likely to meet with nervous phenomena of tk
innvt diverse varinics in children than in adults. In like manner we m^
with the nm-t widely ditlerin^ elinieal symptoms. If you had stiidirtl ti^
rliiiical >yinptoins of nervous diseases ui the adult only, vou wouM If i-
snnicicntly |)rrpar('<l to diagnosticate proi>erly from similar symptom? in tii
<:m' nl* the chiM. Symptoms which if occurring in adults would be ^'-
niljcant of serious lesions of the nervous systenn may arise in children n»:c
simple rellex conditions which only simulate and do not represent acrai
diMa^*.
( hildi'en are much more ai)t to become imconscioiis, to have convubin
atta<l<>, and to shnw disturbance of the functions of important nervoit
eeiiti-es linni Keilex irritation, than are adults. The whole cerebw-^pin*!
<y>teMi in infanev and (»arly childhood Is so impressionable, so excital«k.
and -n hyjM'rsen-itive to even slight grades of irritation, that diseaa*? of a
nervous type, whether primary or secondary, dominate all others.
We have, then, imt oidy well-reeoguizeil {mthological lesions with tbtir
eharaeteristie symptoms, as in a<lults, but also the same groups of >ynJi'"
toms eau>ed l)y dillerent pathological conditions, and, again, i^ex nervoff
phenomena without organic lesions, (id infinitum,
These reflex |>henumena are so nuich more numerous than thfflevk**'''
arise from or«ranie le>i(.ns, and are so irregular in their manifestations, tiA
from a dia'^!; noetic \>uuvl v\f vu'w, they are most important. They also»^
OF THE IfERVOUS SYSTEM.
591
Bto all dkturlmDoes of the nervous system, whether ftiiictional or organic,
Ho such a degree that what we have learned concern iog ceiH^bral localization
Bl the adult beoimes of mudi less value in the young suhjei't. Attempts
Wf> lociate minutely diseases of the ner\*uus system by means of cc*it'bral
BocaUzation are so indefinite, and in tlie Iiand^ of the general practitioner
w fruitfid of incorrect conclusions^ that I have thought it better to pay
Irery little attention to tliLs branch of ueurolog)^ which tor tJie (U'c^^^nt
Biould be referred to the nervous s|M?cialist*
■ Difficult as the study and clinical recognition of tliese mauiibld oiudi-
Kons arc» far greater bcwmcs oiu' task when we attempt to classify and
■rrauge in simple ibrm for the purpose of temJiing the tM:)mplex nervous
Phenomena which we meet with in our nursery practice. Diseases of the
Bervous system c^tnstitute in thciuBclvcs the study of a lifetime, and we
■rho are busily cnguged in general mKlitHuc cauntit hojxi to obtain the exact
Betailed knowlcdgt* of the nervous s[)ecialist. The nervous specialist, on
Khe 0(jotrar>% wlio has not worked practi<'ally among children, studying
kbem in all their various phases of excitt.'nicnt and rest, dL^-ase jujd health,
■nay fail to grasp tlie sjx»cial jihase of nervous disease by which he is at
tiiues ^.^^nfmntf^L
The various pictui'cs of ncrv«Hi^ dbc^ases which I shall present to you
V those which you will l)C most likely to meet with in pmtlice. As it is
L'rostx)pic rather than micixjscopif* knowkxlgc which is most nec<.l*:tl fur
tinicul ijbst*r\'atii>ns in childhmxl, I shall treat the subjc<:'t broadly, leaving
tie finer tf niches tor your later and more extended study of the works of
dlkd neurologists.
We must adopt s(unc divisir>n fijr tear^hing which by its simplicity will
jd us to ktH.*p in mind the \'tu*ious diseast^ in a connected scTies, As the
grasps more readily symptoms pmduaxl by a distinct pathok^giml
lesion than those where such a k^iim has uot been i>r«^^»v*xl to exist, I shall
l.}>eak first of the (jrincipal organic lesions nf the brain and cunlj i\^serving
!br later lectures what 1 have U> say aUmt the various nervous phenomena
Krhich from our indefinite knowk*dge concerning them we tenn fundkmoL
\ have mloptt^l this division simply for the purjKJsc of cleanie^ in teaching.
It is not that of any es}ic<'ial authority on nervous diseases, but it b what
f have found to satisfy prat*tically the ntx'ds of the many classes of students
irhom I have met from year to yc^ar*
The terms anaemia and hypcra»mia of the vessels of the brain, as desig-
lating distinct discuisf«, have been used frccjuently in oonnectJoD with the
1* '11 of disias**s of the brain and f*«iitl. These terms should In the
h -tate of our knowk^lgc Ix* ristrictiAl to reprsflent symptoms, imd
liot diseases, for in the ftiajorit>* of case^^ they are only symptoms which mre
kjBeondary to some primar)* iHstTisc,
I Ner\^ous diseases can as a whole Ix' divided, as may be seen in this
■kbie (Table 98, page 592), into — 1* Oryankf II. Prammaily Oryanic}
UL Fmidional,
592 PEDIATRICS.
TABLE 98.
I. ()R(iANir Whei« thero u a dUtfnctly definite pathological coLihic.
Examples Mmingitia. Hydroe^halua.
II. PRKM'MAULY ORGANIC . When* there is no definite lesion, eo far at vt a:i
present determine, but where we 8uppi.<e thi:»pc>
lt»gical condition naay in the future be di5«>rr;nd.ia
that the disease may then be relegated to the ^x^
class.
Extutiplfs Chorea. Epilepsy,
III. Fr NATIONAL.
1. Probably Central . Whore apparently the symptoms arise from sdistoHiB
rather than a lesion of the nervous centres.
Erawpfes Hysteria. Temporary aphakia, from fright.
2. Reflex Where the symptoms are caused by periphenl iniMffl
of various parts of the nervous system.
Examples Omrulsions from foreign bodies in the stomaek. J/fiw
dyspeptieum.
UikUt each of tlu»se divisions I have tabulated the various disw!
which Ik'Ioiijj: t4) it, and I shall speak in detail onlv of those wbidiTis
will 1k' likely t4) mot»t with in general practice.
Hy ntorrinjr to this sot^ond table (Table 99) you will see at a gUw
wiiich <lis<'jis(»s I am alxjiit to describe to you, and the order which I ta
<ollow<'<l in ih'scrihiii*]^ them.
1 wniiM alH> call attcMition to the fact that this table is not arrai^'edt
cither a purely patholocrical or a purely symptomartic basis. On the «:»•>
traiy, wherever it seenuHl exi)edient to designate a disease bv thename'ii
its principal symptom 1 have done so, although in most cases I have lec
a path«>lc)«i:i<'al term. The table, then, does not represent a reec^ized sri*
title classification of nervous diseases, but is merely a list of the difirsflt
diseases in the order in which I shall speak of them.
TABLE 99.
Nei-vous Diseases,
T. Onj'nnr. II. Presumably Organic. m. I!Sin<konal.
I
Probably Oentzal. Rrf«x.
N..n-tul».-ivu]Mr hi.mi- (Mmroa. Hysteria. p^yor noctunuB
'"-•''- Kpilrp^y. Hypnotism. (periphenll.
Tuf...nul.ir nwriii.- In.sii.ity. Catalepsy. Dental Peflei.
-'^'^ Simulated diseases. Reflex n\TittsiDas.
Thn.iMl..M. nf tlM' Infiolation. Reflei of «.
^•'•'•"'"■'l ^i"UM,.. Concuaaion. Reflex of Itrm
Hyanu...i,lmlu.. Temporary amnesia. ParoxyBmal ?»*?=?
(Nnl.nil nl.>(v>.. Temporary aphasia. Reflex of liii«.
(%-n-l.ral p:,nily>is. Arrested psychical Reflex cough-
Athi tosi. dav^lo^ment- Reflex of hMit
TABLE 99
. — Continued.
■ M&« ^'
Nervous Diseases.
1
L Organic. II.
1
Presumably Organic
III.
Functional.
1
Probably Central.
Reflex.
itim-cranial tumors.
Retarded speech.
Reflex of stomach,
itnMsrmnial eyphilis.
Headaches.
Reflex of bladder.
Uocy.
Vertigo.
Reflex of vagina.
teor-writing.
Sensitive spine.
Reflex of rectum.
jfXLtiB.
Tetany.
»lioinyeHti8 anterior.
Pavor noctumus
iimlysis fW)m caries
(central).
ci the spine.
ereditary ataxia.
ooomotor ataxia.
fringomyelia.
inltiple cerebro-spi-
nal sclerosis.
Bnbro-spinal menin-
gItSs.
eoritis.
[nltiple neuritis.
umlyils of the new-
emalgia.
693
I must impress upon you the fact that the classification which we may
Bern best to adopt to-day will in all probability in the next five or ten years
Kve to be modified by the further study of nervous pathology. You will
oticBy however, that in my classification I have allowed for this progress in
ledical thought, and that the various diseases which I have tabulated in the
ivisions " Presumably Organic" and " Functional" can be placed in the
lass of '' Organic Diseases" as soon as it has been proved that they belong
lere.
In studying the various diseases of the nervous system which I shall
cplain to you, and the cases which illustrate them, I have received so
inch aid from the special knowledge of these diseases possessed by Dr.
iTilliam N. Bullard that I wish to acknowledge my. indebtedness to him.
88
594
PEDUTBIGS.
LECTURE Xl-XV^III.
I. ORGANIC NERVOUS DISBASBS.
Brain. -Cord. — Brain and Cord. — Pkripheral Nertk.
BRAIN. — I^'fon* s|K»akinji: of the diseases of the brain I should litt
have you rxaniiiic a stvtion of the skull as shown in this diagram (l>iacni
HK It rfpnst'iits the Relations lK»tween the bone, the dura mater, tbt ?t>
(hiral s{>a<'0, th(' arai^hnoiJ, the snlwrachnoid space, the pia mater, and %
l>rain. The cliajrnun is ust^ful for the clinical investigation of imt*
diseases, and will, 1 think, aid you in understanding what I am alx^it
(lt'S<TilK'.
Diagram 8.
" ' Ba
D.M.
Sub, D.il
A. P.iir.^
.J P. ?. orSaVli
^^^-SgHHHjH^^WV^ " ^V. P.orP.X.
St'Ction of Pkull and brain.
l^" Bone.
^*^' Dura mater.
'""' '' ^ Subdural space.
^ ■' "' ^ , Arachno-pla or arachnoid.
I.- r-ii. A ^ Plai space or mibaraohnoWspMt
^ '■ ' ' •' M Visceral pla or pU mater.
'•'" BrUn.
^^ ^' \yyi\te matter.
J' Brain.
'■ ^' Gray matter.
Tlir (liini mater i< closely attached to the skull at all ages but cspftifr
so ill cIlildljrMMl.
The -iihdiind >|>a(v lie- Ix'tween the dura mater and the arachnoid.
The snl)Mra<'linnid space i< erosstxl oy fibres, thus making a conn«ii«
lM'twe<n thr aijuliMoitl ami the pia, which some anatomists are nowincfiw'
U^ s|>eak ol' a< one struct lire.
ORGANIC NERVOUS B18BABBL
595
I Meningitis. — If you will again glance at this table of classificatton
ffaWp 9£*, page 592), and at the anatomical 'diagram (Diagnim 8, pagt^ 594),
foil will 8ee that I should naturally first ^wtxk of dLsea;se3 of the cerebral
Beningef^. Of thes*e diseased ttwmngilh L^ the most eommon. Cerebral
peaiogitis may affect tlie dura maier or the pia mater. In the first caae it
B called pavhifffieninffUiiff and in the second leptonieningitk. The form may
le acute or rhroftic,
Pachymeningitie. — Pachymeningitis is in early life so rare, except
torn certain \i*ca\ tniumatlsms, or as a lesion in some *s|M:i*iH< Ji r ;i,^^i^ such
b syphilis, that we need merely mention it, and ean at uiuc pn^'et'd to
Budy the iuHanirnatory conditions of the pia mater.
i Lreptomemngitis. — Ix'ptomeningitis, on the oontrarj% b very frequent
pi childhmid. It may be dividwl primarily a^ to its localittf into (1) menin-
litis of the CH>nvexitie8j and (2) meningitis of the l>ase ; bb to iti* pathobxftf^
Bto (1) a simple non-tuliereular inflammation of the pia, and (2) a growth
f miliary tuliiemle in the meshes of the pia ]>roduehig inflamnnition.
I Til is is <nily a general division, but it serves to prepan* you for the
|iii©M-hat more minute description whieJi is necessary to make yon under-
land tlie vurit**! elinii'al symptoms which are met with in these diseaaes, as
le lines eanuf^t Ix^ drawn siiar|jly as to loeality, pathology, or symptoms.
(1) NuN-TuBERCirLAR MENINGITIS. — Xoti-tuUTeuIar meningitis ia
Mten c-alkxl purulenl mmtnglth^ hut the latter term iV\v^ not secmi so appli-
ble as the former, l>ecause we also meet with a purulent exudation in ix^rtain
of tulxTeular meuingitls* The pattiohigic^d pnMx^s may, attliough in
general way and to the greatest extent atfeetiug the membranes of the con-
tj', attack the membranes of the ec^ntral and Imsic i-egions of the brain.
V>llowiiig, however, the rule that when^ we aix* making a eliiiieal division
diseases we should emphasisse the salient lesions by which we eau in mo6t
tftses distinguish theni, I shall leave the minute pathology of these diseases
r your moi*e extended pathologiinl studies*
Non*tubercular meningitis in its acute form is a disease which may
k robust as well as debilitated childi*en, and may occur at all ages. It
rare in the first year of lite. It is most common in the middle period of
ildhmxl.
Clinically, we sometimes find the non-ttiben^ular form in infants simu-
ing in its symptoms, on account of tlie hK-ality affecteeJ, the tuliercular
furm of the older child* On tlie other hand, tht? tuliennilar form in infants
si)metimes so acute in its symptoms as to simulate the non-tubercular
of the older child.
me rare canes of non-tubercular meningitis have been reporteil where
diswise was apparf»ntly primary, imd for the present^ therefore, we am
of this class of cases as idiofKithie until further light has liec»n thrown
the subjects I myself have never set»n a ea**!' of non-tulx^rcular
ingitis M hich was undoubtedly idiopathic. The great majority of cases
This tabic (Tahle 100) designates the diiiereiit causes w
rirfi' to iioii-tulKTcular lueiiingitLs.
TABLB 100.
Non-tubereular Meningitis.
Prhiiunj (Miid t«> «;xirit).
SeconeUiry.
Trouiiiutic.
Ear.
Spocific di^
Scarlet fe
MeasleSf
Krysipelii
Pneunion
Typhfiid i
Rbeumati
Syphilid,
Cerebrr>-«
InfiolAtioi
PATiioi/KiY. — Tlio patholog}' of non-tubercular meninc
(•ally, wlicrc infants and young cliildren are oonoemed an
ol' the |>ia rnat<T. This, act'onling to Delafield and Prudden
chronii*, tnU'rcnhir, or syphilitic.
In any cas*' ol' acute meningitis the inflammation is apt to
ward inul to inv(>lvc tiic pia mater of the cord. In youi
es]M'<Mally hnpjwns that the inflammation may involve the epc
vcntrii'lr^ and cause a distention of tlu*se cavities with serum.
In one ilnni ul' aeute ncni-tulxrcular meningitis the pia mi
to DrliifieM and Prudden, from whoso observations I shall i
ORGANIC NBRVOUS DISEJI^EB*
BOT
Hfii^uent occurrence, and is attended with the ordinan' clinical sytnptoins of
^pcute mcningitij^.
^^fe Another form of acute non-tnl>crciilar meuingitis hm heen termed the
^KRtdatict\ because it h characterized by the act^uinulationj chiefly in the
Huei^hc*:^ of the pia mater and along the walls of the fakwd- vessels, of vmnable
B[uaiititie.s of serum, fibrin, and pus. Sometimes one, sometime another, of
^yhese exudations preponderating, giving rise to serous, fibrinous, or punileut
Btbrnis of inflammation. The abst>lute ([uantity <>f the exudation varie8
^kreatly. In some east\s death may be caused with so slight a formation of
Ksndation that to tlie nakitl eye the pia mater may lofik rjuite normal or,
HMrhaps, only moderately hypenemic or tedemat*>U5!i. The micn»soof>e, how-
^■ver, in these cases will reveal pus-oeUs in small numbers, and sometimes
■Mecs of fibrin in the meshes and along the walls of the vessels. In other
^■Bses turbid serum in the mt^hes of the membrane is all that can be seen, and
nfae turbidity is shown to he due to pus-i^lls or to a small amount of fibrin.
■Again, either with or without marked oedema of the pia mater, yelh^wish
BMri}>es are seen along the sides of the veins, sometimes apjiearing like faint
Kfeurbid streaks, and at other timt*s dense, opaque, thick, and wide, so as
^plmost to t^mceal the vessels. These are due to the aetannulation of pus-
HkUb and fibrin in large ([Uantities along the vessels. They can l>e seen best
Hoid are nn*st ubtuidant around the largtT veins which run ahmg over the
Knlci. In still other cases the infiltration with pus and fibrin is so dense
Hand thick and general that the brain-tissne, t!ie convt>lutinus, and most of
Hihe vcj^st'ls of the pia mater are nmceali^l by it* This is usually of a
■preen ish-yel low cc^lor, and Is Sf>metimes so thick as to appear like a cast of
'the brain -surface at the seat of the lesion. Sometimes extravasated red
^blood-cells art' minghd with the other exudations m the result of diapedeais,
Hnicroecopic examination shows numerous white bhwxl-i'ells sticking in the
walls of the veins and capillaries, or the vessels may be bkxjked with them.
It is evident that a large part of the pus-cells accumulates as the result of
emigration. The conntxtive-tissiie cells of the pia mater may be detached
om tlieir plac*es or degenerat*Ml. In some eases there are considerable
cunndations of pus lietween t\w pia mater and the brain-su instance and
Jong the vessels which enter the latter, Mon^ nirrly, pus is found ujkju the
surface of the membrane. The brain-snl)stanoe may be comprtt^ised by
fthe a<'*'iiraulated exurlation so that tlio ennvolutiims are fiattene*!. The cor-
neal piirtion of tlie brain may Im' simply infiltratetl ^vith serum (cedematous),
W it may imdergo degenerative fhaug<'s and may lie the seat of punctate
bemf»rrhages. Not infrcHjUfntly the inflainniatifm extends to the ventricles,
fhich may contain pnrult*nt s(*rum, ami to tlie pia mater of the cord. Thia
.form of infiltration is mf»st fn^picnt on tlie convexity of the brain, but may
B^xtend or even be ci^nfined to the base. It may be h>calized, but it fre*
ffquently extends widely o%er the surfaces of the hemispheres. Bacteria are
otk'n pri*sent in the c^xudation, and I shall explain tlieir relationship ti> the
Uasions when speaking of oerebro-spinal meningitis.
Tlir nini-tulKT(nilar U)rm of mcningitLs may als<.> be ch
niH' th<' j)ia inator at the bitso of the braiu aloue may be h
nuninj^itis), «)r only tlu* pia niator over the convexity, or
inat4T, (H- (iTtain <*iiviinistTilKHl |)atche8 of the membrane. In
pia matrr is thick and i>pa<|ue, and thert* is a formation of
tissins with a prcMluctioii of pus, fihrin, and .serum. The re
oi* tht'sc inlhiinmat4)rv [mKhifts varies in different cases, and
«is<s in linn and at times extensive adhesions between the c
the pia niatcr. Other ix)nditions which represent the resi
inHaininatioM may also Ik* pn»sent, but need hardlv be re:
furthrr tlian to say that the ventriehs of the brain may in th
<Mnitain an inereastnl amount of serum and may be dilated.
also may U' thirkencil and roughemil.
Symptoms. — When* non-tnhcrrHlar inryihif/iti^ is seci>nd
or to otiier <liseas4's, the eharacteristie symptoms may of coi
('at<'<l and even ohsenre<I by symptoms resulting from the e?iM
thr ^uj)pos<'<l prinjary or i<lio|)jithic cases the symptoms, espec
ehiM is ovrr two yeai*s of a^re, an^ rajnd in their developmeu
is sluu-t, from seven to ei<i:ht days, and the disease mav ofi
in fl>rty-eii:ht hours. The dis<'as(*, when affecting the con\
lM'i:ins with iiit^'UH' headache and a high tem|x*rature 40°—
( l(il"_l():/>_l(Mr^ F.). The n^spiratious are rapid, 30-40-50
tiv«ly ?-<'i:ul:ir. The pulse is (piick, 150-160—170, but is i]
\'nriiitinii. photoph(>l)ia, <'ontraet<il pupils, and delirium are
viil-i<»ii- iu'i'iw early. Later we may have blindness and pan
Di \(;n'()<is. — As the iliairnosis of non-tubercular meniui;
ditlen'MtinI one ih)\n tuhereular meningitis, I shall reserve w
OBGANIC NERVOUS DISEASES.
599
activitj' of their growth present opportunities for repair which do uot
in adults. So long as a di^ase of a necessarily fatal character ia
[not present, the possibility of reecjver)' should not be lost sight of* Vio-
lence of the nervoUxS manifestations df>es not by any means always indicate
I a fatal issue.
Treatment. — The treatment of noa-tulxrcular meningitis varies with
[that of the disease or condition to whicli it is sea^udary. The child shuuld
be kept in a cool, dark room and prtitected from noise. In the treatment of
meningitis, whether it Is a symptom or whether it is idtopatbie, the inilicn-
tinus are to reduce the temperature of the btxly and tf» supjx)i"t the general
. strength until the disease luis run its ct)urse. The former is mxy>mplLhed
best by the applieatirm of mustanl derivatives to the lower extremities, by
sponging the entire body every tJiree or ibur hours with water at a tem{>era-
tare of frtmi 15.55°-22.22° d (6O°«70° F.). and by the applitiitbu of cold
[lo the head* The strength should be supixjrted by the admiuistration of
[inllk, and, when necessary, of stimulants.
Cask 258.
Treatmeot of meoiuglUA witki UsiUdr't ooll.
The methml of applying cold to the head by means of Letter's coil is a
valuable one, and I have here in this bed a child (Case 258) with meningitin
whti is ln'iug tn'ate<l in this way,
Tht* apparatus ealk'tl I^eiter's coil is verj' simple^ and consists of a light
[flexible metallic or preferably nibber tubing, which can be bent in any way
[desired and applied to any part of the body or Urn lis aa well as to the heiid.
I)r Kr:i-r r»iMirt> tin* f:i>«' i(';i*«' li-V.i) <.f k muU* infant, fourlo*»n in- Tit
Will .!■ \i i"ji'-l ar.-i jipvii-u-'ly |M'rfi-i*tly wi-ll. It beiran to !»•• irritahl** uii-i
Til-— • >Miijit«iri»-« iM'iilinMi'ii I'lr iilmut a iiKHith. "When it \va> br«>uu:ht
l*riiiMr:itup' ■•!' :i7 4^^ ('. ('.•'.».'»■•* F.), ami it l»ad no otln.T symptoms Ik-vit
«'\|Mrii.| iV.iin ih«- tMiiwiitinii nf tln' ifuiiis., whii'h wore hot iiiul t«*iid«.T. T
r..r.\iil-i II .MiiMTii!. aii-l t\\'» «lay> lattT h«'nu|il('iriu of the loft side. Tl
Mi.;i:i :i:i.l im-'ilar. Tl.- t.-iup-ratun- wa- :W.r»» C. (101.r>o V.). Son^ati.
h-.ih -i.i- '. Ori ilii- t'..HM\vini: iiijxht tin* infant bcpin to have convuMons.
witli irpu'uiar iiiii'r\al- until tli*- n«'Xl nmrnint;. The i*ntin* vohintary
\\:i> tli.ii f.-iii.-l 1-- ]"• in a -tal»«»rt'»nir ^|^a^nl. The h'sxs were ri^id. the li
nil \h'- trtjrik. mimI tlnTf \va- niii.-^lhiilMnM^, This t«»nie spatiin ^vas interrupt
lialt' an li'-ur l.y a «l.»ni<- -••i/un- invnlvin^ <'hirfly the i'Xtr«*initie:*. "Wh
nia!.in-t:t!i.-ii- •••«nlitiu«--l. tin- tliuinlK and tin? tinir<'r*« wen' l>«.'nt into th
f..r-:»ni.- \\>V' tlfV'il siri'i i'\t»nil»-tl uimih tin* anus with »ihort rhythmical n
Til-- itil- ri-tr ••\tniniti»- wi-n- >iinilarly atliM'ti-d, th<iiiL;h ti » a milder d«
rii' :.:- :(':-" ••xitinliil t'» tin- tiu'f, i;i\inLC ^i^f• l«) t'nnt«.»rti«»n.«*. The reftpinili
l.iit i!m :• u:i- n.' livi«lit\ •»!* tin- ^kin. Tin* piil>i' wa.- 14<>. The teinp«?r.i
In-j r Tli!»f ilay- lati-r. tin* pn'vitm!* hyiiiptmnri huvinuj in the ini^ui
ill-:-- U.I- a •liniinuti'Mi in tin* ••••nvul-inns, hut eon.^cious nes.s aIn1o^t ent
ui.-l lli-n- \v:i- an iriipa-ini: t«*n«l«-rn'y Id mnia. The pu]>ils were Oontni«
r:i!i!' i;ia'''ili!\ 1" >\vallt'\v. and thv infant irradiially sunk, dyin^ at 6 P.M
Til'- |i.i-t-ni->rliMii ••\aniinati«'n wa- mtuh' twonty-four hours at\er d»*j
tlif -kuii an*! «|tll' rtinir tin' «lura niat«T tin- (■•mvolution.'s ap|x.'an>d flatten
I... !i -ii. Irl\ •■'-inpii-i-i'il. Tin- vi.Mn«* of tin- eon'bral eort»*x were miicl
■ •i'-!- ^Mii.i :" tin' \ i-ii-ral lay«T nf tin* anirhimiil was snuMitli and drv, li
I "J . ;ti ' ii..lii I. •Iia:in'i«r. -iiuat'-ii alMuit th«* middle of tlie asocndin*; fr
I ii\ ■; I" •■ - ..ftli" ii ft In-rni-plnTi-. tin* pia niat«T was coven*d hv a thin. '
I\'iij'li Duu'iir !li<- n im"\m1 *»i' tin- brain ><'v»'nil <ninoe.s of clear serous l
tl..- l.-.:- r.il \. iitii.l'--. <Mi -'.li'.n i»f tin* ln*inisph«'n*s the c«*ntrnin semi-4>v:
:i! -. u- !!••■: 11 i.i:!iil-»r <'f \;i-iiii;ir puint-* on either »iide, hut tho fiub^tar
-j :.■ :■ -. . ,■.:..!'. ll.al ■•f fli.- 1-f't, wa- v.-ry soft.
'Ill ■}■■;.• ''.Ill iriiM- Mi.'i I' f.tii-nlar niiclf'ii'i nf tho left heniit^phere wpre
OBGAXIC NERVOUS DISEASES.
601
^^f ^ifl ket attack, in all pntbabilitjf was produced by m fall^ in which he atnick the back
EThis hend. No cut or bruUe wa.« dc^teeted. Later, on tho dny of tUia faU| he bt^gart to com-
klaln of ptiio in bid head and to vomit. H«^ was wry f«.nH^n:^h, and Uy ia btnl protcHHtng
^u eyet from the ii^ht, a« there was greftt photopliobin. The l>oweis were regular, and he
Hook small quaniitiea of food. A week later he betriiirie detmoua, aud thin txmdition con-
Knttcd tor two weeks. He was then brought to the Childrun^s Hoepitalf and from time to
bme wa.^ deliriouii during a peTiod of Ave week^. The delirium was sometimes aetivef and
Ki«n it would dii^appeiir and he wi»uld recognize hi« parents. He wai» very eru6s in the In-
pervahi of the dt»lirium, and would roll hL* head from side t? side. Hid appetite wm poor.
Die never had anj^ convulsions or pamlysia. For a time, however, he had incontinence of
■irine.
I Binoe this attack he has been gnuluallv growing better^ and he ia now oompamtivelj
rweUf although hu sometimes complains of slight pttin In his head, at which time the head
bboU hotter than at others. He abo sometimes haa a little photophobia^ and when exposed
lio imusual heat or excitement ia rather restless and fractious. Hia pupils haTe seemed to
ibe eliij^htly dilated, but their reaction ia normal.
I The treatment has been simply to keep him perfectly quiet. His diet has been eare-
ifhlly r**gu1uted, and 0.18 gramme (S grains) of bromide of potash has been administered
heveml tinier during the day. At present his pulae is 98 and rt^gular, Mb temperature is
|06.2<> C. (02.7" FO, And his r^spiraliong 25 and rhythmical.
I The diagnosis Is probably traumatic non-tubercular meningitis.
I The ne3Et case (Case 201), which I have had brought to »how you as possibly one of
Inon-tubercular meningitis, U a child two and one-half years old.
I He was healthy at birth, and remained so until he waa eleven months old, when he had
hn illness lasting for two or three weeks, characterized by high temperature, but no other
Kdeflnite iymptoms beyond apparent irritation connect>:^ with the U^Ah.
I When he was seventeen months old he had a similar attack^ only more seveiv, accom-
■Mnied by delirium, photophobia, high temperature, and, in a few days, paralysis of the
H^gf and left arm, while he could only move the right arm slowly. He had a tendency
flo turn the head to the right, and his head was retracted. The ftiTcal movements and the
■Urine wen* normoJ. He was unconscious for two dav«. An examination showed that there
[was nothing abnormal in the ears, nor was any thing ubnormat found on phyfticiil *.»xamin»-
nioD elsewhere. He cried out m though he had severe pain in his head when the attack
llMgAn. After a few days he l>egiui to improve rapidly, and, although he had never talked
llt^fore, soon began to express bimiself in words.
I During the following year he had Home InmbK* with bis ears, and grew very weak, so
lihat be could not walk. Later he had an attack of croup, accompanied by perforation of
both mf'mbmnaj tympani.
, Tf>-day, a^ you see, he Is oompamtively well.
I In n?ganl to the diagniMiii of thise last two cases, we are only ju^tt6*xl in taylrig Uiat
Iff they continue well, and do not show a return of cerebral symptoms, the most p^d>abte
littplanation of their ci^ndition is a non>tubercular meningitis.
I In this next bed is a little girl (Ca^^ 262), four years old, who fell and struck the back
lof her head. She did not complain of much pain until the next day, when in tbe evening
llier face wui« flushes), i^he vomiteit], wan restlesa, and was constipated. On the next day the
igymptoTOB increased in s(*verity« and two days later she entered the hospital. Her head wai
■TPtmcted, There was an ery the matt lus condition of the skin of the faces, clbow^^ and knees,
I The ptipils were equal and reactini wolj 8he woj^ v«>ry nvitJess, but >*h<»wed no evidence
■of pain. Her pulse was 182, the rMpirations wen* 44, and tho tcmp'mture was 89.1* C.
I^10l2.4^ F.). %She was able to take nourishment and to fi^tain it. She had marked opisthot-
■MlOi. Paring the following night and day fthe moved her hands c«jntinuously, and early
Hfl thn morning vomited. The erythema of the skin gradually faded away. She talked
pncoh*T«'ntly mo*t of the time. Tbe eyes wen^ ttxnd, Tbe fwt and hand* wen* cold.
I Yesterday at timos sh<? fehowpd labored breathing and the pupils were dilatc^d^ The
■tiead wafi not retracted so much, hut the mui^les of the ni'ck wen^ very stiff. Th<* pulse
nraa much more feeble and alower. The abdomen waa retracted, and there were petechia
602 PEniATRIOB.
i>ii tli«- fH(H', ('nMiw>, anil kiic<?s, nioiit iimrkt'd on the right side. Last iiii;l.: >hrv-.----
ri-ll«>- ainl li'T ImMthiiii: was n^uiii laUiriHl.
T«»-<iu\, a-* y«»u mh-, thrn* is oMisul-niblu twitching of her arms and hi:-. Tj-p. i-
rt'lli'\«-i an- alisfiil ; tin* plantar ^•t^^•x^'^ kw diminished. Nuthinij abr.unruii if f .• . :
fxaiiiinatioii of thi- t-ars, thn)at, chest, and Hlniomen, or of th«- urine.
Tlii> «'a.M' i> |)n»l»aMy tme of traumatic non-tubc*rcular men in in ti?'- Tin ^. 7:37'- .-.
rlHon-sivnri' and the jM't»H-hi«' would make nie KUt«]ie<;t that we might |v»wir.!yl«^ ;■: -.
witli a raM- lit' ri'rfl)rti->pinal UK'nin^itU. The symptcunsi, liowev«T, an* n«it !?■--••.
i:m<li- n- I should »'X|»<fl in the latti*r disoiuu*. while the aouf^ onji^i't loll««wirji: :Tti:.3^ .-
iiatunilly p"«iiit t^wanU a simpler inflammation «»f the pin mater. We ca:ii;«.:. h T-r- :
<a-«-. of thi-* kiinl «lftlnit«'ly di't«Tmin»» tht* dia^uusis without an auto^isiy. I*, i- '•..i--.:L.
tli'T»- an- n«» I'thfr ilifi'it^i-s, such as typhoid ffver or pneumonia, devt.-lnpin-.:. ^-.'itbt-jr-
hility I'f it- iM'ini: a lulM-rcuiar m«>nin^itis is exceedingly »nial1, considt-rins; tLs-.jL-t:
|HTi«Mi «if rhiMli'HHi wluMi the typical si^ns of this dis«.fadc are mof>t mark^J. ar.iii-r,:-
<if a "U bat lit"' rharactiT.
(SulixNim-nt hi-tnry.) On ihi* f«>llowinjr day she pank rapidly, and *he di='i. wi;:'
aii\ -]>aMiiiKlii' iiinvniii'nts or <>(.>nvuUi<Mi>, 011 the ei^litli day of thf disca^n.
OEOANIC NERVOUS DISEASES*
603
LECTURE XXIX.
BRAIN.— (Continued.)
TtTBKRCCJLAR MENIKOrTIS.
second form of leptiime^niiigitk whieh I shall descrilx.* to you is
leil tul.>ertjiilar im'timgitis, aod I liappen to have a mimbLT of cliiklren
lustratLDg tkis diseikse in the wards of the Childi-en's Hospital to show you
[>-day.
Tul)ercular ineoingitis is a disease caused by the tuberele-bacillus at-
icking the pia mater ; it occurs most cjoranionly in early life, nins a siib-
cute course, and is invariably fatal. The disease pn^seuts many irregn-
M^ties in its maoifeHtatioiiH^ and its typical Hymptoran vary aL*eording to
He age of the patient* The most ty{)ieal cases of the dit?ease are seen In
liddle ehildhocid. It occurs more commonly l>etwet»n the ages of five and
fven than at any «ither iMTiod of lite. It U nirv in the first year of life,
ipei'ially in the early months ; the numlier of eases increases rapidly in the
econd year and dtx^rea^es as nipidly afler the eighth year. It is comjmra-
ively m rare in adnlt life tliat out of tli*" large numIxT of adnit patients
lat I have met in my s^'rviee at the City IlL>spital only a few en^-eA
tubercnlar meningitis have (snue under my care in the last ten years.
uberenlar meningitis, tlien, can W' considereri to be tsseiitially a disease of
irly life, and to Ik* most a>mmou in the middle iK'ri^xl of childhrHid. In
large numlier of castas there is a tubc*rcular history of one or Ixith parents.
; is hereditar}^ in the senst^ tliat the individual inherits tissnt^s whicli are
lore or less receptive to and which pn»vide a favorable material fur the
evelopment of the Vmeillus of tubercle.
Every child should be pn»te«:lc^ in all possible ways against tul)ercular
iection, whether by its forM] or by human Innings. The tul>ercU^lmcillii8
ppcars at times to attack individuals in cases where the ipiesti(»n of iuheri-
loe can aWjlntely l>e eliminated. We should, therefore, take the gnatest
re that child rf*n shouUl not \w under the care of tnl>ercuIous nurses, as
le nurse is the mcmlx»r of the family wlio comes into the cUjseKt relation
rith the child. As an illustration of the truth of this statement I shall
icntion a ease seen by me in oonsultation with Dr. W, L, Richardson and
)r. H. I*. Jaques,
^A hi^j (CHf^*y 263), flvo yearn old, dW of tubereoJar ncninipti^. The nutopy iIiowinI
ive tubeppular le«inn« of th« mtMiint^c*, with enlugod bronchial lyniph-gUnd)* nnd
»aodul« at the apices ctf hi>th iunnK Tho child up U> the time of th*? atuck had
I been peHbctly well. There wr# no history of tub«?rL'ulcifti« on eitlier the fatbrr'i or
I mothi^r'i fide. There woro tevftraJ other children in the fiimilyf none of whom had «T€r
illioil^ Ill-*l>>l> ll>i:« III \ f'.-'X- V<>IIIIWll\'l& WIWUM bMi/V.-t «^«AAt^tAO 11V41PC UliU UJ
(if til'- lipnu'iiiiil L;lunils tiiid curubrul meningod U at lea.st sigiiitictiTit.
It is not iiniisiial to meet with a tubercular meuingiti
tnlnixMilar «Hs<'as<» of tlio spine. This complication cxvurred
y«ars old wlioiii I siiw in consultation with Dr. Scudder.
TIm' «'liil«l ^('ji-j' li»U) was 1mm njr tn»atod for Pott's disease with latera
^piiif. II«' \v:»> plju'iMl on a fniiiio f«»r five wiH'ks, and tit the <;nd of iha
appi'tit.- :t!i«l wi'iijhi ami Ix'ijun t«» hiivo n coiitch. Xothiiicj especial, how«
tli«' liiiiL'-. Tin* 1m»\vi'1s l)roaiin» <'«)iinti|)ato(i, and he then bejo^aii to have
lurl»aii««' aiitl i.i vninit. A f»'W days later he U'canie unconscious, and o
lii> piipiU w.p- fouini \vid«.'ly (iilatcd, uneven, and not re8p<jndini; to lig]
nin- wa^ usually alnuit :is.Ho (.V (102° F.). The pulse and respiration
«jiii(k»ii -il. ili^ ln-ad wa-f n'tnurtt'd, and on the day of his death he had J
'rul)t,nular nicninji^itis may also ownir in connecrtion with
liip, tlir latter iK'injx much more common than when the spi
I iiavc seen a (iisc <>f tliis kind in consultation with Dr. Bro\"
trat<'«; the ini|M>rtan<i' of n'coj^niziug the occurrence of this co
A (liil.l iCax' L'fl.'i), r..>ir yoars old, was l>C'ing tr«.'ated by an irre^uli
di-.'a-- ..I' th.- |jip-j..irit. Th«' child had bjMMi allowtnl to drag itself iihoi;
iii.;it Ii.i.l I..-.M Willi ilruix-i and not by apparatus. When the child was
lirwii- «:in- li.- had liini taktMi to the country and placed in a house an<
th" liy-j.-ii.i; -iirr..iiii.liM'_c> w»^r.' i^fjod, lie kept the child in bed and tre
ni" tli«- tu.ih.xl Ml' .xt.MiMon usually employed in tliOi%e civses. The child
iiiipp.\.-. I.\it ai'i-r a I'-w wi-.-ks lo.-t in weight and in appetite. Its tempei
l-.-M v:,ni,.._. jV.mm :;7.1!^ t.. :i7.7^ C. (9?»o to 100«> F.), rt»se to from 80.4« t
1"* I*' A I'U flay- later Uk- child became somnolent and had convulsi
\\ h' !i 1 -aw til' ra-e with Dr. lJri»wn it was evidently one of tuben
ORGANIC NERV01T8 DISEASfiB.
60ft
^^Bnary infection by tlie tubertle-ljarilliis of some other portion of the body,
^Kic^ as the bronclual or the mesenteric glands. Tubercular meningitis,
Hlierefore, is merely a }>art of a general tuberculosis* It, however^ in t*arly
^Efe Ls s<^ prominent a part of tuberculosis, bith in ita clinical ^ym|»toms and
^bi its patholi>gical IcBioas, that I have placed it, Ofjt, as is tasual iji adults^
^undcr the heading of a general tuberculosij^, but as a separate disease in my
—division of diseases of the nervoas system.
H Pathology, — Although the nidus of the tubercle-bacillus which pro-
^ duces the pathological lesions of tubercular meDingitls is in some other part
Lof the body, and the lesions of the brain and its meninges are always
ondary, yet, as the clinical charactcristi*^? of the disease are th<jse of a
rimary cerebral nature, I shall destTibe only the morbid lesions which
ir in the brain.
The nmcros(]M}pic jvathologic^l condition which is seen hi the brain as a
Bult of tlie action of tlie tubercle-l>acilhis is a growth of miliary tubercle
"in the meninges and ui the <>erc1>ral substance* This gniwtli is especially
[larked in the meshes of the pia niut<'r along the c<iursc4>f the blo<xl- vessels
It the base of the brain. These small granulations are conspicuously
iumenius in tlic ehor<iid plexus and cans** grt^at irritation in the neiglilxiriug
This irritutiuu is fnllawwl by a transudation of git-jitcr or less extent
ato the ventricles, A'X'onijKinying this transudation is also a fibrino*puru-
it exudation between the pia mater and the cereljral convolutions at the
of the brain, notably in the fissui*es nf Sylvius, Imt at tim(*s covering
[le whole couvexity of the brain. The amount of exudation is not jiiti-
srtionate to the number of tubercle. The ventricles are sometimes so
Ustendc<l as to burst tlie S4^ptunK Pi-essure is thus bnuight ujhui the
BDtral ix»rtions of the bniin, invnlving esixxually the o|)tic tlialamus, the
[>rpiis striatum, and the eorpus eallosum. While, as I have statt^d, the
rmptoms vary in different intlividuals and at difleit^nt agts, the patho-
[igiml h^ions, on the other liaud, with the exception of their location, are
[)mi>arativcly stable. What Is of esf»ecial interest to us clinically, however,
that, although in a typical case of tul)erc»ular meningitis in mifldlc child-
the symptoias, as a mle, cc»rn^[KKjd to the pathologiad lesions, yet
some casf*s we find an t»ntire lack of such symptoms as would natimilly
suit from the wide- spread and pnmiiuent lesions,
Symptumh. — From what I have alrt^ady told you in describing the
rmptoms «if tuU'reular meningitis, we should first consider the course and
lie typical symptoms of the disease as it occurs in the middle period of
^ihildhood, and then st:ite the variations which (Kxnir in infants.
By carefully studying th*- patholi»gy of tubt^rcular meningitis we can
Imost deduce the sequenoe of symptoms which we should expect to meet
rith in the mifldle period of child 1io<k1. In fact, in the great majority of
uses ciccurring lM^twi?eu die agi\s of two and eight years tJiis sequence is very
Iriking. Remendit*r tliat as we are dt^ing with a Rjrmptom of general
uberculosis we should exf»ect to find in the early stages of the disease that
606
PEDIATRICS.
tlir nutrition is atttn'tod, that there an* a lessened appetite, loss inweiglt
an;i*inia, and in fact syniptonLs wlii(*h warn ii8 tliat .somethiug L* aSki
the cliildV ^encnil liealtli. This ix>ndition may last for many wftt j
evtn nmntlis, varying jts to the time wlieu the tubercle-bacillus has left b
oiiirinal nidus and nii^nited to the eerebral meninges. Only after thkb
♦ KfMirnil «lo wr Ik'^ux to gi't symptoms of cerebral irritation. Thf chill
now lMM'ninr<< {Ki'vish and eaprieioiis, and is in some cashes ca^ilv frighteKd.
A> tht' tulK'nular growth inen^ises and causes further oongesitiun of ik
hliMMl-vt^H'ls, the sleep is disturbetl ; the child complains of dizzine^^cc
>liLdit cvani'st-^'nt pains in the lumd ; it staggers slightly in its walk (toii:
ataxia): sonirtinus it <Ties out sharply, esjiecially at night (^hydi^xi-p-iili:
rry). \'t»niitin^ not api>an'ntly eonmn^ted with the fiKxi, and UjoJh
witliout nauM'a, is a coninion symptom. These are symptoms of inia-
tion *}i' the nervous c^'ntn's, and may last for a week or two, aiv»nliii£:
thr drvi'lopnirnt of tlu' patliolo^ieal lesions. The tem|)eraturt' i-? iwalv
ni.Mlcrati'ly raiM^l, a7.2°-.S7.7°-,38.3° C. (99°-100°-101° F.), hutunsa
day- it ri-r-. a dv^^w^* or so higher, and just before death a con^iderii
elevation may iMvur. Tliis chart (Chart 19) shows the tem[¥?ratun: ■ f i
CHART 19.
V
MR i| It' HI '
Ditys of Dincattc
U l/ M K
. 1 9 . W
n
JL3^J
^ 15 , 16
17 U IS
11 ■
.K
il¥.
Mi:\
M¥.
MIC
UR
ME
UK
MEI
HE
HE
\ 1
•
■ ■ 7^
/
\
1
■■l-r-
i ■ '
A
/
,
V
L
/
L^
&'-
^
a/
V
\Z
^
J
F^—
/
U/vv_.
^^
/
— H
/.
— i
A -
-.KM..
J .
3cr
3:r
1
35--
TuUriMiliir iiu'iiincitis. Male, 4 yoan* oUi.
rliild live yr:ns <»ld who lately diiKl in tlie hospital. It represent-^ ven'ire;
wiiiit y«ni will usually lueet with in uncomplicated cases of tubemiit'
nicniiiiiiti^. ()r<'«nirs(' it is iin[H»ssil)le to determine the exact dav of i^f
iM'Liimiin'j; nj' the <li-r;i>(' in >iicli an aiFwtion as tubercular meain^ti:.*'
that the tir-t d:iy inark(<l on the chart is merely approximate and s*ms*
a >t;M'tinii-|H»iiit to ^Imw tlic <'liaracter of the temperature.
'r\\»' \>\\\so u\ V\Y>v \- >vA\\v wAvaV vx^wviWued, but it soon becomes slowertl*
ORGANIC VERVOCrS DIBEASEB.
607
orxnalf and is apt to intermit. The respirations may in the early part of
disease be quickened, and at timess are of a sij^hing character. Obstinate
[instipafion is a common symptom, Ilyiienesthesia of the skin, with occa-
ionai waves of congestion, esjK^oially of the cheeks, is sometimes met ^^^th.
The pain in the head iucfeases, and the child is apt to hold its hand to its
Drowsiness, at first sliglit, smm beoomc'S very marked. The child is
athetic and lies in t)ed, refusing to eat. The nrine is scanty. There is
lotophobia, and the pupils are ctintracttHL Tubercles in the fundus of
lie eye are mrely seen during life. Abdominal jmins are quite frequent,
depression of the alxlomen (boat-shajx-d) is notic^xl in a certain num-
er of cases. Drawing the finger over tlie skin usually pn»ilnces a bright
line, which becomes in a few minutes quite intense, and lasts perhaps ten
tir fifteen minutes, which is much longfT than would be the case in a healthy
child. This phenrunenon is called the taehe ch-ehrak^ and is (piite fre<piently
with in tubercular meningitis, though it may be absent. This sign is,
owever, in ni> sense typical^ and is seen in a number of *»ther diseases,
be child at this stage of the disease is apt to roll its head tm the pillow
Imost <v>ntinuously.
The patli(»logit"al irritation has now gone (»n to exudatioti, and we Ix^gin
get syni[itnms of pressure. If diarrha^ ap[iears, we should 8us{>cct
ibercle of the intestine. Sopc»r now conies on rapidly, and tiie child can
aroused only at times. iStrabi^mus, nysta^mas, and ptosis may ap[»ear.
The pupils an:* dilated and irregular, and their reaction is liist. The Mei-
iuiiiui secTctiun is sometinit^ markwily increased. Convulsions, generally
tial, and of a rather mild type, may apt*ear. At times imralysis of the
or of the arm and leg (hemiplegia), and interference with sight (optic
itis), may occur. In some cases the piilse now becomes markedly slow
ad irregular, 50-60-70, and it ia very common to find an Intermission in the
CHART 20
OieTTifrfltolceB xwplratlon. Tulx: n 'u Ur mrn tngitfa. ChUd, A yean oM .
e, though this must not be considerL*il lus diagnostic of tubert*ular meoin-
"iti^- The respirations may not be perceptibly diminished at tirst, but soon
i?«ime slow, 10 to 15 in a minute. A peculiar form of respiration, called
Jheyne-Stokes, usually occurs at this stage of the disease. ThiB type of
Hpiration is characterized by c**mplete or almoet oi>mplete oessation of the
spiratory movements for a number of seconds. This is followed by a
lint return of the respiratory movements, which gradually increase in
Bpth, rising for five or six inspirations and then fading away again ao aa to
imjK^rceptible. This chart (Chart 20) represent** thia type of respiratiooa
mS PEDIATRICS.
jMMurriii^ in tin* tliinl wwk of the* illiu's.s of a child four years (Jd wLcfc
of tulwriMiIar nimiiijritis.
A liri^litriM-^l t4ni|K'i*atiiro in tuliorcular meningitis iiuliwitt'S a n-.mpl;-.-
tiitii i»t' Hiinc kiti<l, Mirli :u4 pulmoiiarv ttilK^rctiloi^is, pneuiinaiia, i>r tan--
in till' int4stiiir. At tin* rnd of the discu^^e, however, the teuifn raiuiv H-^
nipitlly, a> «lo tlir piilM* and n»spi rat ions. Hearing:, tiLsto, ami .•?uiell7^»'iii.
Ik- nniinpain-*! for xjuie time. The |M)sitioii which children wiili iuli?pT-i'
nuiiiiitritis ot'trii take is ^Mlnle^vhat ehanicteristic. In all forms ol' nirnir^'ira
thtv ail' apt ti» Imrv tlirir heads in the Ix'delotheA. Tlierc is ott«-n siKk-io-'li:
ntrartinn ol* thr hrati, and they are iiielined to lie witli their knt^-f tr.
up. 'Vluiv may U' spiisnKKlie opisthotonos, aij in this ca.se whiili I ?tL
|nr«*intly show yon (Casi* 272, |mi^» G18). The disease variesi! in it-lKsi
luit u>iially la>ts for fn»m thni» to six wet»ks. Death may be prtivdtii i^
^•^•ntinuc*! n>nvid>ions for (HThajw several hours. A striking leature^iJK
not int'ni|nrntly ^MH-ni-s in tin* ("onrs*' of these ^neral synipt^ims L<a{«r3;
ntuni to i-onsriousntss after tlie child liiis lK»en lying in a stU|»or llirs-vrr-
day-. Tliis |»h(innnrnon often indiie*^ the |>arent.s, and sometinie^^^vmij:
phy^irian. to t'litrrtain Ii<»ih»s of impmvement. It is, however, alway-ii:-
sivc. for it has no favorable significance, and Ls SiNUi foUoweil byanj"!?
prnfomid >tat«' of un<i>ns<'ionsness. These symptoms whieli I haw nri-
turned do not, of I -on rse, always ap|M*ar t4>p^»ther, but mav be pit-^iii i^
ditUrcnt ;rn»nps, varying with tlie individual. All the svmptoni* nuy'i.-
apjMar trnijM»rarily. Theiv may Ik? tonic as well as clonic tvmtnR'ti-ib':
thr liml.*^ and riLridity n\' the nin-k.
|)i \(;Nt>-i>. — Thr diairntisis of tidxTeular meningitis in tbt^ l: I.'
pnind nt' rhildhnnil, aiul witli tlie se<iuen<v of symptoms whieh I lum.i^"
riiimirijit4tl, i- in»t ditliridt. l)nt yon will at onc(» jK^rceive that tlieilia;!; •?
in thr rally days or «'vrii in the first week of the <li.setLse must m-'t^^an.'
Ih- vrry ilitTKult. It i- by wat<-hinir the <*oursc» of the syniptoni.s aii<i ti:-'
LiriHr.iJ Lirniipiii;:, rathrr than by the eoiisidcratioii of anv one *vcip:-
<»r rvni niir L:rnii|) oi' syni])to!ns, that we are justifieil in niakinir ji W^"""
di:iL:ii'»-i-. TIh- diaiiiiosis. tiicn, must, a** a rule, lx» hehl in alievan'^ ■'■
m:m\ tlMv-. Krllrx vniiijtinir, with a nunlenite temjx^raturt*, irreciilaritvuv-
int* rmi--i«»ii tA' thr pnUr. apathy, and many other symptoms of niN-M-
ni« iiiu-iti-, I havr ntbn srrn, Inttli al<»ne and in combination, in (usf^-^J^^
th<y rrjHi-rntrd im ri'i'j'bral Irsioii whatever. The active de velopniHjt : *
-rii-iiivr rnii(iitii»n ol' tlir n<'rvons system in ehildh<xxl are so exa^i-nit<'l ■■
rMiiij)arI.-nii with tlio<c oi' adults, that wiiatever disease mav bcnre?*i'*-
lial»lr tn piiMhwr -o protiuuid an imj)ressiou cm the child's nervou? itt—
tint artiial diM-n-r of tlirsc ecntn's is readily simulated. Thus I-.t it.-'
thr-.- a|>parrntly rri*rl»ral >vm|)tonis may mask by their undue promii***
tlir -yinptniii- ol' thr rral di-^caH'.
Illu-ti-ativr ni' this ditliriilty an' cHTtain cases (Cases 466, 467)of pc?>
innhia. whirli 1 >|i:iil d<'<rnbr to you in a later lecture (Lecture XUX-
p;iMr \»s\), '\\\ \v\\\r\\ \\\v' v\\\VW\\ \vdA v?vN\i9staut vomitiug, soon beianies**
OROA^'IC NERVOUS DISEASES.
60S)
^ ihetk, and later were uncjouBcioiis. They mlled their lii*ads, liad a mcHliuin
Ijteniperature and au irregular pulse, and one of them t>bo\ved irregularity of
Ti>^|umtiuiL Tht¥k^ KymptouLs last^il for five or six days, and dlsai>jx»ared
M'ith the development of an ai>ex-pneumonia,
DiFFERENTiAi, DiAGNiJsis. — The differential diagnosis must be made
between meningitis in general and other diseases, anch as (1) dtsea^eH of the
0tom/ich, (2) poliomyeUtis aiUa^wr, (ti) pneumonia, (4) malaria, (5) tiiphoid
Jeter, (6) mphiiis^ (7) rhemnaiimnf (8) mphnVm^ (9) ceirbrospinai nieninfiitiSf
and (10) fion^uberciiiar mcmngitiii,
jU (1) Diseases of the Stomach, — Unless the chdd is very young, acute
Bpastric .symptoms are, as a rule, not diffieult to rceognize after I he first few
Mdays. We may at times, however, be suspieious of cerebral diseaso on
« meetiug in an infant with wutiuual vomiting and au elevated t<:'mi)erature
^here thei*e is no di8<x*verable souret^ of reHex irritation to acx.'ouut for the
Ifiymi)toms. Thi^ Is esjieeially the case if there are some irregularity of
I respiration ami a slow piilsr^. These may Ix* east^ of tubeivular u^enin-
jitifl such as I have deserilieil that disLtise iu the first year of life. Again,
Ibowever, they may be simply cases of reflex vomiting. As illustrative of
[fhis class of reflex gastric dlHturbance I shall cite this ease:
A male infiuit (Cn»(* 26ft), oigrbt months old, wba iiitack<Hi with voniiting whicb X^Uid.
f -witli fihart inU-rv^uk for two days. There werf apatliy and slow, intertnlltcnt pul«e. The
temperature wa* 87. 2** C. (W^ ¥.). Then* were irregular rejipimtion and rapid emaciAtion.
[ThU patient made a perfect recovery in four or five day*, and the ejise wa^ evidently of
p gastric origin. The slow, intermittent pulst^, and the modemte tempemttireT which would
\ have been !*o alamiing in an older ehild, led me in this ca.^, as in others in iho firet year
\t*t life, to eliminate tuliercular roeningitis. In my experience tbi§ inleipretation of «yinp-
I l4ini£ bafl proved to t>e correct.
(2) Poliomyelitis Anterior. — The following eai?e of poliomyelitis an-
terior n>!embled tuliorenlar meniiiptis : it 15, however, the only one whieh
1 have .^een where the rt^semhlamt* of the two disease;? was so striking :
A Hoy (Cum 267) , eighteen montlie old^ showed for over a week symptoma clotely aimu-
Itttin^ thofe of tubercular mentngitia. Obetinate ooneitipfttioD and apathy were pre«ent, fol-
lowed hy unconsciomnefts ; there were alao a marked #a<:A€ e^Mra/*^ distended IbntonoUe,
irr(»)^ulHr pulse, contracted pupil», eyes turned upward, and convuUive attacks. Finally^
]mnilysls of one of the arm^ appeared, the general »ymptoma paaaed off, and the diagnoaift
uf pt»liomyeliti» anterior was easily made*
(3) Pneumonia. ^ — The oases (Cases 466, 467) of pneumooia which I
have referred to warn us tliat we nhould hold our diagnosis in abeyance,
sometimes even for n wt*ek,
(4) Malaria. — Althcmgh wo must admit that malaria closely simulates
almost any disease, it is not usual t^i mistake the malaria of older ehildreu
for tul»enular menm^ki^. In the first two years of life, however, malaria
rinay afieet j*o insidiously tlte j^ueml nutrition Wfore its charaeteristie symp-
[toms appear that some doubt as to tlie difiereutial diagnosis may ariae.
fhe fullowiDg case illustrat6?i this tact :
a9
610 PEDIATRICS.
A iiialr iiilant (Cuso 2ri8), twenty months old, with a history of tul*rctJ'«s ::•
inothtTs )-uh\ Ik'i^uh to show syinpti>ius of anaemia and malnutrition with ijo p>p>7: t
cttus»', t-iuh lie rith»T iiiijirojHT fintd ur l>ad generul hypene, to account for it AAtriT r
tlm-r week-: it had attacks of uno4>nsc'iourtnc:is la^ting for hours; at other tiiut^ drji-ar^
witli irn-cular puUt' and n.'spi rat ions, wh*» present. The temperature was -Ji».5' io4'>C
(10:>"^ t.i 104° K). ThfH' w»'re slight convulsions, and the fontanelleg wern disttn-W i:
lir^t ihrn* was lu* jHTitnlicity (»f the tivnipt^ims, hut a week later the attacks w^rf- ?Tii:--_Li
ni«)n- pri»ii«»uiicc«l rvcry itthcr day, and the infant was hrigrhter on the inter^-fniujcao. 1.
lived in a inahirial district.
On thi' a«lnnnistnition of quinine and on removing the infant to a non-malarx.-^'i
tin'M' syinjitnms cntin'ly disap)X'artil.
Tin- J«'t»'(tii»n of tin- plasniiKliuni would, of course, have determined the diicniiL
this ca-c, l.ut it rould not be obtained.
Another cast', whicli I saw in consultation with Dr. Parker, of Prin«t«.
is also vtTv instructivi' in warning us how careful we should be in makiiiM
(liaj^nosis of tnU'rcular meningitis in cases where there is a por^bilhri
malaria Ixing the (^use of the symptoms.
A niul«' infant (Cast? iJtl'J), fourtwn months old, had always been wi-U until te-"*
ilays pn-vii>ii> to the time when 1 first saw it. It then began to be frc-tful audtokp;
diarrlm'a. Tlii-* c<»n<litii»n continued for about a week , when it fell into a stupir, Icas;
very anjiMiiic. and it wajs necessary to feed it by means of a dropper. At time* it wwlJ :."■
out .-harply. The teinjM'nitun' varii'd from 37.2® tt» 88.7® C. (99® to 102** F.). Thii^-'
ratinn*' wen* ii>-iuilly n-i^ular, but at times were of the Cheyne-Stokes type. Th«paL^*if
ab<iut V20, >n!n»'tinirs n-i^ular, but at times intemiittinj^:. The pupils were eomeriai* - -
tnnttMl. but sh'-wiMl no irn-irularity. No other abnormal conditionii werv ni»ti«d. sii
as panily-is or >yniptonis connected with the lung, ear, heart, or throat, but the &u:£'i
duriiii^' 111.- tw.nty-lour hours pnvious to my examination was bei^inninir to U- dr-finrt-i
Tli«.' fii.-/,,' c' rihrulf wa> vi-ry di>tinct.
On cImm- inquiry I louiui tli:it then" was a slight ixiriodic-ity in the symptom?, rb"T-/:*
a ri-f of t'iri|Hn»tun' on ••ncli aft«Tnoon and followed by the stup«jr bt'Ct«niinj: ^i:J'-*i
I'--. Alilioui:li tlif infant liad been unconscious for a wei*k, and was becoming w^rf J •
taking' !.-.« n-uri-linimt every day, yet, on the suppos^ition that it might jw^ibkl^-
"b-cun- ca f malaria, 1 d«-<'id«-d tbat quinine should bo administered in supiweiiifl^. "-
tin' ri.xt day a -iii^lit iMipri»vriij«'iit was noticed in the infant in the aftemotm. liapp***
J.— «niii:it..<.-, I. Ill it- t'-niiM-nitun* and y\iW remained a.s on the previous dav?, l'-*''-
foll..\viriL^ dav. wliirlj was th«'sec<»nd fnun the time that it had be^^un to receive the <iaJ>-
il raj)idly l"<aMi«' conx-iou- and beixan to drink milk. On the followine davsit wa^ivpn^
to liav had a n m1<->- niirlit and to have had two slight convulsions. Ita tempentuiv i: !"
niMiniii- \sa- :5s.-jM'. (l(Hr:>° K.). and the pulse was 115 and not intermitt<-TJt Oc ">
folL.wiim d:.y ili.-n- wa- niarlv.'d improvement in every way, and this continue-] »i::- -
iMt.rnij.ti..ii for tl..- ri.'\t four days. The infant then c«>ntinued to improve wpi-iT- "l--
t"Mip.ratinv aM«i i)u1m- b.-rcmini,^ normal, and some months later it was rep^rtrd t ■ >■
P"rl«clly \v.-!l.
(5.) Typhoid Fever. — In my exix^rieuoe typhoid fever in vouugolil-
drcn is the disease which, lu-xt t<» non-tulx^rcular meningitLs, \< m(R?tlikl'
to simulnte and iw mistaken for tulxTcular meningitis. We inav ak*:* lia^''
('onsi(leral)lr dilHcnlty in ditfeivntiatincr tubercular mening^itis from the c^*
tnlMTcuIar nieniiioitis wliicli may oceur in the cx)urse of typhoid fever. Tbr
cxtremo <'(Tel>ral <-(>nir('sti<>n which at times arises as a symptom of trpt*^
fi.'VC'i' niuy u\>u wdd Vy^-^Vv v.\\V\wv\llw.^ to the differential diagnosis. T*
ORGANIC NERVOITS DISEASES.
611
PMbive pijiiit, however, between typhoid fever aod meningitis, whether
^ tubercular or non-tubereulart is the absenoe of lencooj-tosis in typhoid
jver and iti4 pre^senec^ in meningitis, provided tliat the latter is to any
ptLTulent-
According to E, S, Wo^kI, in meningitis the chlorides in the urine di-
inish rapidly ; heating the urine precipitates the phosphates readily, and
he amount of iudoxyl Ls inereast*d : the reverse of these reactions occurs in
yphoid lever.
(6.) Syphilis*^ — The histor\^ and general symptonLs of syphilis are to be
ught for wliere a syphilitic meningitis is sus|MM*ted- The tempemture is
»t especially high, antl the symptouLs are seklnni acute. The pathology is
to be usually that of a chronic bai^ic meningitLs.
(7.) Rheumatism. — Klieuniati.sm is naid to (x*cyr m a (*anse of men in-
Itis, but this must l^e rare, and I shall merely mention it, as 1 have never
ict with a case of this kind, A high tenifK^rature and acute symptoms are
id to be the rule in rheumatic meningitis.
(8) Nephritie. — In addition to the other diseases which may simulate
bercular meningitis slu^uld lie mentioned nejjhritk, in which the symj*-
ims of unemia simulate, to a certain extent, those of tubercular men-
ingitis. The urine should always lx» exaniimnl in tloubtful leases of this
kind, as where uneniic symptoms resulting from nephritis are prt*sc^nt the
disease will be shown by such exayii nation, and we shall thus be able to
idifferentiate it from tubercular meningitis.
(9) Oerebro-Spinal Meningitis. — It is otten tjuit^:- difficult to ditU'ivn-
tiate the (?arly stages of tulH?rcular meningitis from those of cerebrO'Sj)inal
meningitis. In typical cases, however, the diagntwls is easily made^ as the
long pn>dromal i>eri(xl of tubercular meningitis, as a rule, does not o<x^ur in
cerebro-spinal meningitis, ami the tem|KTature in the latter disc*ase Is almost
always high, while in the former it is, as I have already told you, raLsc*d to
only a moderate degree. In fact, all the symptoms of cerebrospinal m^*n-
ingitis are markedly acute in comparison with tliose of tubercular menin-
gitis, which is essentially a disease of a subacute character. I sliall prea*
ently show you a ra**e of tiiljercular meningitis (Case 272, page 618) which
t simulated c*erebro-si>inai meoingids very closely.
(10) Non* Tubercular Meningitis. — ^On closely studying what I have
already told you of the symptoms of meningitis in general, you will be
able in the great majority of cases to diiferentiate it frf>ni other dLseases,
provide<I that you do not attempt to make the diagnosis t<x> early. Re-
h member that you are seldom warranted in making an early tliagnosls, in
view of the wide range of possible nervoas symptoms which tun be met
with in young diildren. Having determinefl that the disease* is of cen'bnd
Borigin, we must next differentiate between tlie tubercular and non-tulx»rcu-
Klar forms of meningitis by means of the broad niles of w*hich I have just
H^poken, and which I have condenscHl and simplified by means of this table
■(Table 101, page 612).
(>12 PEI>IATRK«.
TABLE 101.
CeRKURAL MKNINlilTIS.
NiiiituUTCiiliir. TuljerouUr.
r>iially -.ninlarv (po^Mhly primary). Sivoiitlury.
N.'t li.n.iiiary. Urroditary.
A< ui'-. Subacute.
rr-.«lr.-iii!it!i -li<Tt, if any. Pn»droniata lonp, dofidcni.
IIr:Mljuhi' srviTi' ill oiloo, wltli doliriuiii Iloudache li»»s sevopo ut lii>t. I'UT :r*li:i^:.'^-
«*iirly. ami >«»i»ri tnllnwid )»y somnolenci'. creasing ; delirium K'sscomrn 'nminix
lMi.'t«'iili«»l'iji rxtn-iiie. Phutoplii»bia not *o marked.
C.'UvuUioiis vinlt'iit. ConvuUions less vioK»iit-
T»'m|Hratur»' hiu'h. Ti'iiijK'rature moderutf.
I*ul-- and n-pirali'iii rapid. Pulsi- and respiration slow uiid ir-TJ-ir
Duration Awn. Duration long.
Tian>ii(lation into tlio vontricli»s may occur in either form. TheyciOiis?'
tin- infant \\w lumw tin* two forms approach eai^h other in the jimikr7
of their symptoms. Caillr has lately shown the value for diagii».'i ■:
C^iiiiickcV mcthiMl of tapping the spinal canal.
Infantilk TrnKKCTTLAR MEXiNGrris, — Acxx>rdiiip: to some extaW
ohsrrvations made at tlic hospital in St<x*kliolni, infantile tulwreular dk^
^itis is (■hai'a('t*'riz<'<l in tlie first ycjir by an absence «>f prodroma'A a
siicMm «levrloj)mrnt of acute symptoms, a short course, and a fatal irot
The teiniMM-atiuv is hi;rh, :^«.S^'-;^9.4°-40^ C. ( 102°-1 03^-1 04- R). h
re>j)iratinns are quiikeiKtl and e^mijiaratively regular, 30-4<)-oO. h
|Mil>e is liiirh, 1:>()-14()-L")0. Clonic spasms and strabismus ofteD ^^
I*anily-i- i^ (piite fntiuent, ami (liarrh(ea is present rather than omstip:. ■:
r»nli:iiiir of the fontaneHes is usual. Sinkinjr of the alKlomon i= -"*"
N'nmitiiiL'^ may oeeiir, hut is not t^sjK^eially common. Sharp erie^ an: ••*
^iniially met witli. The diHen'ntial diagnosis from non-tnl)oiviilar mil*
^riti- i- <lil!ienlt. S»|>or and coma at the end are frequent in Ixithdina*^
Th" duration is seldom more* than a week. It may lie on Iv two day-. y^
in rare eaM< the infant, like the child, may live for a month.
Pinini:; the second year the symptoms of tubercular meninptis l"*"'^
of rather an irregular tyjKs sometimes assuming the character of :h*^
whi.h aiv seen in the first year, but soon corres|3<->ndin;r iu»^re nearly-'
tho-r wliieh are met with in the middle jK>ri<Kl of childhood.
i*i:<M;N<>sis. — Where wc are smv of our diagnosis, I believe that i- "J
prn'^iiD-i- we >linnld i:ivc no hojx* of n»covery whatever, ex<x^pt tlwtifl^
extrenu'ly rare ea-es which I have just mentioned a ti»miiorar}' remisJ'-
niay lake |>la<e. The reporteil ciises of absolute n»cover\' fnmi tiiberccif
ineniniiili- <annot hut Ik* lookeil ujM)n with scepticism. Indeed, the &*
tul)erculai' lJ»rm> of meniiiiritis simulate the* tubercular so closclv thatwiib"^
jM.-t-niorteni verifi<ation recoveries cjm Ix* sup(x>sed to be possible, bui *
hanlly Im- accc|)te<l as j)rove<l.
Ti:i:ATMi:N'r. — The treatment of tul)ennilar meningitis up tothetiD^
when t\\i» vVwv^LW^A- \s v'>vA>\\A\vA s\\v>\\Vl Ivi purely symptomatic; later**
ORGANIC NERVOUS DISEASES,
613
:)iild jnako the rliild tH>mfbrtable by every meAiis in our power. As nu fi^e
[►f tiiben-ular njeningitis has ever been proved to be eared by itxlide of potas-
sium *>r any uther dnig^ it 18 uselei?^ and unwise i** eneoura^^ ourselves and
iie pan 'litis by false ho[)es of go<.xl resulb^ arisinj^ from the administration of
ly drug whatever. Up to the present time our knowledge of the disease
justifie:^ us only in using drug^ as j>aUiative.s for the chiUrs suffering.
The following case illustrates very well the tul»erridar meningitis f»f
, middle ehildJio«xl :
A boy (Cuse 270), five yeniv old, bud nlwayt been wtOl «nd li^tnm^. On D«?c*^iuber S,
thilo «*ndciivorintf to cHfub intt> !*ed, he* fell liiid struck th«^ hack of h\h hmd, He eri«id
Krwurds^ but th« bluw left no tn»rk, and notlifng wns ibuuj^^ht of it. Tht? following diiVt
whiles pluying, hf fi*ll and *truck the* brick of his hcwd, but ihe blow wa* no more ^oriomi
lian be hikd oftmi bud lH.'f^ln^ On tb«j nvxt t^vwtiing h*^ w»'nt U* ii childnnrK purly, at**
uthtng unuguul, wettt to bt'd early, and ^Irpt all night On the following dny he? wa«
unable to eat uwd was eoinewhat fretful , lH>th of wlkieh fonditton* w»Te uniisunl for him.
On December 29 be had a &lii(ht follicular tonstiUilis. Hi* pul^t? and t**injR'ratur»? wore
Dornial, the checkij were flinhwl, the ey^s dull, and the pupiU normal. Hi* head wn5
lligbtiy hot, and he wsis dull and dh»wsy, Hv did nc)t have any rnoveinenlof the Ikiw**!^ fnr
wo dnys^ but on the thinl day they wen* moved by mean* of mtnlicine. He eontinucd to b«
about the same condition until January 2, when bia tem|>erHture wa* 87,2** C\ (1K»^ F.)i
kftd hi^ puUe (J4, regular and fitrong; bi.4 fiice wai? (luMh»^^ and hh i*ye» were vacant and
anng. He vomited onee on that night, pujiftecl his water involunurily, moved his left leu
kStncKlicallyi and clinched hi* bundii otnaisionally. He wa.' evidently unea.^y» and moaned
i good d**aL
On the following day the pul^ waM occii»ionally intermittent. In the mean time he
une mope and more drowsy, and flnally rt*lapsed into a stjite of unc<Mi^iou«n^aa.
On the 3d of January' the pups Is were normal, but be was* completely unconK'ioua.
he temperature wai 88.1" C. (100.6° F), the pulse 180, and the re^pinitions 80,
I $/(w the child on Janu»ry 4, and on makinjn: a careful physica.) examination found
pothinet abnornuil, except ti ^litfht eont^e.*tion of the ♦*rtr in the nHiji^hWrhood of the miilleu^,
ml in the back over the apex of the lung wa* a slight elevation of pitch on porcui^aion.
ho temjwrature wa« 39J<* C, (101 2* F ), and ihe pulae w»tA 811 and s^tron^. Then* wha
onaiderable twitching: of the arm*^ chiefly on the ritjjht Mde, lafcitinj; from ten it* twenty
alnute«. The pupil** were slit^htly cohtruot«?d, but were alike. Thai ni^ht he divw his
I flight hand aerosi* the face with a quick tremblinfif motion, the ri^ht hx bcinj; drawn up
^aud the whole b<xly trembling; occaj-ionaliy there was moaning and *ighing n'spimtion.
■ Dr. C. J. Blake, who examined the enre, reported that there wan a flight eonge^tioti in
Hihe |>ostenor canal of both ears and aUo in the neijrhborhood of the right malleu*. Both
Banembran;e tympani were clear, normal, tmn^parv-nt, and without injection uf the manubrial
Hfl^lood-vc^^eU. Then* wti«, in fact, no evidence of di^^turbance of the ears* Ort the pi*teric>r
^^Prtll of each exii-rntil auditory canal at the anterior third, more pronounced in the right tlian
in the left ear, wa^ a eircums«crilH*<| patch "if injection nueh a^ t» olMM^rvod in ca^es of inlinm-
inutory proeef^i in the mastoid antrum, and occasionally uncomplicated congestion of the
ddle erir. Dr. Blake thought that the eioigcstion wa^ merely a eympioro of the muninge«l
ingestion and wui not the cnu»(e of the dif^ea^.
During the next few days the boy*« C4)ndition varied hut little. The cycfi, uaually
bloted^ wriuld at times open completely, when the eyebnlls could l»e a**en to move fhmi side
} tide. The re«piratit>n was sighing, interruptetl, occasionally almoU inaudible, and then
>a time noisy, At time« the breHthini^ wai* HUspend*i<l for J»evenil minuter, when bright
1 tpot^ would ap|)eiir on the cheek*^ ; th«*He would disappear when the re*»piration wa* h*-
nfd, The yiatient moaned occaaionally, and theni was .^iroe twitching and moving of the
^xlii*mitie«» but no convulMons. The pulse wa» fair in strength, but at times Intertnitt^^nu
i KunpcfBture varied, bat was nnjdenite in degrw.
jin—ililf. ami iMtirinittiMil. The left urin was ocoa.aionall y niiseti to il
s))u>iiiiKli<' ii)i»ti<>ii, tht' child inoaninir us if dJptreiwcHl. Later the ev
impiU (lilatrd, tl)«' iii»tri]> fxpandiMl, and a bluish color itppeartKl an.iuiid
Tli»" Ln-Mtliiiii^ iMvaiiu* v»Ty difficult. Durini; an attack of this kind 1
ari tf iM-ititr in.trihuiid, and each attack was thought to \\e his last.
Tin* »']i:mir«' tVnin day tn day in tht' child's general condition was a
Ih- wa-, h<»\vrvfr, ^nidually IrtHiiniin^ emaciated.
(.)n Jjuiuary lli lli«- pupiN of ]>oth eyes were much dilated ; the r
nititi..nl«'H.,. with j»tn>is ,.f the rii;ht lid, while the left eye moved occa
sid«' ill a einli'. Tin* face was liviil, and the hands were mottled wi
Latir. tlic li-fi cyr h.H-amc quiet and had a slightly contracted pupil.
On tlic foijuwirii^ day, January 13, the movemcntfi of the left ey
riirht pupil hciuir dilatttl, while the left one was contracted. Durii
erninata wen* n'taiiictl, the howds ini>ved rejjularly, and the urine \i
Tin- pul>c wa- s«» weak that at times it c(.»uld not be found at all a
hrcathiiiL^ wa-i at times iiiauilihle and almost imperceptible.
On January 17 then,' was ^lii^ht discharge of pua fn>ni the mouth, <
eye. Durini; the next tlay his bn.>athini; grew more and more ditBc
tlMtuirli In.' «()uld not jx)s>il)ly live nuich longer. In the evening, hoi?
w:i- much ea>ier and his whole a]))H^arance was greatly improved.
nft(ii>ive. and then- wa^ a loud huhhling sound in the throat.
<>ri .lanuary P.» the rii^ht nostril was nmch more dilated during inst
Tin* l*..rilie:id was -hiny and slightly anlematous, and the veins were ]
<).-.';»H.'iially he moved his right hip-joint and shoulder, which had beer
Tli'i-e \VM- anotlier >lii;ht discharge of jms from the mouth, and when h
^. "III. d ni.ire si'ii-itive t«» touch than before. During the night his h
W'T n-taiitly moved, and he moaniHl as though he were still in pair
>lil] n-d.-mutoU^.
Ouriui: the II. xt day he was in a state of deep coma for four hou:
(le.'p *i-h and >eeme<l -i»mewhat conscious. The pulse was soft, into:
atiiiLT.
On J:inuary "JO lie partly opened and shut his right eye, which ^
li^'lit. Th- l)r.Miliini: wa< didicult and noisy. The face was covered wi
in I'M. th.' viLrhinix respiration began again, and at 10.15 ho died oniptl
ORGANIC KEKVOUS DISEASES.
615
l«t»o on the undor surface of the frotiUl and temponl lobet, aI&o oq the pout Atid inner
I burdor? of the occipital lobes, were to be teen v«ry Dum«9routi graj, trandluoent nitduldt
About 2 mtn. {^j inch) in diameter. The lateral ventricles each contained altout 50 c.c.
(1| ounce*) of a slightly opa<:iue fluid. Th« ependyrnii was thick, gmjifih, and opai^ue.
I The ehoPfnd plexuses and velum interpositum were markedly injected. In the latter were
I |y be veen Beveral sniall nodules similar lo thote described in connection with the pia of the
LlHue.
I A section of the hemispheres uhowed nothing remarkable, the puncta cruenta being of
r about the tisual fiize and number.
I The basal gangliai ponH, roedullai and cerebellum aUo showed no nppeiiniQce^ worthjr
\ of ipetial note,
Tlie heart waa normal,
I The pteuml suHkow on both sides were f^ from adheaiona ; the pleural cavitiea i!on-
tuined no fiuid.
I Both luugs retracted readily, and were crepitant everywhere except at the apicea, where
I small nodulefi could be felt within the tissue.
r On »eclioD an opaque, grayi*h*yellow, cheesy nodule, 6 mm. (^ inch) in diameter,
iurrounded b}- a narrow itoider of gray and translucent tissue, was found at the top of the
left lung. At the top (jf the ri^ht lung were feveral closely aggregated n<^>dulei9 of a similar
i mppearanoe, forming top;ether a rnuii about 2.6 cm. (1 inch) in diameter. The other por-
I |i<>na of the lungs were nonnnl-
I The bronchial lymph-gland* were enlarged to 1,2 cm» () inch), ihnwing on section a
I jellow, opaque, crumbling material.
Tlie apleen was of the u<«ual eise, cf>lor, and density. On aeotlon the folliclee and
trabeculje were found to be fairly dii^tinct ; the pulp wa« firm and of a pale red color Two
or litree gray, translucent, sharply defined, ?iUt;jhtly projecting nodules, 1 mm. (^ inch) in
diamett^r, were to be seen. The kidneys wore nonnaU In the lower third of the ileum a
I(vi« of substance of the mucous membrane was found in several places. The edgoB of these
legions were elevAted and thr-tr ba^ea granular. The liver was found to be normal.
The pathologioal diairnoais was —
I Tubercular meningitis,
I Acute hydrocephalus,
I E^wndymitist
I Tuberculosis of the velum interpositum,
I Tubercular nt^dules in the lungs,
I TuberculogJA of the bronchial lymph-glands,
L TulM'nulosis of the spleen,
^k Tubercular ulcerations of the intestines.
I have here in Bed 3 an ioteref^tiag case of tubercular meningitis to
show you.
This boy (Case 271) is three yean old. There is no history of tuWrcular or syphilitic
disease in the parents.
Three weeks before entering the hmpilal, the child, who had prp%'iomly been healthy,
began t<» complain of f»aio in the JilMitnnen, and t" hare anorexia and a feeling of general
Lgwlaiie. Somewhat later it was notio(*d that the eyes would at tim«!S turn inwards and thai
I tlie head would be drawn back. He was in thi4 condition for two weeks before entering the
hospitaL
On March IS he wa« brought to tlie hospital, and was found to have a temperature of
88.40 Q (toi,2* F.), a ptilw^ of 120 and not intermitUnKj the respirations wer»' 40. He
was in an uncomciou-s and drowsy condition. His head was drawn back, and he did not
wish to He on hh back. The tongue was not coated. An examination of tho heart, lungs,
*nd urine showed nothing abnormal. An examination of the eyes, made by Profese^jr O,
l F. Wadftworth, showed the pupils to be dilated, but equal in sixe and reacting to light.
k Tbete was internal strabismtis of both eyes. There was optic neuritis and the beginning of
Tritjercijlnr mt'iiliiff^ltlA \fiile, A yen
On the 1 6th the head was much lets retmoted. He IimI ▼oinited €
ftnd oJicc in the morning.
On the 21$t h& had » conruUion, which was the first that had
course of the illneBi^. He wus aUo found to have imrital opi^thotono
partidp»te In the euntraotion, but the head was dmwri back alrnt^t (
was found tu have Cheyne-8tokea re«pinition, During thii? dav he
vulBive attacks, and remained in a cimtlition of opi^thotono* in the
attacks. The^e convulsive attacks lasted abxit half h minute emch i
tween them were about four minutes. There was incutitineDce of uiii
pube waa rapid and irregular^ and the extremities were cold. Thi
obtained on this day, and lasted for twelve iriinules, 0*12 ^mmme (2 i
2 grammes (* drachm) of bmndy were given Mjbcutan^HJUnlj, Th
opisthotnnrrg disappeared in twenty minutes, and the child i^mainc*! n
On the 2fUh the record waa that for two days the child had been
retraction and strabismus were 1efte« the nvataemuA had diaannAftMiil m
ORGANIC XERVOCS DI8KA8ES,
617
■N^difn^i. You see that he has the charucterifilic Hs|»ect i>f a typical ca*e of luben^alur
Ff 't<. The eyes are of)*?n and staring, the bond Is dniwn back, the abdomen if
tr 1, and Oil drawing the tinger over the thigh you ae«? the tache ciribtsiU U very
kiarked. The re^rpinitions ar© of the Chey?iC-}5toki« typi% ibc puUe is intennittent. The
■Mnpemture htis varied from 87-2® to 38.8° C. (90* to 102* F.), but ha* ri^en within the la«t
Hwelve houw Uj 40* C. (104* F.), which indicatea that thc^ fatal i*au© of the ca*© is v^^rjr
■ (Subsequent history of the case.) On the following day there were a numli^r of con*
Prubfon? ♦jccurrina: in rapid ^uocesaioni eapecbilly involving th*^ left side. Th<* child groanod
bind Aj^hed a nunilM r of limes ; hU axtDi and legs wore rigid^ hi.* eye.«» were rolitd upwunls.
Kj^t two o*chxjk in the morning ho took «oine milk, but afl*^r tbut refui*ed it, and from thai
Blme until hi* dt'ath, at 7.25 a.m., he wa* In a condition of continuixl convulsion;*.
■ I ftliall uow ask you to c-ume to the* autopsy -riMim, in onJer tlmt you may
ne the rcj^ultn of the ]K)st-mortem cxaminatioii.s of '^mn' eliilth^'U who have
Hied of tul)ercular uit'iVinj^itls. Dn (lannett lia.s eome f?[xH.'imeu8 here to
■how you of a ea^^* whitjh luis jiLst ilknl iti tlie hospital Wht'U the jxatieiit
wa8 alive tlie uise .siruulattHl cerfbn)-Hpiiial nieuinghis very eloiJi'ly^ and you
Bave aln-acly j^ec^n it m the wards. It w a ver>' iustmetive co^, m it Ls an
Rinusual one, and illnstratos an im[K*>rtant fa<*t in connection witli tuWrenlar
ineningitis, — namely, tliat tlie patk^nt may recover teni|MirariIy from an
pttack of the dij^ea.^:^ and finally die of a rt?eurreiit attaek. ThL^ Ls, how*
pver, a very rare occurrence,
I You may remember that when this infant (Ca*e 272) wa« alive I explained to you th*-
Dtfllcuhii>4 which may an^e in making a delinite diagno8ia in ea^es where ci^rebral sytnptoni^
Are present
■ It was twenty-one months old when it entered the ho«pital. The history obtained
notn the mother was that she had always been healthy^ hut that the father wa« supposed
ltd have had the primarj^ lesion of syphilis three yeara previously, although no »ecc»ndary
|«iianife»tations had appeared. The infant was bom alter an unuBuatly long labor with a
|pn.»lonii«'d fiirceps delivery.
i It wtijf ntutod to have lieen healthy until it waa nine months old. At that time it had
k convulsion, which first afleeted the right and then the left side. It was uncon^ciout} for
Ben dayst and was somnolent for four weeks. Two or three w»_**^ks later It^ general couditiou
■mppoved. During Ihij* time the infant did not u»e the muaclea of tta left side or limb*,
Imd it could laugh only with the right side of ita face, Im body was turned continuously
110 ibc left; senaation was not interfered with. It gained slowly in strength, and tlie aymp-
rt lually disappeared, until it wjw thirteen months old, when it seemed to Ix* crmi-
I I well, all motor difturbances hnving certi?ed. In the following months It had
111 ik\Mk' flight attacks of the same nature* The final attack from which it died occumHi
Krbcn it wa» twenty months old, and bt^gan with a convuUion on the right «ide with
kwitching of the muscles on the left side and fk>thing at the mouth. There was %\9*i
kto»i« 4>f the left eye. It did not crv' out when going into the convuhioni, but had marked
bpUtbotonoi^ which lasted, Uy a greater or It^a extent, for five weeks. Ihiring the>M flv<«
Biriieks it wa^ uncon»ctous, and there were several slighter attacks.
V On entering the hospital physical examination f^howed that the infant waA of m^--
Blum 8i7.e, pale, poorly developed and nouri?h<'d, and unable to standi the left l**g being
■ireaker than tlie right. Ni>thiiig abunrtonl wfis found in iH»nn4*i'tion with the heart or
■utigc. She could u*e her extn'mitie^ piirtiiilly, but Ihert? waiJ an evident niot4jrdifturlmnr«»
■if lh» whole of the left iiide, and i^he t*^>k hold of objecti with her right hand only. The
■ndex and little linger of the left bund were fnHjuentJy found lobe ext*«nded, the «e<:iinfl nmt
■kifd flngcn being flexe<| partially. There was abo slight drooping of the left eyelid ^ and
■lli Uoea of the left side of the face were obl1terat««d. There was a very •light drrjopfng of
r.lS I'KDIATIllCS.
!!.•• '.• !! r..ri:»r -•! llj«- iii«»uih. ThtT*' \va> i»lii;hl >tni1»isTiiu> of lh»- lot't •■;.••. :i: : . j
, I. Iv .!" |».'\vr ..f llif I'll f\t«T!i:iI DM'tu-; iiiu^d**. Tin* pat»'lUir n-tl».it- •.«..r ..„
.• Ml.- !« :i -i*l«* K\:iiiiiii8Hii»ri nf tin- unklcM-lnnu?: was m'^rJitivi/. T::*' i jii.i.-
u-i-!. w.j. -..iii.'.\li:ii iiilart:«Hl. Tlu' i'hiM muKl not ^p»'tik, and a:i| •.l^.'.l.;.
«:• 1. :-?:i:i.l r- :i«lil>. N" t\ i'lt-iu-*- «•!* u hi-^tory c»r cvrfbnil iiijiir>* couM 1- "k*.
. •!. »i".r. r. "I..- «t' il»«' •li'-t \\M* 1 riii. (i iiu'ln lariT'T than that <»t* tlif* livai. T.
I- J... :i..- \\a- -• ..l-.up- that at tlu> |HTi«»il th»' <liairni»>i-' ^-muM ii'»t )•' 'l-ni i: !•• :
• :i j'-.i!i-:. I" iiiu that tli«- •liihl wu- ^uli^Tinl!: tnnii tht» r«'sultii "fan atta- k f . :•'•
•..' •ill.-.' t>. -T |w— .iM\ tV.'iu t»rtiarv .'•yj»hili>. ••r that u <*i»n*bnil heniorrhaj- Lil:;i
\M:i. a !.-n':ir - -pa-ti«" paralx^i-.
\Vi.i;«- 1. !li.> lii.-|.ital til'- ( hil<l pn^-ontiMl a nuinlMT »»f dilVm-iit r.i-rv.'ii ; '
At tin." - -Im- w.iuM a|»|»«ar t«» 1»«' l*"r day> >«'iui-<MHiiat«»^«* and would iii»l Tak : i!.-.
Tl.ir.' :il. lit ]i«r: iIh.ms r«»ll««l uj> ami .-hi' w»uild havo. slit;ht twitthiiiu' i -Ij
:i:.- .\.i» n.-t |.-:ili/..-.l. ami linn- \v«'n' n«» convulsions. At anoth*-r lii::--, ?■'• ■
• ,..':• i!\ tliirni- ilir uit;hi, -ln' \\a- luuiid tu !»»• uiicoiisriou^ in tht^- nn'rr.iiii:. uu'i'
■ i«i IiL-IiJix 'Ira\Mi l'a«-k ami luT ryt's tunu'd up. * Nyp'tait^nius wa* prt-^i.t. h !*
v.:. .|il:it.Ml ar.d 'liil i.i«l ri-a«t t<» lii^lit. l»ut wrn* <Hpnil in sizf. Cl«»iii«- I'-si* l-
n- :.! !'.' -t ami tin- iiin'*!*'.- ••!* tin* riijlit >idt', Hi'xion of the fini;:erj? of tin- ri::';: -
Cask 272.
Ii«'i irniif tuUTfular meniuKitirt. Feimile, 21 tnonths oM.
• :• ••...;•.'•. a;. 'I twiiiliimr nf tin* nm-rlrs nf tlio wrist sun)otini<*> oocurr-d. T>^
" ■ : '• .' 'I" ill'- li''?' - '-f tin- »-t«Tii«»-ma*ti»id iiuisfle on th<» ritrht Mdt*. Tl!»r. ••••
: •• '• • ••• •"•"• -lulit -i'l'- ••:' tli«' fact-. Tht'n^ was no .^pasm on thi» loft ^:*i.. . •X'-.rt '
• ' ■■'■'= -':. 1 J'll. I'lit tri'ff wa- a iiy.-iagiaus of tlio I«*ft evo. Thesf. (■.•".i'.' r- •
•••• !:• •'.•t.i- .«i .,i..i ■■..urr.-.l Iso linn'.-* a minute. Tho pulse wa- IT'J. .if.'', ^a-
!•.. !•• -|. :.ri I - w:-. so. rapid and mtllinir : the lenipvrature \va- :j'.*.4= C. i-C
1 : :i. L' \.M. Hi t.l ;. A.M. (».:i»; irraniinf (•; irmins) of t-hlonil was jriv.i, hy.: ■:-
" ■• '■« •'•• :•• '..••■■•"'> ■ -t" l-r-'iiiul** «if p.«ta»ium wu?. .t^ivoii overy thn^i.'Mjiiriri-^ • t •'
• ••. • -1 ■ •.•ii. :..!. :i at:.!- w.ili tin- clilund. Tlio .spasms hecauiM K..k> n.ark.d :i:'-' -
'' ' •■' •' '■-•i'i'.ir uptM II A.M. Durini; the n-mainder of tlvia;. :.
. •'!! ■ :•. '"-r »i «■: I.-- r..nvul^i..n^. It wa-* aid.* to swall<»w hnindy arul ::*.i.i: -
•" ■' '•> '-'^ :ii-'Utli ill .-mall i|uantitic« at diflert.»nt intervaN.
• ' •'•"■ '1 'V r..::..ui. ... ;1,.. MttaoU ih.- ivpnrt was that tho child had .''loi.l v.e:: •.:
' -^ '• *' !■• ":■ '■ "i|'''". ••Ill tlitTf had Im-oii no eonvnlsion*i.
•►•• t'.. :•.-.! v. ii.^' .i-.v {I- ,-..!..liti..n ifniained about the same, hut on tb' i!-x- •'.
•!!••.:•• •■• V I. .1.1 ..".I. ..- ..f p:!-.... wli.-n >ho wnuld stniiirhten herself out. tlir-w = •: •
•■.:•.. :i: .1 ,:•, :.iit
'*•' -•■" '■ ■■"•''■ :- ■::•'.. Jil. .lit 11 .V.M., shr boi^an to have the same twitrnin-^:- -
•••: •• • I-:- v.. .1-1'. •.v.-uv....v.vl. Tlv.v w,r.' of the .same character, except that tlr -v
ORGANIC NEfiVOCS DISEASflB.
6UP
Imuf^les of the left ftiot coQtnicted feebly. The coovtikions ceased at about 2 P. if., and
I the vhild romainf'd in a etup<>r
I Oii the following day it wae reported that she had bad no convubions, but apparent
lattaekf of jiain, when she would cry out and thpt»w her head back^ and that she had had
I an attack of opisthotouofl, ia which coudUion you will remember you once taw her. Thi*
|45onditioii of opisthotonos at liraes would he much more marked than when you saw her,
Itu that Ihe heeU would almost touch the back of her bead. The next symptom which
liippeared wa« stupor. The temperature at this time was cuniiiderahly elevated.
I Un the ftillowing day there were no convuUiuni$T aud her condition w*»b about the iunii*
|4ii» *m the prt'viouij day^ but the head wa& drawn back and was rigid, and the legs were drawn
I up and were held rigidly. She lay in this condition, moRt nf the time in a 6tup>rt crying
l«>ut t»cca^ionally, and moving her left hand and ami more than ?he did the right. At timen
■ •he would ap{:>ear to be^leepinc: natundly and the rigidity would pfk»» away.
I The opiiithotonot; gradually became more marked and more frequent in its occurrencei
Imnd, although the bowelt were moved regularly every day, she took les^ nouri-^bmentf and
I the temperature continued to rtJ*e, and varied from ST.?** U^ 40° C. (100*' to 104*' F.).
I The time when you *uw her in the condition of opisthotonos was the &iith week flt>m
I the time of this last attack. During the last week of her life the opisthotonos became le«»
f marked, and at timeii passed away entirely. She opened her eye«^ but the puplte reacted
I wery slightly. The lM\ pupil became Bomewhat larger than the right and reacted slightly «
I while the right pupil did nt>t (eact at all. The «pH»tie condition of the right wrist and left
[ knee pers^isted^ the patellar rcflexea were equal and normal, and the child lay in a semi-
Lstupor, with a temperature varying from 88.8* to 39.4° C, (101*> to 108° F.). 8he took loss
I And lew noumhment, and had a flight cough. She gradually lo«t in weight and became
f weaker, and on the day before nhe died her rejipi rations for a time were very rapid, running
* up to 100 a minute. Death took pluee appiin^ntly frtjm exhaustion.
The long duration of thi* last attack, enibriR'iDg a period of eight or nine week*, made
I the diagnmi^ very difficult, and prevented m from mnking the clinical diagnt^^is of tubercu-
I lar meningitis, which theae flp^cimena just found at the autopsy prove to be the diaeaae by
I which the child was affected from the beginning.
This chart (Chart 21, page 62C») represent* the temperature, pulfte, and respiration* of
tbi£ ca»e during the last twenty-one daja of its life.
On examining the brain you lee that the dura mater if normal, the pia mater of th«
' cf»Tivexities i;* pale, and the cerebral convolutions are somewhat flattened. The pia mater
at the luu<(^ of the brain bhow!$ cou^iderubte inl^ltration with fibrin^ which U quite flmii but
I there is little or no injection of the blood-vesieU. In many places in the portions of the pta
I mater at the base of the brain where the meahee of the pia are not infiltrated with fibrin^
gniy nodules ut^ large m a pin-head are to be ieeti. The lateral ventricle* are at least aix
times the u^ual !^i2L% the layer of brain-Hub^tanoe between the cavity and the convexity being
<!!onHidenib|y thickened. The ependyma of the lateral and fourth ventricles h thickened
L mnd granular. On section the brain-^ub^taace h found to be pale, and the puncta cruentA
[«matL Sections of the batal ganglia, ptms, medulla, and cerebellum ahow that the brain-
[■uhatAnce ii normal. The spinal cord fhow* in grow nothing unnaturaL The heart it
I normal. Beneath the pleura of both lung? numerous gmy nodulei the liae of pln-heada ara
I to be Keen. At the apex of the left lung ie a clieesy nodule 0 6 cm (} Inch) in diameter,
I Both hings are extensively studded with gray miliary tubercleta. The spleen and kidnejt
lahow similar appearances, and the bnmchial and lymph glanda are very much enlarged and
I ahow throughout their sulwtance rheesiy degeneration.
The pathological diaernosis in this caae la—
L Subacute tubercular meningitis »
I Chronic granular ependymiti*,
I Chronic hydrocephalus,
I Atrophy of the bniin*fubfftaneef
I Miliaiy tubt^rculoeis of the lungs, spleeu, and Iddneja^
I Chronic tuberculotb of the lung.
f At Xh* Gannett has explained to yoU| loma of the tubercular ledons are of raceni
620
PEDIATRICS,
prowth, whilo othors aro ovidontly old ones and representative of a former sTirl: T
pfM'. ihtn't'.irt', that tho prfsmivof oldor tubtTcular l«?sic»n8 in the meningf-:. i- t-: •■
CHART 21.
iJii^d
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Di^mt in Ltist A^ttack
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K.riiri.rit luUTCiiljir ineniriis'llls. Iju«t 21 davM of life.
111....- whirl, ppMl,,.,-,! th.' .-.yrnpfMins in the last attack fi\>iii which the infant died. }«:■-■
t-^ u> tliMt th.' cii^.' !■« ..M»' of rcnirn-rit tubonriilar m(Miinpjitis.
TIhsc cmm's ni' nviinviit tiilKTciilar meningitis are ratlier rare, ami tir
discu-t' \- >M \\\\\\\>Y\\\\y \\\\a\ \\\ \\w ^\^v •dXXaiiV. \^^a^l. X. ahall recall tovi«r
UHGAXIC: NERVOUS DISEASEK.
621
linds the case whieli was under Dr. Towiiseiid*s care at the Good Samaritan
Ho^pitaL
A litilo girl (Cuse 278), fiv« yetui old, rniered the Good SmmimtAn Hospital witb bip-
liseA^ on the left nidr iind doi^iil Pott's disease. 8h»? wa« treiit«<l ia bt'd fur ibesij db6as««,
iml did vrry wt'll IW u tim*^, but on May 7, after h week in which *hc* i^howi'd unorexbi
ind lois of weighty ^he begun to vomits and on the following day she (^rirnplHmed of head^
|li»h*' nnd |vhotophobiii, Sbt? rolled her head from side to side. Her bowch were con«tt^
iLti^f und could not he moved by enematHf and her alidomen wiis muob retracted. This
»i>ntinued for four days, with mi times delirium, aceompauiod by marked droweine&g^ Tht'ns
^%«re also pto^iti of the left eyelid, flight convulsive movemente of the limbu, and frequent
atting of her hand^ to her head, a** though she were in pain.
<*n Muy 12 she had recovered wi much thut the played with the other children and
ftmlled for hoT b(»ok§ and toy*. The left pupil, however, remained a little tmaller than the
•ight.
On the 15lb of May, and again on the 20tb, 2Ut, 25th, and 27th, the patient became
•dritwsy, and ctiru plained of beaduehe. In the intervals between ihejse attaclu eho seemed
bright and well. During the drowsy period* her abdomen wa» retmcted and her boweU
p coni^ti^vated.
Vfyitn the 27th of May until the 20th of July she appeared aa well a» uiual. On tha
niter diit*? her temperature? suddenly ro#e to 40.1** C. (104.2*" F.). She had pain in Lho
■head and pliotopbobia, and the right pupil wai* larger than the b?ft. Thi* lasted only two
ttyp«, 8he then became bright and well again, and continued so for over ten weeks.
On Octi:tber 2, having been perfectly well on the previous day^ she began to vomit and
I complain of headache. Two days later she fell into a stupor and became completely
iimatose.
On October 6 the left pupil wa* widely dilated »nd the right one wm contrK!ted to the
W/,0 of 2 mm. i^^ inch) ; ibere were convulsive movement-^, and later in the day she died.
The po6t-mortem examination (showed a recent tubercular meningitis. In iiddition to
hefte l€4ions there were Anind Home older large tubercles of the brain and the remains of the
Iprevioud attacks of tubercular meningitiii,
Kothing el&e of importance was detected iu the other organs.
I will now ask you t*> return to tlie wards, to gee a oa^e of tulierciilar
meningitis in a ehild, two and a half years oId> who entered the hospital at
, what wa8 snpjwj^ed to be alxiut the tenth day of the disea^.
The hiJ'torv* of the cast* (Case 274) i^ that the fnth^-r's mother and the mother'! mother
land brother died of c^onsumption. When this child waa one year old he had measles, other-
inrise he had always been well. About two or three weeks ago it was noticed that the child
ilrpt more than usuaL At that time he appeared to be feverish and his tongue wa* noticed
► ha coated, but there whs no nuu!«ea nor vomiting, A few dayii later he vomited onc« or
» during the day. The bowels were constipated. Eight days before entering the hfi*-
|>ital he had a sHght convuli^ion, and three day« later he cned a great deal, as if be were
In pain, Two dHya before entering the hospital he had a number of oonvuUions during
the night, eiieh la-iting about ten niinuteR> On the following day the convulsions occurn^
ain. On the day he entered the hospital he be^n to have convulsions at three o'clock,
vhich bi.^ied iibout two and a half hours. He was al»o noticed to have marked internal
||inibi9muj> of the left eye and laliefht 8tnibi«mus of the right eye. The muscles of the neck
' ?w»mewhat fHmtract*»d, Then* was no pnralyAtg r»f the extremities.
Hie pupils were equal, they rcuet*^! to light, and were somewhat dilated. The con-
JnactiTfe were injected, the left one es^)eoially »><». SenMition was not impaired. The knee*
Jerks and anklisclonut were absent. Therr was a marked tache efrihralf. The r*^jMtationi
irere irregiilar and sometime* of the Cheyncs^tokes type. Tlie child was unconicious and
ra* very pale. The heart was found Uj he beating v**ry rapidly, s<jtu<iUvu*;tk *a V\^ %A^£Ki
622
PEDIATRICS.
lH*ut!» in a iniimtp. No B/mtflfs were detected. The tempermture was S8.8* C (li'l- :
During thi> next dHV thu child luy in a ^tatc of 8tu))or. He continuallv mured t:^ .-:
f.tn-finijrr and thumb, k«*pl drawing the head to the left, and was very rwtlt*. HrT*
n'lxtrtcd ti> huvr cried all ni^ht and tu have put hU hand to his left ear. H-kTi-a
his i'ves widi* n|N'n. tiKik nourishment well, and had lesH «trabisniU6 th&u when b ct*^**-:
tlu* hi>'>|)itiil. On th(> tullowing day (about the thirteenth day of the diaearej bt nr^r.
rr>th'ss. hiul H»nh»."» nn the t<fth, and his tongue was very dry. Examination »f tims
f^hnwi-d nnthiii^ al>nfirnml. The abdomen was somewhat retracted. He wa* i':s< i^-.^
anii ^^']lt a p»4k1 deal. The iMiwels were moved regularly, and the movemeDts uppnuvivk
well dii^e-'tfd. lie to«»k alniut 90 o.c. (3 ounces) of milk every two hour». Ur. it*f!.«-
in^ day there whs n(» es]NH'ial change, except that the uiUM:lea of the neck v^ 1'=!*
c«»ritrmt«'d and th«' tnrhe ririhraU came out more slowly than on the prvviuu? -iiT i
A\ii\\\ panily»i> <•!* the left side of the face appeared on this day. The left evelidn-i
nit her slowly, and the left i*orner of the mouth seemed to drop a little. The pu>Di
irn-^ular. « if fair strenirth, and intermittent. Ho did not take his nouri-thm^Lt >'«'.l
Ye.st«'nlay th«* <'hild wjis in about the same condition.
T«>-ilay yr»u wh' that ho is lying in a comatose condition, with his eye* h»lfrt>*i
The pupiU are rather irn'ijular, dilated, and do not respond to light. The face is a^.^ti
(•yaijntir, e.-jni-ially ulmut the nose and the eyes. The respiration is decidtdlj of 3j
ChryrM'-Sti-kes tyjM*. The pul^e is irregular and intermittent. On drawing ny i^r
ovt-r hi" thi;;h y«>u s«*e that the iache cirehraU is well marked and that it lasie khxi'^r.
or tift«*eri minuteu. The head is somewhat drawn back. What I wi*h especiillv v x
y«.ur alt«'nti<»n to is the tenijK?rature chart (Chart 22). You will notice that the'.nf*
CHART 22.
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TuUniilur meningitis. Mule. 2V^ years old.
tun- }.:..l riHil y.-i-nluy fr-.m ;i7.:>° C. (99.5° F.) to SO.o® C. (108 2** F.), and that i: i-- "••
rai-iilly Hhul: until it Iim> r.-aelird 41.1° C (10)° F.).
Tlii- ri>i- Mt" t'lMiMnitun- i- very ^ilX^ifioant, and denotes that the child willditTrrr-.''-
(Sul..^. .ju.iit liiM..ry. ) The child died quietly on the evening of what was *\y^^^
In- tlj.- M'V<'iit»M'Titli day nf tli«' <li<«'5l>e.
Tin- :uit..p.y \v:i> in:i.l«- ]>y Dr. Mallr>ry. Ripor mortis was present; the left puf^l *^
dilai" .1 ; til. IV \sa- iu<.denil" lividity «»f the dependent portions of the bodv.
Heart— Thf li-^hi veiitrit le wu^ dilated and ci>ntained dark dotted Uood. TtteTiw
ORCANIC NERVOUS DISEASES.
623
LunfiTS' — A number of finmll* flatieoedf gray msMes were found in the pleiim ; on
Uii'v wen^ found to be miliary tubercles. The right Itiug was adherent to the
I plouni by strung fibrinous adhesions, beneath which were niilmry tubercle^) espt.'cially
i the areiis covering the ribs, the diaphmgin, and tbt; upper third of the sternum. A small
umber were also found in the subatance of the liiHg. The braDchial gland« were enlarged,
; of them being L2 cm. (J inch) in diameter. Thi* gland on section wa» yellow itnd Aiime-
l broken down.
ploen. — The spleen was of about normal size and showed many flattened miliary
cltf , Beneath the capsule, on section, there were found numerous tuberclea of varying
: the larger on*:* were yellv>w and the smaller f»nes gray.
Peritoneum, — There were fuund Rcattered all through the omentum, on the surface
the root of the mt^i*entery, over the bladder, and particularly on the under surface of tht»
ght tide of the diaphragm, numcroui* miliary tuberclta. The lymph-glands of the mesen-
' were considerably enlarged, particularly beneath the stomach. On section they showed
cleSf most of which were quit«i large and hiid yellow, cheeay centret.
Intestine. — In the intestine about the ileo-ctecal valv^e there were several small utcer>
itions upparently in the process of repjiir. In the caK-um then^ were two narrow uloeni
out 1.5 era. (I inch) long. The bfl»es were injected. The walb were not broken down.
Liver. — Many rather targe tubercles were found beneath the capsule of the liver.
' They were flat^ but not cheesy.
Brain. — The ctmvolulions of the bnun were flattened. There was marked fibriuo-
I exudation at the ba«e of the brain^ covering the optic commissures and the adjoining
The third nen*e was chiefly injected. Many small tubercles were present in the ti*-
► of Sylvius und over the convexities of the brain. In the right half of the cerebellum,
t beneath the piti, about the centre of the base, was a yellow nodule about 6 mm. (J inch)
I diameter. In the left lateral ventricle anterior to the velum interpt^»situm waa a siuiilar
iule about 8 mm. ({ inch) in diameter projecting into the ventricles. Both ventricles
moderately dilated by the senfU^ fluid. The ependyma was everywhere granular:
bii condition was due to small, gray, transparent tubercles. No tubeitdes were found in the
liird or fourth ventricles.
Kidneys.— The kidneys contained a few rather large grayish areas with her© and there
^ yellowish sj>eck.
The patholoirioal diagnOBis of the case was —
Old tubercular ulcere of the intestine,
Chronic tuberculosis uf ttiL- mt^enteric and bronchial lymph-glands,
Solitary tubercle of the brain,
Miliary tuberculot^iA of the pia, lateral ventricles, pleura, lung, spleen, kidney,
peritoneum^ and liver.
In connection with tlie other cases of tubercular meningitij^ which I
Bpokeo ofj I shall now mention some cases which represeut the earlier
h of life, when, ai? I have told yoiij we are led ti> expect a variation in
lie eymptoniK and a a)nso<|yeot difBcolty in the diagnosis. The first two
represent tubercular mcniogitis as it st:» often appears wdicn occurring
infants under one year.
The tir^t case was seen by me in consul tation with Dr. Kinibal^ of
male infant (Case 275), ten months old, had always be^n well and stnmg. For a
1J8 before I saw him he had been rather dull and feverish, but had shown no other
I symptoms. lie wafl evidently cutting &onie te«Hh at that titne. On the day that
f him, except that he was somewhat fretful and that he put hi» hand^ to his moulb li
i his gums were disturbing him, he seemed v^ry well, and carefhl physical examlna-
I revealed nothing abnormal in the ear, throat, chest, or abdomen.
(i24
PEDIATRICS.
<)m th«' djiy iMllowini; my vUil th*» ^ligllt *ymptoiiM of indi"«po?iti««n vhiokh't:;
)trivi<iu<'lY *'hnwii di>u|)|N'un*d, und he piay«!d with a toy whistle, blowing ii Lix!rj.i%:
-t^iiiiiii; ti» 1m- viTy wrll. This coiiditiou lasted f«ir two or three day*, when b? i-ft:^
!>iu}tid and iiru<iii^ci«>u«, und ul>out the U'lith day fniin the time that I s&w hixiKini:.
*'.'nvul»i"ii?'.
Tlii- CUM- >.hMuld iiiipri'Ks u|x>n ytm the difficulty of making a diagn<>i9 b ib:^*
pr-riod «>f it tulHTi'iilar iiii'iiin^itis, and how guarded we should he in giving cipr^sc:
y.'Uiii: infunt-, ♦viii whrn* tin* cha rafter of the di^turhancc Is ver>' slight.
Tin- iH-\t CUM' (C'usc *J7()) wu^ the infant, eleven months old, whom I exumiLei bifz
yt»ii nrj thr l:Jlh «»f Mureh.
CUAKT 28.
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TwUTrnlur in(Miiiip:itis. Male. 11 months old.
Til.- lii-i'Tv :it thai tiin*' was that h«^ had always* been well and 5tn>ng, vn'^p:*-'*"'""
l;:i'l li;i.l hr-'iuliiti- ill I ^c.riilHT aiid that the cough had returned at interrals. H^ia^^"
Miai tiiiM- ~ix t.-tli. Tlji-n- was a tuhm-ular history on the mother's side of ihe f;: .•
M.- li;i.l r.n::iiii.-.l wll an«l tliriviiii; until you saw him here, when he seemed fHTer/ii'-
inih.-r ilnll ; tli'-:*- w«n- aii-Ti-xia and insmnniu, and he wa« said to have become iLini *'
Th.' t.-MijHTMtmv \iui\ 1 II ralh-r liiirh, .S'J.4o to40°C. (lOS® to 104o F.), the pukc-iui"-"**-""
T'LTular. and iln- n-|)iraii.>ii- rapid but rf'ijrular. Nothincr abnormal was found "i: jij''*-
<'\an\\uivU'>\i, u\u\, w- \.\\»' 'J:.\\\\\'^^^'v'\v' >^v^\\v*\\«kvAVtf\\.^\v.vi diai^noftia was eiven andaic*'*
URQANIC NERVOUS DISEASE8.
625
li^nofiis. Ho remuiiu^d in thb conditUm tiiuil Murch 17, when I outieed un sippiiretiL
bpruacli t*t Chejy iiB-»Su>ke» t^pirutiMn und a littlM rvtnwjtiuii ttf the bf»d. Ther« w&« no
^ottiphubitt, And llii* pupiU were i^quiil uiid reacted well. There weiv no vomiting liiid
taeke ceritriile. The liowcU were regulnr; the tendon retlexe« were exaggerated, but
bing ehv abuormuJ was found in th«' ItingK, hi-^tirtf or ubdomc*n. On the following day
WM found t*j have pUjith of the Jeft eyeiid. The funlanelle was depressed ; the abdo-
en was dktended. He gnidually grew worse, and died on March 22^ about ten days alter
enounced Bvmptoms of any disease had 1>egun.
Here is the chart (Chart 23, page 024) of hi? temperature and pulse. The respirations
Bring the whole course of the ditjetue vnried fnim SO to lOO.
Thii? next cise^ whicli I saAv io con.stiltiitiou witli Dr. Broderiek, of
^uth BuaUjo, reprt'seuts tulxTt-ular meuiogltls a-^ it apt>ears iu the 8€e<3nd
of life. You will notice how at this period it is rapidly appix)aehiug
de characteristic symptoms of the disease whie^h are met witli from the
nird to the seveDth or eighth yeai", ai»d even later.
A boy (Case 277 )| fifteen raonths old, had always been healthy. His mother wa«
Jlhr, but hi* fiither had died of tuberculoftie. He bad twelve teeth, and wa^i cutting one
' hb canine teeth, the gum over which was swollen and tender. He had always had a
dency to constipation. He was (>erfect1y well until he wii> fourteen and a half monthi
i, when he did not have a movement of the boweU for a week. He became fretful, and
awards the end of the week hia redpinition was noticed to be of the Cheyn6-Stoke« type.
lb pul&e varied from 80 to loO and was rpguhir. The temperature in hia aiilla varied
JK>m 87.4'' to 88.P C. (99.G"* ttj 100.6** FX At time* there wa* rigidity of the handj?, but
were no regular oonvulaions. He vomited at the beginning of the attack, but not
erwaids.
When I Miw him, in the second week of the disease, his eyas were rolling fh)m side to
! and there was much Meib^jmian secretion. He was unconsciou'^t but he was said in the
gbt to have put his hand to hh head and to have cried out as though be were in pain,
bere was Wime ^tifthe^ of the neck and back. There wjus a rather marked fnrhr eer€brnie,
dd there was decided depression of thie abd<Mnen. The pupiU were equjiUy dilated and
•prjnded to lii^ht. There was considerable emaciation.
During the following week at one time for a few seconds be bad decided opistbotonot.
la gradually sank and died. The duration of the diaeasQ was four weeks.
40
WX^ *■■ ■ »V^K^.fcK^ VXA
the ttT«'l)ral sinuses is a very unoommon condition. The
t'nNiuciit ill iiii'anoy and early cliikllKxxl than in adult lite,
the formation of an anto-niortein clot in one of the siini:
As a primary eoiulition it is exceedingly rare. It is iisiu
xiinr eonditit)n whi<'li has produced a deep impression i
vitality, such as profound anaemia, exhausting diarrhcea, o
]Mis in any part of the IxkIv, hut esjxH'ially about the scalp,
A |)urulent «»torrh<ea Ls |)erhai)s the most c*onimon etiologi
not ntM'cssarv liert* to do more than refer to the traumatic cast
such :ls involvt* the ear and the sc*alp, as in fracture, or wh
caused l)y compression, as fn)in a cerebral tumor. Tlie ]
se(M)n(lary eiLses inehuhs the Unions of the different prfx>
caused the thromhosis. That of the idiopathic or undet<
well represented in these* 8i)ecimens which I am about to
-7!»). The thrombosis may take place in any of the cerebra
times may oc<ur in the course of a meningitis. When
formcil, the venous branches behind the obstruction beeom
chanically, and thus give rise to capillary hemorrhage a
the flnor of the ventrichs. When the thrombosis has tali
nciirhborhood of some inflammatory focus, such as a puru]
|)y:eniia nuiy result.
S> lew cases have Ix'cn n^[K)rted where the diagnosis has
by a po-t-ninrtcm examinatitm, that the clinical descriptio
inii-t iKcc-sarily 1h» very limited. The symptoms which
whn-c till- cniiditiou has lK*<'n found on post-mortem exan
>\u'\i i\< to sullice fl)r making a differential diagnosis duri
this and other intra-cranial conditions, such as occur in ur
ORGANIC NERVOUS BISEABBS.
627
' a boy (Case 278) ten years old who had chronic otorrhoea, followed by
ite symptoms of fever aud aural tt^udenic^is. FoUowing thesse symptoms,
week Iat<?r, lie had a rigor, and rjptic ociiriti^ wa^* developed on the right
Kxpl^jratiuu uf the lateral siniis dibelosed a elt»t, which was i"emoved,
[id the boy recovered,
I \vill now show you the resnltj* of a jKiat-mortem exanii nation which
been made by Dr, Whitney on an infant nine week^ oUL
This infttiit (Ctt^e 279) was seen by you with me in the wardj af the Infants* Hospita)
Iwo weekji ago, and at thtit time it wat» apparently well and strong. Yuu isiiw it two days
I uncon^Muus and having an irregular type of cimvulf^ions.
When tirg^t fteen by tnCj January 16, it was, »o far aa I could ]udg«^ strong and health j,
Iwcigbinjjj 4805 gmmraes (about lOJ pounds), which at aii wetks is decidedly a greater
|wdgbt than the average. The average weight of the male infant at birth, m I thvn told
II, is about 3250 grammes (about 7 pounds 2f otinoea.) Allowing for a daily gain of aO
omes (1 ounce), the weight of an infant bix weeks old should be 4&10 grain tiie^ (about
l9 fxmnda 14 ounces), »o that this infant weighed 296 grammes (about 9| ounces) more than
Jthii average infant of the earae age.
On eiiterintj; the hospital it took ita food well, had two or tbrei^ apparently well-dige«ted
iejectionw daily, slept well, and aeemcd to thrive for the following week. No one would
iJiavo known from iti outward appearance that anything was the matter with it if it had not
en carefully weighed, when It wa^ found that it was loeing. Th<? following in the record
' ito wt*ight from January 16 until it^ deaths January 30 (Table 102) :
TABLE 102.
Date. Wtjllfht Gain or Lno.
GvBLmm&a, Graminee.
Janimrj^ Ifl , 48t)5
January' 18 . . , , . . . , 4*\rtr> L^ie*, 160
January 20 4G.^0 LoBa, 26
January 21 459.5 Lo«a, S&
January 22 . . . . . , ........... 4010 Gain, 1&
January 23 4orH) LofA, 20
January 24 ..*,... 4425 Lcias, 66
January 25 4420 Lo«i, 6
January 26 4420 Lo«fi, 0
January 27, B.30 A.M. . 4110 Loas^ 810
January 27, 0 P.M , SU1*5 Losa, 115
January 27, 7 F.M ..... 3026 Los*, 70
January 28 3945 Gain, 20
January 29 .... . .... 3l>r,5 Gain, 20
January SO ... 3T36 Lo», 280
On January 23 the low of weight wa* very evident, «Tid vnriou^ changes were made in
b» infant's fo<:>d} but with no good result, as he vomited and had ihin watery di4»cbarge«
f^fVom the bowels.
On January 28 be seemed weak and did not look well. A wet-nurB4> wa» procured for
im, but her milk did not agree with him, and in fact he liecame miich exliausted when
ing to nupse.
At 7 P.M. be was examined by Dr. Haven and myself, with the following renult. Hia
npeniture was 88** C. (100.4'* P.). His respiration* were 86, and weit? natuntl. Tlio
iipiU were normal and reacted to light The fontanelle wai very »lightlf deprea^ed. The
iiild did not seem to be in pain. Nothing abnormal was deteetud In the thorax, abdomen,
' throat.
On January 28 he vomited considerably during the day, and had a natural yellow
•tniiL'lit >iiiu« :iii<l in tii'- ]i>>rti«>i) nt* tiio iiii]M'ri(>r loiiL^itudiiml .xiiiU'^ iiu
ilii- i- a f.TMi'il rM «-l..t, *lii;htly iliftNilnrizi-*! in part*, lnu t-a.-ily n-iiitiv
uiid •viilnitly :tnt*'-iii<»rt«'iii. The* other ^illU''i•H eniit:iiii a littli' liMi^i-ly-
>inr:ii*«' 111' tin* I'niiii i- iii«»i*t. and the spiuM-s l)otwe«*n th»» eoiiv«>luti<»ri>
all"! rl'-inly tV'Mii thi' pn-ofmH- uf a mti>us fluid. Tho hlcHKi-vcj^jiC-U n
inji'rt.'.l. ['\}*>i\ .•j»'iiiii«: th"' latrnil veiitrieh'* and tiirninic back ih*- f"
viritritli- i- ^i'mj t«i In* cnven-d with !Uiiin*n>us thr<.»ml><>st's of the \*\\**y*
t';ir.' !<• I..- uiiivrr^ally n-dih-iwl. The ♦•jM-ndyina is routxhMn:»d ami iiiti
a l"l ly «i'P>u- Jlni.l in tin* cavity nf the ventricles. The vc'in«» of tli»
lill.il with dark rl«>it'd hl«HK.l which i?* din*etly oontiniious with that f
^illll-. Tin- -ul'-taiH t* th<' l»rain i^i ni<»ist. The spinal coTil pn-T-i'iitr
t't" ilji* v»>-fl> of !h«' )iia niatcr. U(»th ^id«s of the heart contain dark
li'-art ii-t If i. normal. Thf hnii;s un- »*li«:htly (iHlcniatous. The o
ii-'tliitii; .-il.i.orrual.
A- a •iimmarN nf the vn^o wr liave an infant nine wfH'kj* old. ap
U' II 11 1 . t» .la Hilary I'i. wh«'n it hci^an ti> li»!*e in weiirht. By Januarv
•Jno L:i:iiiim.-- if.-: iMinn-) with. ait >h«»winir any other symptom <»f di
L*7 ii li:jil l<»-t ■l*^') LrniMiiiH'^^lti MinuM's). Two days lat«'r it was attacl
ai.'l <li.d. Thi- aui'psy .-h<«w»'d ni>thinir abnormal except a capiUary
VI lit ii«li« cau-d li\ a ilimnihosi^ «»f the stRiitrht corebrul isinus.
Thi- |>.itli..l(iL'i«'al diai;iii»i-i in thii* ease is that of a sinus«thn.)nib<
• TJiiiii, a cmditi'Mi whiili is exeeedinjrly rare, and instances of which es
hav.- -I Id' •III 1 11 ri'|K»rl«'d.
Tiranl n-port^ tlir ras<» of a Ik)v four yc*ars of age, whi
al)lc inti-n-i and value as ivpri'scntinjr ^?e«>Ilda^v siDUs-tlm
Til" i]i:l.l (Ca-.- Uso) wa-* well until h«' had moasleji ; from that tii
and Mr- !i'_th. dii-i i)ri'\i<.u- t'> eondnic under medical observation hi
«'.'ii\iiNi ri>, Ii.hI 1.".mi -lupid. and had not >jK>ken to any one.
<> ' N.iiiiin.ifi..!! li.- wa'- f..und t«» ]>e emaciated and tt* have a coatc
wif.- . ..\. f. i| Willi -..nl.'v ; hi^ ]>iiwrU wen* const ipat«:*d. He was 8emi-c<'>
:iii.| Iri-l -li'^lii (■■-iiv ul-i.«ri-, ill which tlic left arm was ic^'nerallv affe<
OE0ANIC NEBVOUS DISEA8BB.
629
|g;geraU*d when the limb wa« niuied, and wt*ft> th^n •eeompmiii'd by iniiniloufl movc-
\U of the fiK'e, Death incurred two week a later.
The post-inortetii exuminHtiun showed thronihcksis #>f the cfn4>n»l sinuses. There w«re
RtniiU ftbflcees€4i in the lun«r^, appareiitly fn>in infurctiun'*. The longitudinal and
ral sinubt^ contained well^mnrked decolorized thnrmht. In th<^ latter they wvtm soft ; in
foniit^ft firm. There wsa pus in the left tymptinum urid in the iniit«toid finuACB. There
no perforation nf the tnembmnA tympani, iind no neorcMis of the petroUH hone.
HYDROCEPHALUS. — T shall next de«4orilx* a dismsc of the bniio
ich in {.'li'dnuAerized primarily by an exudation of fluid into iW* mem*
of the brain or one of its eavities.
For kiek of a better name, we designate the disease bv the t(Tm repre-
ting the most prominent pathological eoodition, — namely, Iiydrfxi^[>halii8
ater in the heiid).
In order that you may clearly understand what I am about to say, I
fidsk you to refer again to this diagram (Diagram 8, page 594), show-
a section of the skull, the wrebral membi-anes, and tlie brain*
The general shaix* and cireumferenee of the head in infancy and child-
od vary in the individual to a Cfjnsideiiible degree. This has already
en spoken of in a previous lecture (Division II., IxH^ture IIL, page 61),
d is merely referred to here for tJie purpose of illustration, bei^anse the
till and its contents have so close a connection in the mind of the student.
On the other hand, when these variations in size pass a ct»rtain limit, or
c5ombi[UHl with certain nervous phenomena, they have a difetinct patho*
ical signiticance.
Hydrocephalus may be (1) external or (2) internal.
(1) The external variety eonmst^ in a tmnsudation into the gubarachDoid
and the meshes of the pia, represented in this diagram by Sub. A. 8.
[Magram 8, page 594)* This external variety is verj' rare, and may he
iher congenital or acquired*
(2) The internal and common variety of hydrocephalus wnsists in a
nsndation Into the cerf*bral ventrich^. It may be congenital (intra-
TiiK^) or acquired (extra-uterine), and its cause may he meclianical or
flamnmtory. Acquired internal hydnxieplialus may be mmie or chronia
le acute tbrm of tlie diseaj^ usually ooouis as a symptom or a cause of
niptoms in the (YHirsc* of such disea^ea mn rhaehitis, cardiac and renal
Bease, pertussis, and meningitis, and in vari*ius other diseases. It may be
appai-ently idiopathic. The chmnic form of acxpiired internal hydro-
phalns resembk^ so ch>sely congenital internal hydnx-ephahis that we
n oonsider them t<»gether, and, scj far as tlie name of the diseas<* Is eon-
Hfdy the term hydrocephalns would be restri<'teii best to (1) congenital
l^tnal hydnicephalus and (2) ehronic acquiretl internal hydnicephaliis.
9 other woi\ls, theix* exists jmthol<«gically a certain class of etrusions into
ke ventricleB for which no cause is apparent. When these effiisions reach
certain amount tlie resulting symptoms are quite typit^ of what is called
Ifdrocx^phahis, and clinically the term has therefore been confined to
I this cJas^,
Mtvhanicul. Iiiflamiiiaton'. M.echanictil.
, L
Acute. Chn>nic.
In aiMitioii to the effiiftiou which takes place in cith
iiiti rnal liv<lr(HH»pliahis, there uiay be a oombination of Ixjtl
nininiunicatinii Ix'twtvn the fourth veutricle and the subarai
means of tht* foramen of Magendie.
(1) ExTKiJNAL Hyi)K<x^ephalus. — External hydrocepfc
a-i a cnnf/rttita/ dis^'it^^^ hut this occurrence is so rare thai
siiid eoneerniii'x it. I luive met, however, witli one instance
analo«r<uH cinulition which I saw in consultation with Dr.
Jamaicii Phiiii, from whom I rei'cived the complete notes c
siMiiis very likely that this was a i-a^o of congenital cyst.
A 1". iii;il.* ititaijt iC':iM- UHl ) wus lM»rn of u healthy primipara. the deli
li\ r<.r. < ji>. TIm' iiitaiit aniH'unsl to Ik* Ktn»ng and vigorous and was not <
wji- iiaiural in >lia|n'aiMl -izr. uiul there wa« no evidence of undue or piMlii
j>ri--un'. It^ \vi'ii:ht was 'MV.VI irruinnies (8 pounds^). Nothing uniui
hImiiu tin- iiitaiit t*<ir .-t-vt-ral ila\>. ♦»xcept that it did not nuise well.
woulil iiv ami n-l'ii-r t<» rnirsi-. \i> mother had a Huffioient supply of pi<
WliiMi it wa> tiv«' <ia,v> i>I(l it looked rather pale and thin, and on th
ill.- iiiK"- \Na« u'i villi: it it*" ]»atli. >he notieed that its right arm twitched c<
tiiiK-. Tlii- iwitihiiii: iricn-a-Jtl in fn^iuency and fortv and was accompj
iliariu;.' ill tip- infant .- farr. It hecanie very pale and was cyanotic an
i'\t -. At liiiK- it \v..ulil try out shaq>ly l)oth during the convulsive twi
int«rv:il«. >.';n"iini«'- it w.»ulil jmss into a otate of 8enii-colla))ise and i(
\"v\ I'al.-. At ilii- tinM- al-» it would jerk its right arm cunvulsiivelv
tini.« a !i.i:.ut<-. TIu'-i- >|»a-in<Klii.- movements seemed to be confined
ORGANIC NERVOUS DISEASES.
631
at there had been twenty-five bpafimodic attacks within the previuiw twenty-fgur hour*.
be infant wm still in ti sUie of colUpet?, the pulse and respimtiong were very weak and
ulaTf find g(>nietime> it would lictuiillj stop breAthing for a minule. It wne semi-
aounflcioUA, lu pupils were dilated. The abnoniuil nigm faund in the cheat were
cichangL*d.
On the ninth day the convulsive nuivemont« hikd ceased, but the child was »till m i
) of ooUapse and rumained perfectly donimni and puMive.
I the tenth day the convubive movements began again, and at times the infant ap-
l lifeless. On this day oxygen was administered for Ave minute* every hour* The
bmndy wjw increased to 0.72 c.c. (12 minims). The infant had be**n too weidc to Duree for
evemi days, and the mother's milk waa given to it by mean* of a dropper.
On the eleventh day the oxygen wa« given for ten minutes at a time every hour, and
andy whenever signs of unconH'iouBne«8 appeared.
During the next few days the infant began to show signs of improvement The
Jiau KoufHe became less distinct. The ateietrta^is of the lung remained unchangi.^.
^During the time when the infant wa* so lU them wa* no disturbance of the Iwwob or
kidneys.
On the teventeenth day modified milk was subfitJtutcd for the brea«t-milk. From this
' the infant rapidly improved. The cardiac si>ufl!e Wted for »\tl weeks, and the atelec-
gradually disappearedf the last signs of it b€»ing a little diminished respiration In the
jfiki back. The oxygen was continut^ in small doses for six weeks; 8400 litre* (200Q
Fga11oni»] were u^ed, Of this, of course^ a certuin quantity was not inhaled, but escaped^ ai
Lthc funnel was held rather lightly over the infunt'9 mouth* The infant had become con-
ptiderably emucititt>d, but when it wa^ four weeks old it had greatly improved, andj although
weighing only -'U05 gramnu*>i (TJ pounds), bxiked fairly well
When the infant wa» n little more tlmn four weeks old the head wa.s perfectly normal in
" abape and frize. The fontAnelle could be *ceii puU*iting naturally and was normal in fehape
i^nd sij^e.
I have here a tracing (Caw 281, L) from a photograph which was taken of the infant
I At this lime.
On the following day the boftd was found Uj be m>ticeably altered in shape, and this
Laeeond tracing (Case 281} XL) was made from a photogniph which was taken when the
Cjlsb 2SL
11,
Convipnital external hydrocephalus or congvnliiil eyiL
blld vrm somewhat older The rounded, full forehead had dtsappearedi and^ instead of l«x>k-
^ing riuiaml, the child had the appearance of an idiot. The report of the nurse was that
while it was bt-ing dressetl in the morning it had vomited ftori»e fluid like water, and thai
[the bead had a.4«uin<Kl this f^hape within the oour»c of a few minuter. Both segmefits of ibi>
ontal and the fHirictal bones had flattened, and apparently' had settled or c<»llapsed. The
^nlerior fontanel le had entirely ettAsed, and the frontal suture could not be fell, A line
Irawn from the vertex to the root of the noac was entirely simigbt, instead of showing the
normal curve. The width of the forehead w«* also dimini«he<I The entire f^nta) bone
iaa so fiat that it lay upon a lower plane than the parietal bones,~perhapi 1 cm, (| inch)
riotii'«> iilijrctK or |M>R:onSf although it appcarvd to notice light slightlv.
Am fXHiiiination of the eves by Dr. Dixon showed that externally i
ri'iriMiil. Tlio pupils w«-n* iiinaller than natural, and responded slowly t
Lii^lit wa-^ iiotir(>d soni<>wh»t, hut the infant would not follow it, and i
c*<>ul«l st'i> bfttfT from th<* sido. Tlie macula and disk showed no india
tion or fxudiiti'Ui. Th«'rv was a very slight degree of astigmatism.
Thf infant oould neither talk nor walk. It had a vacant manner
and it H>ni«>tim(>s rttpiin-d an effort Ut stop the crying. Otherwise it ^
v<']<>)Hil. It had one tmHh. The hearing was defective. There was
di-turl'anrf.
F>>r tlif pa>t thrfM' or four months there had been a return of the up
of th«' rii^lit arm ."imilar to thoM? which occurred during the acute attac
ninliac (li-turluincr. During one of its digestive attacks the infant i
«'j>ibjilif«>nn (•■•nvul-ion.
A rapid loss of crrchro-spinal fluid is not unknown, bu
tlicn* lias usually Imh'ii a liistorv of injury. Where we do
toiy of injury we almost always find that there is a considei
Huid <*omin«r from tli(» n(>si% oars, or elsewhere. According
in tins rasr tlii' infant st'cms to have first swallowed the
vomited it. Tlic means of exit of the fluid from the skul
throuj^h sonir conj^cnital iMWt at the base of the skull.
It is known that in a ^reat many children who have hyt
similar conditions the atrophy or non-developinent of the
show any symptoms until they an* a year or more old. '
not notirr anythinjr, and the physieiun is unable to, beca
tln' <>|)|M>rtunity for sntlicicMit ol)scr\'ation. To determine im
youn«r cliiMrrn, unless it is mark(Hl, is a very difficult matter
the eliild is l>n>u«i:ht to the physician to determine this conditic
OROANICNERVOCH DISEASBS.
633
iptie atrophy can be foiuid l>y nutans of the ophtiialmotscope. In a consid-
[<!rable pnjporiion of cases of tills kind there i& a diniinutiau of vii^ion which
id not cxphuntnl by anything that tlie f>cnli8ts tell n8.
HencM'h mentions a (*ase of hydi*ocephalus in which the fluid dmined
". through the nose to tlie amount of 100 to 2<X> c.c. (3 J to 6| ouncics) a day
ftibr quite a long time, so that the hydrrjei^plialus was reduced tHuisiderably.
H The acquired ibrni of external hydrcK*epljuhis is exeeedingly rare, and is
Bu8ually found in connection with cerebral atn>j>hy (hydnx'cphahis ex vacufj).
There are certain eases which tan for the |n'csent be clasi§ed under iUii^ head-
Bing until our knowltHlge derived fn^m |K>st-morteni examinations IxK'omeft
f more pre<'ise* These cases are so mre tlial it is impossible at present to for-
i0 mulate in detail their sympti^mat*>l<^gy and diagni>sis. I have met ^ith a few
(cases, however, wliieh in their sym()tomri were so signiticautof a rapid devel-
opment, with itii sjK'wlily fatal issue, of an external hydnKx*jihalus, that the
diagnosis of hydroeephaliifi by the elimination of other possible can^^ieB haa
0 iseenic*! to me rati*)oal, and lian bet^n supported by the pist-mortem exami*
|L nation. The symptoms may develop, according to my exjjerience, in yiKuig
■ infants who either have been fairly well or Imve l>ec*n atrophic. Fhys-
ical examination in the^e cases has revealed nothing abnormal aWmt the
I head or any of the organs, such as the heart. The infant, ai'ter a shiurt
peritxl iff indefinite symjitoms^ at times lasting only a few minutes, and
pepresent**d by nervous twitching, perhaps a eon\TiIsion and rapid collajiiHe,
suddenly dii^. I have met with thret* cases in my jiersonal praetiee. Two
were, after minute p>st-mortem examination by Dr. William F. Whitney,
found to represent as their only pathological lesion exterual hydroct^phalus
with oedema of the cerel»ral substantH^^. The thinl ease showed this coutlitiiin
merely w^ a symptom of pernicious ansemia, and 1 have spoken of it in a
previous lecture.
One of tbe»« caiet w&s an in runt (Cafte 282), ten monthi old^ of h^lth^ parentage, tind
[mlwAjB perfectly well, exwpt thiit for two weeks before its det th it had cried nitwj tban
I. Usual and Wii« somewbut irritable. Five days before it» death it was Aomewbnt languid,
jlmt U>ok ItM food well, und whi*n I exafnined it the night before lU death nothing abnur-
al was found. On the following morning it had a few convuUiTe movenienta and died
[iuddenly.
On po«t-mort«*m exuminiitinn nothing nbnonnal wa* found, except that ti large aniounl
Lof cerBbDMipiimi tuid ebiii]KHl innn tht* cmniuiu af s<Hm as tlie «kull And parietal dura
tinitter were remoTed. There was mho a genetal cedemAtou^i condition of the brain.
The other cate was a female infant (Case 288) ^ »even and one-half nionUu old, whicli
I had \H^*ii Buffering from malnutrition for several inonlhs and wa« very weak and puny,
I On tbo day of its death I examined it carefullr, and* with the exception of an atrophied
lieondition of the muscle^^ and a weak action of the hearty nothing abnormal waa diseoverRd.
Il^ilhin an hour after I hud seen the infant it bad a few convuUtTe attacks and died frud-
fdenly.
The Htitopiiy, made twenty-fiiur boun alter death, thowed nothing abnormul extemallj.
igor mortif waji present. There wa« great pallor of all the organs. The skull was nornial
in development, und the fontanelle waf normal. Tberv wai cerebrcMipi nal fluid in exoes.
he bniinHiabstanoe was very moi«t and pale, but otherwise nothing abnornial was noticed
I the brain or meninges. The heart wai of nomui] tlie, and Ita caYltiei and valves were
I
r
ORGANIC NERVOUS DISEASES,
635
SvMFroMs. — ^The ^ynjptonii^ of t'ongenital iDtenial hydnx^ephalus are
essentially those caused by pressure. We naturally, tlierefore, find the
fontanellt^ bulging and fluctuating, and the Ixme^ thiti and ii>rce<l out of
pf»Hition. As you ?^ in this j*kull {Fig* 92), the tcmi>oral aod parietal
bont?s diverge as they extt*nd upwaixl, while in the normal skull they
ascend alraont perpendicularly . If the di^iease has existed for some time,
the up|>er wall i^f the orbit beeomes flat and the eyeballs protrude. The
Fro. 94.
Hfdtoccphiilic bnln. W&rrcn Museum. Barv&rd I olverslty,
L'bral presssure often producer a strong collateral eirenlation in the
the forehesid, when* the vess4:'ls ap]>ear like tortuous blue ei>rd8.
Funeti<joal disturhanees arv uuniiTtnis, an4l vary in alumsl every t^ase. As
lie, the children are idiotic, but at times, even in marked hydroeeplialus,
we find the tueutal mnditicm normal, even when [mralysis Ls pn?:?ent A
notable instant^' of tins fa<'t is presented by this little girl wliom I have had
brought here to-day to show you.
This child (Ciise 2S4, page 636) it Ave yea^n old.
You «ee ihnU Although *ho bos eoniplet4?ly lc»t the pnwc^r of using her legt, fttid biu
head Atid distended, bulging foniAneUe, vet f^he h bright and intelligent. She
nursed by her mother for t>ver a yeart and cut her flrst UxHh when the wm fix motithi
She wfi» always well iirid «tmn^, but hiph -tempered. She bM never hud any diiieafio.
When *he wm Htp months old sbi* fell fWim lipr crib and ftruck her head, but it did not
a»f^m to hurt h»*r especially* Hor h<*«id wa* always noticed t4) be of a peouliar Khapc.
When *bt? wa* eight months old *li«T feil out »>f a chair Hnd wa« Atunned, but wm* not oth«'r-
hurt. She ha» had convulsifmi* fr*mi time Uj timt*, but her iniud ba^ always b«?n
bt. She was unable to hold up hor h«ui until the wa* three yean old, and hat atwayi
lotnoplalned of more or lena fhintal ht^at^h**. Her appetite ha* alwayi htmn «iMiilve, and
686
PEDIATRICS.
her UmU for fciod ftomewbni pDouliiir, Shv Imd gndtiftllj grnwu itroogftr, md h\
t«> fttlrtnpt U* wiilk She iilrrpe well» ftnd her bowel* mi? rof^bir. Her bisdtti
om. (22} inehcs).
CanKenltal intenuii hjdrooepliAlus. FemaJe, 5 reaa old.
As the various cerebral centres become affected by pres2*iire, wi?
that syiripttmis arise «jrrt>i{i< Hiding to the parts of the bmiii whkh m
affeetod, Ani<iri|^ thesi* symptoms are nystagniiii* and^ less frequeatljt ^
bismus. The py|>iLs at first are usually moderately dilated. Latter lit
Jiecome fixwl, ami seusihility to light is I*j4=it. The Uc^riug lasts forilo^
time. The tibility to walk i^^ interfered with. Partial or general coa^
jmralysis (usually paraplegic), and cimtractiires may occur. Pik m
head im <>ften eomplaiiud of, but, m a rule, Is act s<.> severe as in me]
There is diffieulty iu keeping the head erect, ai^ it li^ 60 heavv. Thft
tion is often gixxl, and tlie appetite usually extreme. The r^piriM
normal from adaptatii»n. The {>ulj*e Is usually not retarded. The temuer^
ture, as a rule, is n4>rmal. The atliptjse tissue is often abnormallv m
I>iAON<:)8is. — As eongenital internal hydnscephaliLs is almost iov
attended by enlarg«*ment of the head and separation of tiie sattim,
diagnosis is not €^|RM:4ally diffieult, and is determined bv ooimnrioi
measurement's of the head with those of a iiorinal liead of the
I have desrTil)id the measurt^ments of a normal liead in a previoi
(I^ef^ture^ IIL, page (Jl), In addition to the enlargement of the
symptoms of (Hreet intra-eeplialie pressui-e make the diat^oeis vt-rv
Prcxsnosib. — These eongt^nital ejises, a^ a rule, die before chiUIhuoJ
been reaehtd, but tliey have Ikh^u known to live to middle age. Dal
ooQura fn>m some interim rrt^nt at!k*tion. Complete reeov^erv is
TREATMEX-r.— The treatment of congenital internal hvdrwephil»
been varied, but without niurke<i success. When tlie efiTustoa is in*t '
and is not increasing, ^mxlerate pressure with a rubber bandaee ^eem
have a favorable result Where the disease is apjxirentlv not in an
state and Ls characterized by a very slight inereusc of fluid
venri
ORGANIC NERVOUS DISEASES.
837
rough the anterior foutanelle of a Htuall (jiiaiitity of fluid at a time had
leen of temporary benefit. Tlio poiiit of a^pmition i?hoiild be 2 to 3 cm*
} inch to 1| inches) frt^m the mi^liau line, no m to avoid puncturing the Ion*
itudina! sinus. In this way the amdition of the patient ie! often rendered
iore satisfactory.
An operation fijrelironic hydrocephahL* presents no twhnical diflirnltieii.
!)f cour^ only certain cases are suitable for openitiou. Mo<lerate etfusious
[ould be let alone, ako those cases whei^ a rudimentary development of
he brain Is susj^^f^cted, CW^ where an (ijx'ratioo h es|Kvkilly hidicated
re compai*atively lioth physically and mentally well devel«nKxl up to tlie
me when the enlargement of the cranium Ix'gan. Such children should
how the syrapt^mis of din^'t intra-cranial pressure. Thev an? evidently Ix*-
>ming wTak-miudHl or idiotic. They do not learn to talk, or they cprickly
rget what they liave learnctL They may also have IjecYjine totally blind,
rhe power of walking ijs interfei'ed w^itlu Contractions and partial and
neral spasms are of ordinary ot^UMTcnce, Unlaws the pressure is si)eedily
iemoved, atrophy of the brain rt*sults, and if they live they reniiun idiots
c life. Such cases as these you can best refer to those who are skilled
II nenroIo|^y and surgery.
I have in my wards today a number of cases of congenital internal
ydrf>ce|»halus to show to you, which are of considerable interest in view
f what 1 have just told you.
Of these illuBtrative cme» I will first show you this infant (Cas« 286), two ywi old,
rbich id fciuing in iu mother '« lap.
Th»? spfdiil point of int<^rcst in this ens© is that the drcumferenco of the molher*i hejufl
id that of the child's head Jirt* iilmo«t identitiil, 62 cm. (20| inches). You will notice the
rerhafijupnju; bmw and deop-act ejm^ the globe-shaped head and open bul^ng fnntaitn^Ut^,
iQ frfjiuU face and oblique parietal bone^i of the infant's head in eomparit$oti with the oor^
a), round shape of the m(»ther> head.
The histfiry, w> far us the mother U oooceniedf i« negative. She has had no miscar-
iagt'ft. The infant waa Ixjm at term, and cut its flrrt tooth when it waa ^ix montht old,
t now has sixteen teeth. It haa had no eonvutaions. It ha^ for some time supported it»
lead alone and sit» alcme, but haa never attempted to walk. The intelligence aeema normal,
t U apt to tleep with it^ eyelids partly open. Iti digeadon i« good, and its appeUte i«
y go4:Nl. The b<jwel« are rather relaxed. On examining the head you will see that >t U
ibnonnally large. From the root of the no«e to the occipital prominence it meaaurea 32
, (I2j inches). From the baee of one mastoid to that of the otlier it mea»urei 83.5 cm.
13| inches). The position and movements of the eyei are normal. Tou will notice, un
looking at thf head frum above, that it h triangular in shape, with the t^ue of the triangle
; the occiput The nnterir»r fontnnulk* you see u widely open, and u about 4 cui, (11
fh») in width and Icnirth, The protruding overhanging forehead makea the lace look
■ill. The epiphv!^**^ are tiot cnlai^ed. Examination of the lungs, heart, and iplaea
lowa nothing abnonnal. The child weighs 10»442 gramme* (23 pound*).
In thin next WhI i;^ a hoy (Ca»e 2B($, page (ISK), threo and a half yean old, whoae head
typical of congenital inU^nial hydrocephalus, Thu circumference of the head ia 67 cm.
!2| inc h<«).
There i* no history of diaeaae in the parents, and the mother haa had no miacarriagea,
he child** h<Hid ha* always been large iince birth. He has never had any convulsions.
le cul two teeth when he waa four month§ old, and i^hen he was a year old he had ten
itfL He walked when hi^ waa fourteen mtniths old, but his legs never seemed strong*
888
PEDIATRICS.
Ho hfti nerer hid anj pRnlytU, but he g^u Urvd eiutily. Nine motiUiii mgn hr U\ ^f^tm
•tep, and half an hour 1at«? btgati to vnaiit and was aam nolerit. Danng tbi Ul^
Cask 286.
CkxiseoiUil intenuJ hydrooepli<u.
two dayi the Tomiting and Mmnoleiice continued, but He waa nercr utuxmatkiii. ]& ^
then beje^an to increase in eii&ef bo that his mother had to l*tiy btm larf^ ha^ k^^
accident he had always held hU bead up. He talked wli(?ti he w«s fiAc«ii mai^tk.ti
Oaak 287.
CcjUigetiltal int«rtiAl hydiooepbaltis.
eeemed to be an unumally bri^lit ehild. He holds his eyelids partly open when h#a ^
and he hafi lately had atrabkinus uf one of hU eyes when he looka atendilv «t an obwi T*
h«adkmBiked\^^idM^«i,^\k«t Wiad, \imtrtiding fontanelle, and U tmther
a
ORGANIC NERVOUS DISEASES.
(j39
0 Tertez. The euptiriQciul veinfe of the he«d ure prominent The face, aa in the other
did (Case 285), is small. The mo?ementa of the oyes are normal. Frum the tip of one
^told proct»8 ity thtit of the other i* 4L6 cm. {IB\ inches). From the hiise of the nose to
oocipjtiil protubenim'c if ftho 41.5 cm. {\Q\ inche*). The anterior fontanelle b widely
letl and b 2.5 cm, |^1 inch) |t»ng and 2.6 cm, (1 inch) wide. An examination of ihe heafti
pgi, liver, and spleen fth(»wfi that they are normal. The abdomen is prominent The
dial epiphyses are enlarged « and there is a slight outward l^owing of each tihia. The
ine is etruight The patellar reflexes are not incrcafted^, and there is no ankle-clonus.
be urine h pale, thin, und clear, and contains no albumin. An examination of the eyei
r Dr. Davift ^howa no marked diniiiiuiion of vision in either eye. They are hyperme-
&pic, und there h a converitrent strabismus, probably accommodative. The optic disks are
Iher wider than usual, and their vcissels diminished in sixe. There are no other signs of
W-ic atrophy. Th»'re h no dilatnii'in of the retinal veins or i welling of the dbks. The
nmination, therefore, shnw» thnt, with the exception of an early «ti%ge of atrophy of the
^ic nerve fn.im pressure, the fundu:» oculi is negative.
In this eai^c a chronic ongenititl effusion w»is apparently actively increased by a blow
the hei&d.
This little boy (Ca*e 287, ptige 638), a patient of Dr. Haren's, h an interesting case of
fdrocephaluik, with it* accompanying disturbance <*f the motor function of the legt, and
io mental impairment. Me i^ a charactcnstic picture of the disease. He cannot walk|
Cabi 288.
lnt*'nial hydrocephAliw (pfobablj oofiireiillal). FemmJc, 0 ?
-. is able to sit in a chair. Hb legs are atrophic^ his alidomen is distended, and he it
rtiewhat emaciatpd. Hi* head, as you see, is decid**dly enlarged^ and he is mentally weak.
appetite h excen^ive. He is very ft^tful and peovi^h.
Caaes of thi^ kind are very apt to live for only a few years, and are aspecialty liabk to
If tbey are attack«'d by any intercurrent disease^ i^iich as pertussis.
This little girl (Case 288) is six yean» old
640
PEDIATRICS.
Hhp u •'nUi lo hiivo been norromlly devHuped mnd h«»nJrv ui luriti, w w^^fi
huM her ho<id u|t until «he wa* two y«wi old» She Iias never walked
Vou iiMiicii uit liK^kiug at the boiidi both in fn^iit aii4 in |iroiflle, tliMttittk
Uri^o. It meii'^un^!^ 65 cm. (26 Inchoi). Tbo movcmenU of the luuuli ami i
Sh« cikrinot tUnd unless she if fuppuriinl, Hiid thefw U a s|iAfltie condhioii «af iktliqp^i
•xugf^emttun of the knee-Jerlu. Sbo urticuljiiisa Wttll.
8he reprttienlB a cm« of partiul recovery frnm cUrt>nic hvdrt)ee|iluduB, pni
ooogeniiiil variety Her geneml development will prubftblj filway^i b« i
I ahall now ask you to ofmie to the operating-rtMjm and
of chronic wtigenital internal hydrocephalus which Dr, Lovt*.
ojx^ratt' ujH>n.
Thl* fint infant {Ctm 289, T) i^ aii months old.
II WM tiotieod when the chitd wiu imt* we«?k old thtftt itii hisiid wsi b^r
10 tijte* When two inontht» old the circumfcn'uce of the head v^ «ftid u
cm. (16$ iTichet). Somewhat kter the circumferencfi of tU«i b«Md wm 14 8
ftfid when il wu5 thn-e montbs old tlie cifciitti fere nee was 44>.*'i cm, * Whoi
witis livf riitjntli.s <4d the Linunifervnc© wna 66 ciii. (21} iiiche«), 'tn**'
nieaAuna* 57*5 cin. (22^ inches). There h no hij^tory of syphilis «ir iif tu^«taiM ^^
fuinily. The tnfHnl hm bttd no morked convuUtons, Although snme lwltchiiin(^tl^^>^
and feet have hi'-^ii ni>lie(?d. Thcrfi baa been constant ny^tAgmttf, and thai
cundttinn i« »itmphic. You wiU notice the nmrked pn^toinence tyf the rv—
dbtention of thi> h<^iid. The anterior fontanelle is very larg«, mnd the -
dhtend^d t<i fiui-h a degree that it is thin and glistening. Thetv x^
this kind that uspinilioii nf the cerebro-fipinal 6uid should be mu
relievini^ the i^eneral eundition.
Div LiiVL'tt, iis you «ee» has just rnnde an explaratory fninctxtre at Ihafiito^'^
right side of the head, abtrut 5 em, (2 iiiehoH) fn>m the mocUan litus. Ib pk»of tfe«"^
tn>cnr ht* nnw iiitnidm-efi a liirij**r one, Thmugh thi^ l^f^e trocar hi' has t*^ '''^
atmnds of silk ti> servo a.s u dniinatjfe by cjtpilliiry attraction. V^m will now
289, IL) after withdrawing the fluid from thu right ventricle that the ri|*hl pw^— —
has sunk in, iU i^dife \mn^ beneath that of the left parietal bone, which h Mf^
outward by ibo fluid in the lea veiitrirle. On in*nisuring, m eonsidcrible quaatii|aflrffc
found to have been at^pirated,
Yrm see that, althoui^h the head is very much reduced in aise, tbw« %tv Wi
of Co\lftp»<! uoT vmy tiit^t'T ^V\iTmvvi^ ftym^Oams shown by the infiuit.
•i
U
i «*tJiriMiiui mienittii ny
im of both ▼eotrldet.
ORGANIC NERV01
641
(Subsequent hietory.) The infiint wm very reetle«a during the following night, toatlng
lieftd about nnd crying.
On the ntfxt day 270 c.c (9 ounoa») of cleiir fluid were withdmwn firom the left ven-
ule by introducing the trocar ut a point corresponding to the point of (idpiration of the
III ventricle. The hvad wh* tht*n found to nietiiiurt? 56.6 cm. (22 iuche«).
A No. 8 Bofl entbeter wu* then *ntrt>ducod into ettcb ventri<.le und sewed into place.
« externa! end of each catheter was dosed by bending it upon itself and tying it tightly
Ih a silk ligature;.
Th** nppt'arajice of the cranium after the second afipimtion is here shown (Case 289|
,). You will notice the great depression of the anterior fontanel le.
Three days later 120 c.c. (4 ounce*) of fluid were drawn ihniugh the catheter.
On the following day 138 c.c, (4| ounces) of fluid were withdrawui and the Infant waa
od to have a better facial expresiion.
On the next day, the fl^ after the operation, 105 cc (8^ ounces) of fluid were
loved, iind the head was found to measure 51 cm, (20| inches).
On the following day Dr. I>ane began a series of obaervations on the fluid-pressure in
I caaei which were the first of the kind that have been brought to my notice. He oon-
icted the cnthint'r with a manometer and found a positive pressure of 7 cm. When thio
int cried tht; pressure rose to 12 cm. On this day VM e.c. (4 ounces) of fluid were
toved.
On the following day the preisure was found to be 4 cm., and rose to 5 cm. when the
fknt cried. 90 c.c. (8 ounces) were removed.
On the following day the pressure was the same. 68 c.c. (2} ounces) of fluid wera
lOved on thifi day^ and the head was found to measure 49.5 cm. (198 inches).
On the following day the infant failed rapidly^ had convulsions^ became unooiucloya,
id died in the evening.
After death 5oO c.c, (18 J ounces) of cerebro^pinul fluid were removed. The specific
^vity t»f thift fluid was 1003. It cnntained 1| grufiitiR'^ (28 grains) of albumin to the
e. ThL* WftA metis urwl by an Eh bach's albumini meter.
The total amount of fluid withdrawn fnim the ventricles tn this case waa 720 c.c. (24
i) in seven tappings.
le next case is that of an infant (Case 290)^ seven months old, who was admitted to
lital to-day.
ha8 always been nursed. When it was two days old it had convulsions. Three
later it had bronchitb^ and accompanying this dlseaae a return of the convulsions^
Case 290.
Congenital IntcmJiJ hydrorephiilus. Male, T tnfjtiths old.
hleh occurred as often as six or seven timet in the day. They were loealixed in the left arm
le(t leg. These convutdons lasted for three weeks^ gradually growing less severe,
re was at this time a certain anmunt of rnt».*Htinal di.^turbanc^t which, howevefi has now
There was also a histr»ry of u purulorit discharge from the ean before tlie
; was admitted to the hospital. It cri<j!d nut sharply at ntghu Tlio measurements of
» head are 5*1.5 cm. (22| inches) in cirrumfcrnnce, nnd 8fl,7 cm. (14J inches) from cmr to
r over the vertex. The anterior fimtaoelle is bulging. The eyes, as you see, are markedly
ej^ent and prutrude from the arbita« If you will observe the eyes oloaely you mUV i«a
41
(112 PEDIATRICS.
iliat llni'f is Hi tiin'"* a r-liixht In-inhliiij; uml twitching;. No other .ipajarinfiic ri:i-.
an- n..iii'«il. Tli«' fhi-i iii«-a<-un>> :i:^r> i>in. (13} iiiflu*^) in oircuinfereiuf.
Y«»n >«••• iliai th"' I'Uiltl a> it now \u> <m tin* mHTatinj^-tabU* take^ no notkr -fi;-..:
It ha- I II «iiii<lril i.» n-lii'Vf ihi' cvn'hml symptoms by aspiration on 4c.\u-.i : i-
irnai iiirr-a-.' in iln- iiiimvfntriculur tiulJ i<huwn by syinptoiii-s of incrva-r:l i-.iiri-?.j
A- \."U , I>r. Li«\«*tl hu-i intMKluctxi h tbonm^hly a«^cptio atipiratiiii: iR-^il-rr ;
ri^lil laii-ral \fntriil«- ihmuirh thi- niiu'h diliit»Hi ant<.'rior funtanelle. Tlw a.-jjir>:i: ; ■. - •
i' I'ouuiMirii uiili a waiiT luaiioiucior, whii-h shows a presriuro of 30 cm. Uuviii::-i->i:-;
ilj«' |in--U!-«" I'V !n«an- ut* tlii- \vat«T iiiiinimu'ti.'r, we can now remove a c»-rtai-_ a:.' :•
ilii- lluiil. Ill onliT i«» ili» ihi-, ji whirt' of oihtT ij* given to the infant, and T.iu."^:ii:>
K-'V.-it iutPKiiu'i'^ a tnu-ar in piuiH' of tht* H^piratini^ needle. He thvu iviiiiu^s- 1-
tPM-ar, l«'a\inir tin- raniila in iln* cavity. Next, a^ you sec*, ho intnxiuei'* a N:. '■:'.
ruhlH-r »atlHt«r thniuixli tin* canulu, and on withdrawing the latter the end of lit i»l:-:
i- Iffi ill tin- vi'iitririr. 180 f.o. (4.4 ounces) of clear fluid have been ivnmved fr 'lu :> •-:■
Irich-. TIm* ^pfcitif i^niviiy of this fluid is lOOC. You perceive that the axe;? "4 Dr ?;.-
whiili Ih'Imp- th«' o|H'mti»»n wi*n* diven^ent, an* now parallel. The externa! er.i ■:" u
i'ath*t(T i-^ n<*vv cinx-d in thi* suni«* umnner as you saw it done in the preceding <i<e.
iSuli-'Mpifnt hi-tnry.) Thi* observuticms on the intra-cranial pPi»s#ure in th>cjrr -•-
th"- la-t (<'a-«' US'.M, wen* inadf l»y Dr. John Dune. On the day following th^foper^i.c. •
pn— .urr \va^ f'Hiiid tn \u' 14 cm. by the water manometer. When the child cri"l«^:
incp-a-rd In *2t> cm. 2't cc. (| nuno-) wen* removed t»n this day, and the circuiflftf^:-:.
lln' In-ail was th«*n found to l>e 35 cm. (13; inched). The ^peciHc gravity of this ai-*»
HH)7.
On thr '.••ttiiid day after th«' opcnition the prt^sHUre was found to be the isanu-. ^.^
tim«- .V, r.K'. ilj «.iinc»'>) uf fluid wen.' nMiioviHl, the specific gravity of which wse : --:
i»e Khh;.
On tlh* third day afliT the o{HTution the tube was found to have leak»fd4Ur..-.i-
tln-n* w!i- a -liirlil <"iiviil>inn in ih«? morning. oO e.c. (IJ «>unces) of fluid we?? >'-:' ■-■
On th.- f'illMwiiiir day the tul»c was found to l>e leaking fn»ely, and the infant t^- :.
^lali- •■f" (-..lliip^'- and nl"uM-d t'> nnr-«'. The head uiea.*iured o2 cm. (20i inches).
On th" in'M day ili«'n- was still >onie leakui^e arcjund the tub*?, but thr inlsritTi- :
Ih'II. T (■..iidili-tri.
Thivr .hi\- latt-r. ih»" Ifakai^** nnaind the tube having been controlled in th'* ai:*i '• -
th'" iiilaiit -r.iii.Ml iM'ttiT. liiit it had a thick purulent discbarge from both eais.
DuriiiL' th'- ii«\t l"«'w days th»' child Wgan to gr«>w weak, and then; w:i^ affiins-^:"
h-ak:ii:«- .ip'IiimI til'' liihc.
On th-' .h-v.-nth day fnllowini; the operation the child died quietly, no ^^'-■
syriiploiii- haviriL^ appi-arcd.
Th.n- wa> II.. cniiipl.-t.' |v)st-mortem examination, but the dist«>nded Tentr.«i>»'
f'.un.i t.. <-..nt:iiii T-V.i r.r. (2oA ouium--} of clear .stmw-colon^d fluid, the left ventr./-
tnihi.:- 109 .w ,]i\r ...iiK-.-) and tin- ri^rht 35() cc. (lljj ounces). An examiiisti.:: X •- ■
lliii.l l.y I)r .1. II. Wri-^ht -h-.w-d that it was turbid with a flaky sediment. Im^- --
alUaiii. Th.- >|..-.:ii.- trr:i\ity wa- U)0\K It onitained about 0.1 per cent. "f:»^'-'-- "
N.. -ui: -r u:.« \-\uu\. rii-hr tin? inim.scoiiM* nothinir was j-een resembling the- Hair: • ■
'f il-- '•• i.M-i. :■■>. An it....nlatiM,i ..f u ir„i„,.a-pig with this fluid to determine wb-V
\v:i* "t a III!- r'-nl:ir nature ..r ii.>l iravir ncj!;ative n»>ult3.
Acquired Internal Hydrocephalus. — Both the acciuired awl th' ' "
pnitjil fnini n\' \u\rvun\ liydnHvplmlus may Ik? of mechanical or inllamm^'-'
nriiiiii, JMit the jn'(,i,iiv<l ri.nii shows ovuloiK-e of an mflanimaton- o^iTii::':
'•it.-inr tliMii d.H-. till" .-onp.nital form, and iH-curs very freiiuentlv b -vr-
'i'vil,.,, will, rh:n.|,iii.. A(M,.,iiv(l intmial hydnx!ephaius mav u' *.-ii--
rln-nu\c. \u \v^ ucuv. K.vxxx \v xxxvvs v>^-evvr at any age bs a svmptom of is;
ORGANIC NERVOUS DL*5EASK8,
643
! of a number of dij^ases, 8udi as meiiitigitk, ooe of the exantliemata,
tussis, aiul rharhitirt. It may in any of tht^^e forms bea>me chronic,
be disejy^e may .stimetimert apitoar to bt* idiopathic,
j The ehmnic form of aaiuinil internal iiydnKt*j»haliis occurs usually in
first four years of li(e, and is reprej^nted patliologically by a small
aount of intra- ventricular fluid, perhaps 100 or 200 e.c. (3 J t<j 6| ounces).
IB this cJmmic form ui* aequii-ed internal hydixxvplialus that can best be
Sed under the name of hydrot-eplmhis with the ooiif^*nital internal
Irocephalie cju^es which I have jn^t bIiowu yon.
Symptoms. — The symptoms of the a<:ute form of acquired internal
frdrooephaluB are so closely connected with the diseases in w^hich it occurs
h a symptom that it ib not necessary to s[M>ak of them here.
I The symptoms of chronic acquii*ed internal hydrocephalus are very
liuch the same n» thc^se of the congenital form. The firmer the union
jf the bones the less likely is enlargement of the head to occur.
Prognosis, — The prognosis as regards life is serious. Of those who
BBoover, many are left either with some mental defect or w ith permanent
llindness, the latter the result of optic atrophy. Complete recovery may
pcscur, but b exceedingly rare.
Diagnosis. — The diagnosis of chronic acquired internal hydrocephalus
tf the idiopathic form is in its earlier manifestations chiefly made by the
Elimination of other cerel>ral diseases, though ai\er tlie stage of inflamma-
lory irritation has pcu^sed anti the symptoms of pressure have bea:)me estal>
Ifehed^ a provisional diiignosk can usually be made. I say provisional
iBGaufle the disease is ran*, and a sufficient number of autopsies have not
fet been made to justify a decide*! diagnosis such as t*an he made in the
Congenital form of the disease.
Treatment.^ — The tmatment is purcdy sympt4>matie in cases where the
mtures and fontauelles have ccimpletely eluse*l, except wliere it is advisable
to perform cnmit^tomy. When» they have not closed, the treatment is the
pane as in the congenital form,^ — that is, usually operative.
I have hen» three cases which I feel justified in reporting to ygn as
ftrobably representing ehrouic acquire*! internal liydnM^ephahis. Of course
In these cases we must allow that a tubercular or sypliilitic tmnt may have
been the starting-piint of the intra-ventricular disease
li A boy (Cue 291)^ four years and eight months old, wm seen by me in ooniultatuin with
|>p. K. J. Forster, May 27, 1885. The child** parent* were hejilthy ; hiit mother had other
bialthy children and had bad no mi^carria^ee. The child had always l>een well, tneaAles
y&Qg the only disease which he had e^er had. At Ihe age of «ix toonths, white in the
pooMft of cutting a tooth, he had three e*invul«ictn*, from which he r^scovctvd entirely*
Bift tippi^tite had always been capridou8, but hie digestion wm gtMMi, Hlg hriweU had
Hlwaya been n'guUr, He had lately come &om a malarial regiuii, where he had lived in
I rather damp dwelling for a year.
I On May 6 be vtimiied tweire or thirteen time«. The vomiting then Atopp«Mlf but
iumcxl Utcr ftf>m time to time- lie eoiuplaimKl of jjain in hi» stomiich, had no fcvor, and
netiiiie* appi?«rei1 to fec^l chilly. Hit boweU were oofutipat«d, ajid in the biggin nin|p of
644
PEDIATRIOB.
thi' iittui-k hirt \mW was kIow. Uc had Ix^n subject to nig^ht-terrors for some tim-* pvi'^
to thi'' !«irkn<-ss. Tlu> vniiiiting had U*S(»em'd by May 27, and the report of my exas.i:iL.
1)11 that date is as follows:
Pu1m« liO, rliythiiiiral ; n^piratioiig roj^lar; temperature normal; hA« b»d %!u-
Inti-ly; m* disrhar;;*' fmiu thr oar Mnw ho wa^i an infant; the examination of thrarik
iii>L;ativ«' ; y('>ti'nl:iy inornin^ he had a ^■neral clonic convulsion laitting for >ijm^ riaf: le
ti'ii^iii' i> hlii^htly roatf<l ; he lien in an apathetic state, though perfectly cvit.'icii'j^-i-fc
lo^iiii; ill w(>ii:ht and >tn'ii^h and has lost his appetite ; urine normal. Nothiag abftcx {
is found on examination of the thorax or abdomen. (The examination of th*^ey<s',J':ErU
Chart
24
Daffs of DiMeane
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chrdiiic jiciiniRMl internal hydrooephaliiB.
Ny l'r..f.-^...r(). F. WM.Nwortl), >h..wM that there was much swelling of the optii! r.-Tt-.
""■'■'•""' l'f">">"""' t' tlw ivtinal v.-ssi'K heniorrhapos, and neuritis.) The chili ?««»
M'u.-l. iM-iul.t.-r, uM.l plMvs MlM.ut. His inf^lliironce is perfectly good ; he hai had d-.d'S
<-nMil^..>r.. a.i.l no pMraly^i-. and ...mmms perfectly well, except that his pupils *iv iU»i
ur.. 1... IS t. .tally Mind. Ti,-. :Kv..inpanyin- chart (Chart 24) records his tempennav^
pnlsc frnru May 'JT f. .Inn.- 9. '^
Tl.i. .i.iM ram.- f. .-. nn- in May, 1898, when he was twelve yean old. Heh*3i«
and wa> at that tiin. p..rf,.-tly wHl. 11. was a bright, welWeveloped, healthy bov. r*--^^
yars ni.i. u,. pupiU ivact.d, l.iit h- had never recovered hU sight. He iro^bed li'
ORGANIC MKRVOUS DISEASES.
645
(90 pounds). Hi« boweli were regular; bb appetite woa good. His kneo-
were not increased. Hi« bead measured 49 cm, (19| incbes),
ihall now call your atteutioa to thiB little girl (Coisi* 292), U'n year* old, wbo bae b<«n
B hospital for about two montbd. Her tkinily hifitory is negative^ witb the eiLC^ption
two tnaternal aunts dii^ of pbtbiBi^. Tbe child has never hod any dtis^^ase except
bitia, tneasl«ii» and varicella. Her present trouble tx^gan one and a bulf yean? ago with
It attacks of \o66 of eon^eiou&ue^ without convulsions, lasting bull* an bour^ after which
ould fall ajsleep fur ^ome time. Eighteen monthti ago tbe^e attacks began to be a<!eom-
d by convuLiunSf which usually came about once a months the intervals eonietiuic^
three or four months. The duration of the convulsions and the following sleep were
th« aatne a« in the earlior attacks. These conTuliions have now not occurred for six
fcUi with the exception of one slight attack five weeks ago, when the right eye iwjli.'he<1
tiere wu^ a momentary loes of consciousneM, The convuLsiotm began with twitching
) right eye^ followed by twitching of the right hand. The rest of the body was not
3d. The attacks were ushered !u by intense beadaehe, suddeo vomiting, fever, flubbed
and retmction of the head. The headaches, which began about one year ago, were
nely severe and caused her to scream with pain. They were felt all over the head,
specially in the region of the occiput ; tbey would tai^t an hour or more, until ihe
jed and then fell asleep. They came about every day, but wen^ not always acoom-
1 by vomiting. The headaches oea^«ied altogether for a time, but she has had two or
in the past five weeks. She has lately complained of dimness of vision. Six we^'ks
he had pains in her right hand between the fore and middle fingers and began to
tie use of her hand, Fbysical examination reveaU, as you i?ee, nothing definite* She
re awkwurd In u.'^ing her right humi thuu her left, but all motions, you will perceive,
jBslble and strong. Her right foot seems to drag a little and is a little weak afler run-
but these Bymptom« are not especially marked. The ^eniuition of thr band is normal;
nee^jerk is somewhat increa^RHi, For the post p<ix wet^ks »he bus »b*»wri evidence
dal panilysis. Her pupils at times have Uh-h wi*hly dihit«x]. Dr. Dixon rcport£» an
b^ of both disks, with slight myopia.
kydrDoepholtis. Prutru,-iuu uf ^yvB.
Ihe has been sleeping poorly, and bai» bad a 6ur appetite ; the temperature has Iwen
I 37-7** to SBJJ" C, (100* to ioi*> P.); the pulse CMl and r»*irular; the respirations 24
S^tlhir She was treated with a good general diet and 0.30 gramme (5 grains) of
BOf potassium three times a day. The bromide was omitte<l one month ago. Lately
Pufienned to be mueh better, and^ at you tee, she U now looking very wclL
Phis little boy (Ca»t^ 25*8, I.) is two and a half years old.
•M
PKLUJiTRICS.
Bm b Mid to Imvc boon w©U and ttrcmg m% birth, and never to Itave bM»&aAitf»|
months mgo, irh^ft he woke up tcrv^mmj; in the nig^bt, nnd this wm» r ^ <^m
Fcir two w«ek» he did not fKcogtilae^ iiny om, cried out Ht ttmoM, siHi u «ii^ I
tkm took pkqe unoonsoiouiJy. In the curly dnya of the mtiaek hi? l«y iinixM»iilk l^|
oonadoQiikMi retuniod ho lmproT«d for tlvc or six weeks, atid no other wpedal tk^'
d^tiiin dvvclopod. Two wmht Ago he wan Attacked with oooruhsion^, dccurnogitii
of trom ihiHy-ut to fbrty^ht hoon and Usting from one lo one &nd • half A««. lb j
itttttckt w«rt Uihered in bj o^ng, which WM followed by loas of ixmsoi^ofnts. «f>i^
ktckitig, and tinaUy clonic conrulsionir, Hb mother states that dttring tli# «i!iF «^^
th«! diaeiiii* he iibn«*ktHi at time« continuously and eTidentlx sttflbred the &it4t ■■'^■^ |
i|i^M«nUy in the head.
Oabm 298.
AcquirtHl intonial hydroce^hiOiu, Kemig^'s eifinpiom Male 2H ^^an old.
On exaraimng Ihi' child, you ace that he is well developed and nourbbel TW^
tenor fontanel le ia still open. The fruntoparietal suture on the right side o( iJ>» ^ *
fjuiti? distended. His fi>i^bi'ad is rather buljtrini?. His eye« are sotnewhst p^^^•.lTl— *'
nither dL*preest«d in the orbitiJ, The pupils htv. dilated. The head measure* r
iite^hea) in circumference^ 3S.2 cm. ( \^ iiu-hcA) fnim glabella to imon 27 2 an.
ftioin *mT to ear. The circuroferpnce of tht' chest i« 49.7 cm. (19i inch»^ Ikff^'
BTi^hi hemiplegia and paresi* of the right linti and leg, but objects can b^ gTMprf*^!^^
right hnnd. He cannot wiilk. There are no enlarged glands. Nothing simannillito*
on examination of the betirt, lungs, or Bpleen. The knee-jerks ai^ increasrd th#«^*
more than the left. There is nf> ankle-clonus. The teeth are in eood conliliaa
On placing the child on the edge of a table (Case 298, 11.)^ you y^^y *^ ^ y^i
leg* become MifTenetl (Kernig'ft symptom).
The child seetne to bt- fairly briixht and to be impr«_>ving everv day lie if i
fretftjl than formerly. An examination of the eyes by !>,._ Jacfe ah* * luun I
of the optic TiftTVea, "m\^ t<s^A\v^ V^smaitx\v*%«» vA >Jafc \s?^^«,j, ^^
^^^B 0R6AKIC NERVOUS DISEASES.. 647 ^^M
The child^g temperature ha« T&ried muaXlj from 37,7° to 88.8<> C. (100<» to 101<> F,). ^^H
lie puUe bus been rv^ruUr and gomuwhui quickened. ^^^|
Tht' diat:no6U of this ease i» ovidcntt}' one uf intm-creniiil disease. The diieiue wa* ^^^^f
cute in iU onaet, and wa« accompanied by extreme puin in the head^ convuLgion^f and ^^^|
bootificiniii»nt'2i^, followed by a piirtial pamlysle of the arni and by ]o»8 of the power of ^^^|
r&lking. The protrusion of the eyei would indicate intra-cranial presAure, and the paralysit ^^^|
yme intm-oninial legion, po^^ibly of meehunieat origin. What the nature of the orii^inal ^^^|
ifeAck WA« cannot now be determined, but it wa« evidently of an acute inf ammatory type, ^^^|
nd it «eemfi as though it muet have been connected with an intlammatory condition prob- ^^^|
biy affecting th» ventricles. Following thij% inflammatory condition ^ the symptoms indi- ^^^H
Ite an intra- ventricular effiuion, and I think we can therefore afidume that^ whatever tbd ^^^H
rigi^>^l < liUiio of the diseiise was, the child may now be said to have chronic acquired ^^^|
ntemul hydrocephalus. ^^^|
(Subse<iuent his^tur>.) During the following year the child improved alowly but ^^^|
Uttkedly. He became leas fretful ; be learned to talk betteri and finally to walk. Hii ^^H
CHART 26. ^H
Daya of DUcobg
P Mi
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41. r
40,0'
39,4 •
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17, f
37 0*
366*
38 1-
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35 0*
109
105*
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103'
102
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96-
1 Chfofilc Aequinscl Lniernal bydroeephalua. Male, 2^j jrean old. ^^H
HS|»enture became normal^ and when la«i aeen, at the ai^e of thre« and a half yean, h^ ^^^|
■Mimed to be perfectly well, the piirulysiB of the arm and hand lift%nn«r alm<»«t di«jppeart*d. ^^^|
1 Here h the tempemtun^ chart (Chart 25), ^howint; th*? eoune of the tempvmture for ^^^|
Kwentynme day« in the third month following the cyrigioal attack. ^^^|
648 PEDIATRICS.
LECTURE >C>CX:i.
BRAIN.— (Conc1ud<'d.)
Ckkkhkal Aiisrh>s.— Ckkkhral Paralysis. — Athetosis. — Intra-C'ranial T'-.it
— Intra-Cranial Syi»hilis. — Idicm'y. — Mirror Writing.
CEREBRAL ABSCESS.— Cen»bral absce^^s is a kK-alia?d pordj:
I'lKHphaliiis. It is pnihahly always sswi^ndarj' to suppurativi* dbta^i: ^*>
wIhic. It may ari.s.' fnmi a suppurative condition of the .^calp, ImtiM-:
<'ominon Muircf is soiiu* purulent disoase of the ear or it« summndiDp^. 1:
i- alx) tJ»un<l as a s4hjui*1 to traumatLsni of various kinds resulting in ^up?
rat lull ami in ^rncral pyieinia, and it may follow diret-t traumati- iiij'ry
tn tli«- luain. C'cn-hral aksct'ss is usually single, except when it isppdc*-:
l>y pvM'inia. Although the ahsot^ss may CK-cur in any part of tbe Im,
vrry ruininon locality is in the wrebellum.
SYMiTi^Ms. — A n'nhral abs<'esrt may exist for a considerable time wii-
out pnuliiriiiii; any symptoms \vlii<'h ean be reojjgnized during life. Id'-is^
wlicir >MppMrative disease of the wir exists, a cerebral ahescess may i'
sn-|KMtr(l wiirrc, in a<l<lition to the tem|x?rature, which would natunllyi-:
raixd iVom tlii- pron-^-;, the <*ln]<rrt general ciuidition becomes worse witLc
niiy :ip|»:iitiit <:Mi-r, and where indefinite symptoms, such as mental iliL>-
:m<l init:il»ilit\, ari-e. The temperature* may also suggest the presem<"«
iin|)ii-unr<l j)m-, and the j)rol)al>ility of ivrehral disea.se, in cases whtrt tij;
pii- «;mnni Im' loiiiid eUewhere. Ceivbral ubscess mav, however exist ftfi
enii-idrial.lr prriud with(»nt rise of teni|)erature, and even with a subm-niii
teiMjM iMtiiiv. it i- :ipt to he slow in its i)rogrcss and to cause general cic-
-tlnitinn.il i-:ither th:m loeal symi)tonis. LcK'al symptoms produced by »
piv-iitv t.r rrivhraj al»-eess are rart». When i>resent, however, they i*^
ivjuv-.iitr<l h\ li.achiejic, verti«r<>, mental dnlness, vomiting, and ojnvufe*.
and Miv inlloucd l:it.r l)y eoina. When the abscess bursts into the v.t
trirl.>. ^\niptniM> ot' >iidden collapse apiK^ar, and death rapidly il. 11 ■■' •
Ti". ni..r :iimI <-Miiviil-i.Mi> may occur in eases of cerebral abscess, but ni-itj.'
ol' th. in >h.MiM he <-on-«Ideiv<l as in any way symptomatic of this tvihliti-'L
l»i:<M.N(,>i.._'rhe pronnosis is veiy unfavorable unless the di>t-aH- -x-^
l)e I'r.Mchrd -iir'^icnllv.
TuiArMi-Nr.— TJ„. treatment should be operative if the absct.^? itin W
l«»«':di/« d.
CRREBRAL PARALYSIS.-Iu using the term cerebral panly*
II iiiiiM !»■ nii.l.T,t.HHl that it i< not intoiuUxl t« describe everv di*a* '■■
intiM .•r.iMial .,11^1,, In.,,, ^^U\,■U a i)aralysis may result. Wo mavluivoi
iVMiitii,u paialy.i. f,-.,i„ many intra-oraiiial lesions, such as hydiwvi.yit-
ORGANIC NERVOUS DISEASES.
649
BPebral abscefig^ cerebral tumors, and other muses. The class of cases
srhich I am about to describe under cerebral jmralysis occurs usually io
children under three or four year^ of age. In a fc*rtain projwrtion of these
hetnitrrhage, einbilisiu, aiul thrombt»sis art* the causes of the twixte
ftptoms. Most of the autop8ie8 whieh have been made have shown
cTenjeLs, atrophy, or i>oren(X^phalia, which are pn>bably scx'oiHlary rather
ban primary. In tht^?ie latter ea^^es the original primary cause b not
known. Cerebral paralysis results in a spastic paralysis involvuig one
I or more extremitie?^, and may be in its distribntitm monoplegic, hcmi-
^legic^ paraplegic, or diplegia
I Etiology and Pathology. — I shall first speak of the three known
primary causes which I have just men tione<l, — namely, (1) hemorrhagt* (rup-
ture of one or more bl(Mxl-\'t»sssis)» (2) emb^ilism (a Ibreign b<xly l>rought to
, the brain fiT*in Koine distant part, of the circidatory appamtun), and (3)
,4 tfaromlwsis (an cKrluHiim of one or more of the cerebral blood-vessels by a
^ local coagulation of the blood).
Fkk 95.
Br., Bruin, ilctu.^ Utimurrhu^t:, Ar., JLradinuid.
Of these three known primary causes hemorrhap' Ls the mi>r^t nunraon,
I This heraorrhagt* i^ umre apt to \m} meniupnil than rvrebral* It i> for this
[anatomical reason tlnit the?^' canes of hemorrhage in infmits are less liable to
taJtad than thosi* whiHi occur in adults. I hav<* aln^a^ly descrilM-d to
a ease (Case 186, page 44H) of pn^nmahly mrningtal hemorrhage in
[an infant three days old* This case illustrnfc'd the |>o<*8ibility of recovery in
even ^vere ca^^*?* of iutra^^Tanial hemorrhage*
Thrtmgli tlie kindnes8 of* Pri)fc»8«ikr Nortlirup I am enabled to nhow yon
Ithis s|n^imen (Fig. 95) of a case of meningeal hemorrhage in an infant
>rn prematurfdy at the eighth montk
050 PEDIATRICS.
'I'lie iiiotluT IumI |)uer|K»ral ixjnviilsions, and the delivery wa? bv??-
<'<'|)s. Yoii SCO that the hemorrhage is in the hx-ality where ii k itiJil;
found ill such rases, the ttniMirarhnoid apaee (vide l>iagram 8, pap- '-^a
Iiitra-<>ranial hemorrhage in the infant and the young ehild mayari^pi
various iiuis<»s, siirh Jis in<'nust> of the intra-i'ranial pressure firm viiiiB
iliHas^s, whi<'h pnKhice sta^^is of the hliHid-inirrent, or inim traumata, viifCi?
Inun |)nssim» or from <lirei*t injury to the skull and the brain. Inailiit
to ihex* f:iiis4s, certain ehangi»s in the blood-vesnels themselves, ivpres-
in;; an atliei-omatcnis condition, are supposed to give rise U> intra-OTiiil
lieinnrrhap'. Certain forms of degeneration niay i^use sueh a dL?oiescfr
tion of the walls of the <t'n»bral bhnd- vessels as to result in henwrrat
In thi^ latter <*lass syphilis is a factor whieh must be considered, az* must it..
a<*ct»nlin»r to Sachs, g«?neral tul)ercnlosis, meningitis, and eerebral tuIDfl^
Nt'xt to hemorrhiige, eml)olisra is the most common cause of ilii> *:«
of <"<'i'ei>ral paralysis. S) few cast»H, however, have thus far been sMti*
tnrily invcstigsit^'d hy |M)st-niorteni examiuation.s that I shall notdwdlqrt
this <-«»n<lition, nor u|)on the still more rare resulting }>atholugi<:al kiic.
thronilHJsis, exci'pt t4) explain that tlie emboli and thn>mbi act bvcnnis:
oil* tJK' l)lo«Ml-siipj)ly of a oiTtain jwrtion of the brain, thus prodaciigii
di.-iiitcjrration of the <*(»rel)ral tissue and the resulting paralysis.
As I have nstnl the t^Tms s^'lerosis and porencephalia, it may beWIt
<lctii)r tht in.
Nr/r/'o.v/.s <'onsists of a shrinking and hardening of the cerebral "ks
iisniilly more or less strictly hKiilizcd.
rnrrnr, ithnlin <l«'notes a j)athological hollow or degression in the lc±
niiniiiiLi triuii the cortex towaiils the wutre and usually communitating'ni
a hitcral vcntri<'lc.
The •r^'Hcral |)atIiol(.iri(.al <-on(lition3 to be rememl:>ered in cerebral pn.-
y-l>, no niMtt^'r what the orijrinal h»sion, as has been so elearlv siimmarij-!
i)y I^)V(tt ill his paper on *' CeiTbral Paralysis in Children/' are, fiV.i
Irsinii of the i>rain involvin<r, as a rule, some portion of the motor t»'.:
aiKJ. sii-nii^K atrophy and n'tarded <levelopment of the brain, with a deW)'--
inn dc-ciw ration of the lateral <»olnmns of the cx>rd and pyramidal ti»t^
Kiiially, tlieiv is a possibility that the cause may be a defective devekpnri!
of the nei'Voiis e<'ntres.
Cerel.ral i»araly>is may octMir in connecticm with a number of dtrt:*
surl, :,. the aeiite exant heiuata, iK^rtussis, diphtheria, parotiditis trji^c
i\'\i'\\ and alter continued convulsions. Difficult imrturition, withorvii:-
<mi the n^e of fonvps, seems to 1k^ responsible for a certain number of 'i
>|»a-tie ea>e>, Inith parajdciric and hemiplejjie.
SvMnoMv.— Ilavino- made this preliminary explanation of the kitJ
and extent of the knowieijire which r am endeavoring to convey t^^.*'^
eoihvniinu the cerel»ral paralyn-s of infants and young cliildren, I'cann.*
Mate the important uvneral tl'atin-t^s of the disease which I should like P
have VOU Ve\ue\\\\^v'Y.
ORGANIC NERVOD8 DISEASES.
651
f
4
t
I
r
I
I
If the lesion has Ix^n uf" intrauterine origin, we may get only the later
manifl^tations of thL^ lesion, just as we do in congenital syphilis. In like
mauner, if the lesion has oerurn>d at the time of delivery, the primary
symptom.^ are often masked, and tlie resukirjg symptoms of the more
advanced pathological tx>iidition are n<»ticed later.
Where the disease develops in extra-uterine life it is usually aeutc in
its character and is marked by more or less fever, cumvulsirms, and stuj>r»r.
Tht*se c^rly symptoms are merely th<jse of a genera] nerv(»us explf>sion fol-
lowing an irritation of the ner\'0U8 motor centrej^. They may be the first
manifestations of a disease of any kind» or they may occur in the c<iurse of
cine of the diaeaBes of which I have si>okeii under etiology. If they hapj^en
to occur at night and are of short duration^ tliey may be entirely overlixikcxl,
and the later symi>touLs of a cerebral lesion may be the first ones to mani-
fest themst4ve8. The child may die from the severity of these initial lesions
befr^re the later symptoms of imralysis have deveJojied by which we can
dii^no8ticate the dLst^ase, Screaming, vomiting, and delirium may at times
u^her in the attack. In the midst of or closely following these pirimary
symptoms wmicf the prtmounc*xl indictitions of a eentml nervous lesion,
represented by hemij>legia (iiaralysiB of an arm and a leg on the same side),
imrapl^ia (paralysis of Ixith h^), or diplegia (jMiralysb of btith arms and
bith legs), cases of hemiplegia l>eing the m<»&t common. In rare cases we
find only one extremity affected (monoplegia).
In addition to the paralysis of the limte, facial paralysis may «icriir either
in hemiplegia or in diplegia, and, as a rule, spares the upp<T part of the
fiioe, S4> that the eyes van be closed and the br«3ws raised, thus sliowing that
it is nr>t a jM^ripheral facial paralysis. This form of facial jmralysis often
disappears early.
On examining tlie paralyzed limb we find a resistanoe to morion, the
deep reflexes are exa^erated, and in most cases there is a feeding of rigidity
on the pandyzed side. A few cases of flaccid paralysis have lje«?n refx>rted.
Sensation, as a rule, is not aifectcd. When the child ha*^ t>ome out of its
stupor and the convulsions have eea'^ed, it may be found to lie aphakic. The
intelligence is usnally impainxl, l>ut this, of murs4^s dej>«:'nd8 Ujxjn the Irjca-
tion and extent of the lesion and the jxTifHl when it (Mxnirred.
The intra-ntcrine and t»arly infantile cases sh«»w the greatest mental dis-
turbanfx\ These* children are apt to lye v^ery irritable, and, where the h^iou
IS cortical^ c^pileptitStrm et^nvnlsions are fjuite common. The electrical re-
action of the mus4^U*s is normaL In the more advanced stages of cerebral
paralysis additi^aial symptoms begin to apjiear. The child learns to walk
late, or, if it has already walked, the gait Ix^nmes jxx-uliar. Rigidity fol-
lowed by contracture of the flexor and adductor muMlcs may iKxur, In
certain cases the s|)astic condition is so pronoumxxl that the |)atellar tendon
reflex and the anklcH^lonris cannot lie obtained. When walking is attempted,
the patient is aj>t to ?<taud on the toes, the kuet*; knmk togilher, and the
I spastic rigidity of the nuiscles produces what is c^lcd the s^tic ^alt^
(Jy2 PEDIATRICS.
n^prt-st'iitod in it8 exaggerated form by the cross-l^ged progreseioc na
iti largely miis^^ by the rigidity of the ailductors of the thigh, and ill»:b>
titms of which 1 shall presently show and explain to you.
Till' t4Tni si>ustie guit is applied to the peculiar way in which th«(ii
(In'ii walk. In the uimtv. severe cases, when the child is placed upmhik
tin* contnietion of the flexor muscles is excited to such a degree tk tt
nnablt' to touch his lurls to the ground, and stands on the ballot' ikri<
and the ttH's, with his knees bent. This results in a clinging lalxired viL
wliich iIm' chiUrs tiK-s scrape along the ground and the leet teud too<i
a^iiiijst 4'a<h other on at.i'ount of the contraction of the adductor musik
In the milder e;wes the same manner of progression occurs, butiaoe
su<ldrii and jerky, and the foot can be raised from the ground. Mudz-'
steadiness thus Results in these I'ases.
The artcH'tetl limbs are apt to show some disturbance of their ciixuliiii.
an<l some I'oldness. There are more or less atrophy and shorteuingofci
iNine, but to a less degree tlum in eases of poliomyelitis anterior, bi
n'ltain nnmlxT of cases involuntarj' incoordinate movements are excittiD
the paralyzi-d limbs on voluntary effort (hemiataxia, Osier), and areiaHj
desi;rnat<Hl as |>ost-hemiplegic chorea. There may also be continnuu? m)«»
nients (athetosis) of either a {partial or a general variety. The sphiirta
are not at!'e<'ie<l, whether the ease is one of hemiplegia or of paraplejii. H
epileptitluMu convulsions whieh I have already referred to may appt^'iiiii
earlv in <-<ises of <i*n'l)ral panilysis, but may also be delayed for anumt'
iA' years, so that the |)ossibility of these children becoming epilejuic ma
nlwavs Im- r(>nsi<len'<l.
1)1 v(.No>is. — The irt'nei-al diagnosis of cerebral pamlvsis witlnmt kl-s
tn thr -prrial eaii-e is of irvv'dt practical imiH>rtaiK*e to the praetisiniT [»by
rijin, :ni<l should be thoroughly miustered l)efbre he attempts to dia;n»'*
i'iiU' the exact nervous K'sion or to locate it with the precision of the >kii
nrlI|-nlnLii<t.
The iliaiTiiosis in a niarktHl ciise of the disease is not diflic«ltJ)ut
«l(t«riiiinatinii of the exact lesion is often impossible after the periedol'*^'
lia- pa>H <l :ui«l we are left with a nsulting paralysis. If facial paraka
l>re-eiit, we ran, as a rule, say that the lesion is in the brain; but thisi
<I<M- imt always hold iioiMl, as there have been very rare cases where
paralx-i- was j)re<ent when the lesitm was in the cord.
Th." -yniptorii- on which we chiefly rely in making our diagni>:ii*«»f f
l.ral paraly-i< are (1 ) the (listribnticm of the paralysis, hemiplegie u^uall
|)arai)Ie-ic ; (2) increaHHl tendon reflex; (3) wasting comparatively »li!
( 1) n<uMiial eh'ctrlcal reaction ; and (')) mental impairment.
The |)rin<i|>al <Ii-ea-e from which cerebral jKiralysis is to be distinpii-
i- jM»lioinyeIiti- anterit»r, and I shall in a later lecture when si)eakins;of
<li-ea-e explain to yon tlie -yni|>toms by which we can make a difleiei
<liai:in»>i< hetween the two <Iiseases by mc»ans of a table (Table 104,
GT'J). Fvu' \\w vwYvv.^v^ v>'i: vVvo:\\v->^,\\v>\NvNvvT^ L ^kUI also state herethi
ORGANIC NERVOUS DISEASES.
653
Aotradi^tmction to the chief diagnostic symptoms of cerebral ]>aralysis
Biiicb I have just given you, you will find in poliomyelitis anterior (1) that
H^ distribution of tlie paralysis h usually raouoplegic ; (2) that tliere is au
^psenoe of tendon reflex ; (3) that there is an abt^^nce of rigidity in the early
Hplges ; (4) that there is rapid and marked wasting of tlie atleeted limbs ;
^) that the reatHion of degeneration is present; and (6) that there is no
tental impatrment
111 certain cases also a difficulty may ai'ise in correctly understanding the
hition^ship lietweeo cerebml paralysis and idioty. The cerebral legion h in
Eny caijcs prubably the Hauie, but, acc«jrding to its extent and Ir>cation, we
y have either (I) a cerebral paralysis alone; or (2) a cerebral paralyjsis
ompauied by mental impairment or idiocy ; or (3) idicjcy without cerebral
ilysis. There is a certain class of low-grade idiots in which some
ipairment of motit»n ejcists, apparently due to a mental inability tu oxirdi-
the muscles of the limbs properly. This may sometimi^ be accom-
lied by a diminution of sensation, which seemg to be due to a want of
eroeption in the higher nervous centres rather than ti* any actual le^itiii of
sensory tract When the idiot's attention can be kept centred on the
Rmb, the actual sensation di^es n<>t ^seeni to be much impaired. The diflerexi-
il diagnosk of this condition ot'cnrring in idiots from cerebral paralysis is
sily made, for it exists in those teases only of the ibrmer where the mental
Bvelopment is much impaired » and it h not^ as a rule, aeeorapanied by tnie
Jysis, an there is no weakness, but simply incoordination ; in tliese cases
the tendon reflexes are, as a rule, not increast'ci
Cerebral paralysis can be diagnostieatc*d fr».>m the jiaralysis w liich occurs
connection with caries of the s|>iue, prineijmlly by the pre^feufx* of cc^re-
bral symptoms in one case and the prominence of the spinal vertebne and
the rigidity of the spine in tlie other.
I should also mention here that the rare cases of syringomyelia may
mistaken for cerebral paralysis. The i>^tif»ts of differential diagnosis in
cases are that in eyringiimyelia, altliough the weakn€^ of the limbs
ly be so extensive as closely to simulate paralysis, yet the diminution of
ermic sensation, which I shall presently spc^ak of when dt^scribing the
to you (page 690) » easily distinguishes it from the normal scnsa-
which is present in cerebral paralysis in cases where the test for aen-
ean be employctl. The dii?ease, however, is so rare in children that
it neetl n(»t Ik* dwelt nj>on.
m Progndsls, — The question whic^h immwliately arises when the physieian
BB confrrmted with a case of paralysis in an infant or a child is, What will
me the result of this attac^k? not, Wliat is the s[)ecial anatomical lesion which
■i causing it? Knowing, as I shall prc^sently explain to you, tliat where the
ngion is of spinal origin the (»hanc€5^ for recovery are fairly good, you will
Ht once appreciate the vast difference which your answer may make to those
Biterosted in the child when yon state that tlie disease is in the cord and
■lii recovery is probable up to a certain point without mental impairment
tiM' imiMi IS iniK'ii oiiHHM>i<Ki. iiie (KX'iirreiice or epuep
(•<rcl>r:il |Kiral\>is is so (tiinmon that it should be esixx-i
tlii- i-oiinf^-linii, as it makes the prognosis much more Hori
di'trn-^' to which th(> mental im|)airment may attain and &<
I atii'Dt.
K\<-<|)t in vvvy nin* ca^es, the ehildren can be taught c
Tkkatmknt. — The tniitmeiit of eorebral paralysis u
uii-ati^tiittorv. It is to Ik? directtnl to keeping the pars
PhhI a ('onditioii as |H)ssihh* and thus avoidui^ contractu
'1 hi-* <an U> a(H*om|>lishe<l in a measure by patient and <
and nianipnhition, chiefly in the direction of stretching 1
an<l cultivating the nst» of the extensors. The faradic cu
t'niir tiuHs a week for five or ten minutes is a useful adjuv
sarv, >ur^ical int4Tfen'nee to relieve undue tension of thi
indicated.
The mental t mining of tlM»se causes is exceedingly imp
In* Mttcn<le<l to <ai'efully. In this eouuection it is well to :
division ot' the <'ontracte<l ten<Ions iu iioine way seems to u
cnii<lition. Trephinint^ the skull over the sup{x>sed seat
imt, with our present knowlfHl^* of the usual nature of
M lit a partii'iilarly <'ncoura^inji: outl<H>k. The few cases
nprrMti"*! n|H)n have not Ikhmi lK?nefited.
It -^hniild Im' thnnm^hly nnderstfKxl that surgical oix>ra
eMntirjrtuie- do n«»t iiithKMK-^' favorahly any pre-existing p
dliiMtl'iii. I)iit that it otten )Mits the lind>s in a ciinditicui
:hi<1 . Ir.tii«-ity eaii he a|)plie<l to ^n»:iter advantajje. The
di\ i-inii of the trndnns ot' the contraet<Kl niuscrlcs exist ^
tlir*' I-- -o linn lli:it t liiirmiirli triMitnwiit. \w' v>t«feo^i««.«.,^ 1 -
OBOANIC NEBVOUB DIBEASEB.
655
iinpruvctl theory of polioeni^pfuMw as one of the caufies of cerebral
aiysis. Yim will, however, now uuderstaiid how inadequate are the
iou*i nam€*s, ^uch as njHi^dr pantlifmn^ npaslw rh/Ulifij, spaaiUi dipUgia^
!/e*« dUvaHCj and infmiiiir lu'mipkfjia^ ttj cover tlie bnjad range of pathiilogy
I eymptonis which is represented by the class of cerebral eases which I
^e desiEjnatwi iyidt*r tiie general term rcnbral jmrtdt/mH.
I have a nnmber of eases here to nhow yon whieh repi-esent this c<:iodi-
I of cerebral pai-alysis in children.
The first ca«e h a boj (OftM 294)^ five jeere old. Up to the e^e of teren monlba he i»
to have been in a normBi condition. The d»*eaii€ -which wa* followisd by the «7mptoiiii
ch he now piwents occurred when he wa« seven month* old. At this time he was
eked with fever and a convaUioUt *^d later wat found to have pAraiysIa of the right arm
both legi.
Cabk 294.
On examining the child you aee that tbe thurnb i« tuniod in on Ibt j nd
the ftni^rs are alightly flexed and at Umof fUgbtly i'xUMided. Both legt are aorocwhat
•d at the kn<?e«. The hamstring tendons htv^ tcn»c and unyielding. The kiiee-Jorki af«
Mied. The heck are raised fTDtn th*^ jcn>und.
ThiA child ia a oaie of hcTniplc^ia with affection of the oppoaiie tog.
In mild oasotof this kind the tr«'iilim'ril i*> by iiium>iii£c< mtd etiMrlHdty ; In Uie more
<n forms apparatuti is nx|uired. In a very tevere form like tht», operative inlerlhnstiM
666
PEDtATRfCS.
b nocoManr betet iiiiMa§li» itomricityt or uppftmuji can Ikh iip|ilt«| «4i| t^
In ihU CA»(^ di^iiloii of llio Imiillriog tcndati^ «Ad of ihe Aehilles tefubsi m mk
Op4«mUvf* priH'4^Hlin|rA in cuic^ of thU kind mimi tio rvoo^i^smi a» only neatni^^p^
tion And pn'}Miritig the limU for funhMr t]>Mitmi?ul by m«Rnmpe, t^Irt^tnrifr. tad j|pH
Thir next CUM (Cib»c 2^^) U a girl, live y«an old*
8bi^ liiiii H gfMid rminily hUUrry* Ttii* Ubor wma iMMty^ mnd wai- i^^'t ■oillBaaflA ft I
dovdopod well vkttd wot bcnltby until ahi* wb« Ujh maniiifi aid, irbea tiVMMiBlii |
•bf dM t)i»t inovr hor tiniiA lu aHq (lu^bt to, that the did not uf^e ht*r lell mto •lftU,ttllft
tbo lell leg watt txui Ui«d na well h* tb** ri^bt. Tbb conditiou Im^ pcgtkteL
ftenbml pikralfriiL Dij^leirljt ThvWfx
'^1 iiior»' ihiiii the ri^C
On * xamiiiHtion you set* that .he ba). *tmbbmu«, Sbe dumoi >i,,ld her hmdvpm^
She c*tiiiot .11 up ulom or *t*ifid. Her head h .nmll and tiarrnw, and h^ . llr «»-►
poiterior dmn,.t.r. The r^fl.xe. ^re inon...«i The power of her left arm b ««d ^
paired, and there i« jiome cMmtmetion of the fingers liiid l>Ujow of * .rm»tk^ «hm».!i«L *e
do«. not move her left leg well. The .ensi^tion b dulk^ alike i„ bouT^rH-Li.
*n Idiotic eipr^..ion, «h. i. f^K^rlv develop.^ menUiUy, and *he cannJ^iX
bhe .how. the form of .p«.tio cerebri panily.b which i, L^H^i LwU ik tt
e^tremm*. be».,. mon^ affected tha. the ri^ht. The fac^ i^ ^^^ '^;™ i7Zlr
The pPo^nn.i. of H ,^,, lib,, thi. IB unfavonible go f»r « ^ tntlm«-.
ajjcount of the great mental impiimnent. Operative treatment ia h"" '
ORGANIC NERVOUS DiaEASHB.
657
This litUe gnrl (Case 296), two yean old, was bom alter a severe instnimentai labor.
8li(* hft^ ttlwajs from birth shown weakness of the arms and legs. She was mitible lo
r up until ^he wafe- a year old, and she has never »tood or walked. Uer intelligence ia
p|»arently nomiaL You see that the cranium U norm&l in ahapoi that the parietal emi-
enoc* are somewhat enlarged, and that the fontanelle is stiH open. There is no dLsturb-
oce of the faoial mii^les. The ri^bt leg 'u BlLgbtly larger than the left The teeth are
excellent condition. The upper extremities appear alike*, but she cannot looaen her
ItijO^ere* iil\er grasping an object with her ripht hand. The epiphy&es of the wrUt are much
"^11 laired, and those at the ankles are slightly so. There is no detnite rosary. The bai^k ia
Cask 296.
OerebnLl paralysis, CongeaJtal ucfLLral diplegia and rhacbiiU. Female, 2 jetin okl
aewhat riierid. There it no marked defiirnjity. There ii a tendency to rigidity in both
f lower extremitii**. The feet are inverted. Tht* pat** liar reflex w •« iucreaicd. Sensation
is normal. Sbo can use her hands well, except as above described.
She repn^sents the class of cerebml paralysis which is called cerebral diplegia. Tou
I that 4he \» also rhachiUc
Here is a little boy (Case 297, page a68), four years old, who waa perfectly well at
birth, but who when he was six months old had a number of convulsive attacks without
- any known cause
■ When he was two yean old he had an attack of measles, followed by varicellat and
B later by pertunsis. He has ncvc^r been abl« to sit or stand alone. He is fidrly developed
^l^d nourished, and his intelligence is normal, Ue has marked |i?enerml kyphosis when
^■pttpportod by the arms. When be is aswsted to walk be nlao shows the condition of cross*
^B>BS^ progresiion. The arms are somewhat atitft and ho hi»ld4 the forearms slightly
pn^natoil. The triceps reflex is somewhat increased. The b.»p* an? usually held Runi'what
flexed on the body, and the knees are also eilii^htly flexed ^ with the feet in the position of
•light equinus. The koeea ai« held closely toi^ether. Kigidity is less marked in the ri^hi
42
^K
PEDIATRICS,
log than in the loll, Tb« fMiteilar reflexes aro much incTe#«#d, And MtkIt4lR8aik|i
Thttrv M very markid rigidity of the leit «ide, ao tluU the reHeses m illiH
diaculty.
Tht« treatinent in euch cAiei lu thii> where Ifaers is no RMtfitaJ nspilnnat^inili I
op«mUvc, Section ot the tuld acton of the thj|^h, of Ihe ttexor teodowof tltb^flti |
the Achillm tcndoni It indicated.
Thi« n<^it biiy {Ctm 296), five and one-half y«aj« old, hmm nolluii^iB kiifM^pbv |
that heftTi upon the diieu* with which he is affeoted.
Nothing of ail ahnormal nature wnn noticed about him uiiiil h» wai flAtK8«li«
leased pffvi«i«Htian, llaW.SSf«0^
wlieij U w!L^ iMUfMi thut he entild not walk. He had more or l«aa metital hiiiBlfrTr
ttigmus, fitifrne-is of ttn- mliim'U^^ arul ilejtor muHt-le*, and parens cif the t^Uftmm*^^^
extremities, Tlu* kiitM>jfTks are' much iiicn?iiJN<-d, and ihtfire la uli^^ht aakl^^gonts. IT**
in ihii i'hHmQU*ntiik' manner oillod cn:»«?^l»'g^eti pmg^re^ion.
Whcin nn infant he evid<?ntly had some cerebml lesion, &tid he RpiiawM wrr
whM I hiiv*. explained to you a* .p*istio pamplefiria. There y^l\ prx»hmuf^^h»^
provement in hh phyRip^l conditiun, nnd hU mental state will nlwars bp iinial^JkMT
This boy (Ca^e 2(K*1, ^ix yenr* a[<i, h«i^ no history »^f uny hMtvditJMnr diMib
Hp was htnilthy at birth, but the labor was a severe one, and wu^uvmlaoldl^
ORGANIC NERVOU8 DISEASES*
659
tlifl wna eighteen mo&th^ old. He te stated to huve had convulsions in his third yenf^ uid
ItlieM oonvukions occutretl a^in whfn bo wu* four yenn old. They were foUowt^d hy the
ilysis for which he h^ cume to the hu«pitiil to be treiited. He does not use hu left bund
r Weill and the gniitp of the left hand is less stnmg thun that of thi^ right. Tlio trie<.'{>8
liefiex b exaggemted on both fildes. The left foot can with difficulty be fleited dorftillv.
[The right knee-jerk is normal^ the left is increased. He has flat-f(K>tt and walks with Ids
I left foot rotattnl in. He is now six yeare old, and is otherwise well and strong.
Thih U a case of loft spastic hemiplegia.
The treatment in this case is by mascage and electricity. Apparatus doe* not M*eni to
I "be indicated^ as its c>nly use is to support the limbs or t*? cormH^t deforaiity.
This Ih>v (Cii^e 800) is four yeare old. There is a history of phthisis on th** ftiiiU'riuii
Cask 299.
OasK m.h
two years' tlumtlnn. Mulr, r' yi'Ar* I'l'i
Male.
His mother has four other, healthy childrf^n, but has a hbtory of tlirtv mifcarriages.
Tbb child WMS Iwtrn prematuwlyi and lh*> delivery was tnMrutnentJil, Hi« ho^ itlway* U^n
delicate, and had an attack of measles one year ago. He did not utti'mpt to walk until
he wuM tUrtM* yvfKi> oldr and it wa^ then n*>ticerl that b^^ did not uao his kgii w<'l(. Hi* is
mentiiUy normal. HIk arms appc*ar to be nonnnl. When placed on the (Ifior he gf*Lii up in
a manner like that which if ihown in cttse§ of ji«eud<KbypertJMphir nuiM-ulnr par«ly«U,
When he stands hij» kneeA are highly dmed and a<Jdiict4^i, Hi< walkN f»n hU tof.^, with a
I lendiincy U} tn»5 thcr knis«& This tendency can b« only partially oyeroome. Tb)ct«. \% t)i9>
♦JGO PEDIATRIC38.
a|ip:ipiit sitrMphy «•!' iin' iiin«c1«'.s. Thi* knc<*-ji'rk8 an? ^lit;:htly increased, and :br> ;?•_-■
siiikl"' rl"iiM-. Tho .-kin j-h^'W.-* jionu* disiurlwiriw c»f ciroulHtion.
Hi- r«|»n-«iii- iIh" rlji-s iff o'D'hrul panily!»is which hu> bcuri de^ii^r.ut'ii ':«i-;i :xv
pli-iriji. il»«' ««pli:iii!il n-nOmil I«-i«»n huvini; urtW'tvd the Ifjijs only.
If ihi- iliiMi* o»inliii"ii is u«»i murh iiupMvi'd by pasjaivo xnovcment* of rbtb:?^
iii.i-.i'.:.-, ii may lu- luivipuble Ut msort to opi'nitive treuttnent and divid«- thi-iK.iv ■--
ttiv.ir mH'.i-li'^.
I li:iii|M'n to have here in the wanls a case which appareuih- rr-prfstE:-
iUr >ym|it4»iii> of tniumutic hemurrhage.
Tlii> litil' L'irl i(':i-«' :»nl) is four yeuw and nine months old. Sh** was br::"'.:: -- I
h'-pit:il K- l-ruary 'Js, with u hi.-torv nf haviiij; fallon fi>»in the roof of u ihrt-r-?: -7 ■ j.^:
up'-n a l»riik -:«l'walk. Shi* w:is unconscious. She vomited £(lis;htly, and -b- ttu.-: .-.
have an •■irliyin">i'; «»n tin- 1»*1\ i^ido of her h**ad. Iler pupils were eijuul a:ii pxrA.
liu'lit. Ht-r n -piraiii>n- wrn' rajiid ; thi' cxtivmities were* cold. She mnyf-d a.', ir.':"'
viu'.P'ii-ly. .^.-nii- il-'tti-d 1»1«iik1 wus found in and about the nostriU. Tho temjw ri!':^ Tr
.'^i.:i- V. '.\h.\-' F.»; till* i»uU«* was IH), and th« n.*spirutions wore 26. Sht- sir ^uik :•.::■ ■:
ait«i iii-.i «'iit in the nii^ht. Th«* nmsi^lcs of the left arm and leg moved ui'tivilj.
Dm i!i«- ii'\! ilay it wa«i found that shi' duikl bwallow milk. SIk- i^i.—-] hr? ;"
iri\-l!i!it:iril\. ."^Ih- \\a-» -till uni'nn>cious, and the iiiovcnients of the left arniLiii-: ■
liiiti> .|
On tli." f.-ll.i\virii: day. f'»r a j-hort tinn? th<' ritrht pupil wa«5 lanror than ih^ .'':.•:
W..11I.I i...t rta.i i'» liirlit. Alihi»u«:h she cnuld not s|K>ak, h«»r oye> would foll"W iL- i.:-'
tip- t \.-- :il-.. h:i>l a ri-.tU— in«ivi-nn'nt. An cni'ina pmduocHl a pa^sa•^• »if a i-iiuj -■-■:-
"f I'l.". - aii.i a l«\v drop-* of )»Ioim1. Thi* ni^pirutions wen* verj- de^'p. and ih- i* «■«
ilii^h. .1.
<>!i ill.- t'.lliiwirii; day ^lu' >till contimn-d to move h«»r left ami and U-jr. wbilr n- v-
arm aiul li-i: r'-niaiiiiMl pa.— iv*-. The puUo wa* irrej^ular and intentdtt»'nt ^j- *-■
n p -r:- <1 !■• liM\f >lipt UKin- than at any tinji* ^incc the accident- She wa* still u:.c«*. •■
I'u: W.I- li-> v> «t !•■--.
0!i til- I- \t <lay thf ]inl.-r wa-i irn-irular, a- it was al.-io two davs lati?r. Tt- :•-: ■
W'! ■■ ::i:.;. riii'l -in- -.jmim-.I Imt ryv^ and fixed them on ubjecU at linirt. >-' ■■
1 ■!. "i i. :•■.'- I'.'l \:iwii'il. Shi- \va- >till unc"»n'-cioiis.
'Iw.. .l:i\- i;i!.r -Ik- had -llLjlit npi-thiHiMuis, and there were spasmodic moTKDci'-* ■
til- :• :• :i:rn .-I'-.l l--.:. Sill- -h-jii a i:n-at deal.
n-. rl,. rll .wiis-ilay -h- ap]Man-<l ])riirht«T, and followed objects with her ew- B^
]»Ui-'- \\;i- i'li "jular. I'run H» to '.M).
'r\\...|;i\' l:it-r «h.- -MMii.-d l.rii:iitiT. and moved the left arm and leg less. Ski^*'
Mi.ci.- \. liii.tMiN ni..v.-Mi.'Mt-. MU'h a-» to pu.-h ohjwts away from her. Onthi*diJ^
i::i\- • \\<\- I ' ■■ til It ~li.' uinii'i>toi.d what was said to her. Three days later she ttoA-
p.. . _.-. ■;/. I,...- 11. ..1!,. r.
«)■ i; .. f..!i..wir,i: .la> -h.- lu-i^jin to use her rijrht arm very slightly. Sheat^ifl*^*
M- ■ V, 1 • I* li-|i< - •iUitc r.i'1-ci..ll^.
T". •■ \! .!..> -li- rtpp.:irv.l M,..n. int.'lliirent, and on the day after thttiheks*^*
I1 w I- r.iin.l. h.iwever, that .-.he o<iuld move her right am Ui»-*
> • .!- ?:• .. -I,, lia- alway.- h.M-n i>orfectly conscious, endeavors to «vtv
• ■. ■ • :■•• • i.:.-l-- : i-. tin- wanl-. a.- Wflj lis her playthings.
T .-: .;. !i- -A- :.iv-:.ii ih -hiy fr-.m the time when the accident occurred,-a.*v.^c*^
^;.- ' t 1 -.1 M. Ill .11-!, will, .iiili.-iilty, a-- tiie Hi;ht lei; is very unsteadv
.-}.■ :n.|..r■.■.:^ !,.-.- i.a.) m j.-^i..,, ..„ the left side of thJ brain, reVrewnted by » br ■■
i1::il:.- ;,■..! .- m-'l l.y :rMiitii:iti«!M.
.<:.■- ■; .■ M l.i-t..r. « h,.- w.-k hifr >ho wn.- disehargred from the hi^piul. Av. »'
t!-.-.- •!. .. .ii i n- :i,. ri.J.t :.nM f:.irly wrll. hut walked with some difficultt 01 *« :
■■ ' ■• ' ' '' ^''■' '■'^^" •'- '*'•'' articulation was labored, and h^r'j.ui :• ^ *
OROAjnC NEKVOU8 DI8EASES.
661
ATHETOSIS. — Athetiosis m a symptom, and not a disease, and b repre-
[eented by oontinuoua incoordinate arhyttimical movements of the? extit^m-
■ties, the fare, and the body* This condition may be acquired or congenital,
I acquirttl Form may follow casen of hemiplegia or dipl^ia, in which event
lit affects the paralyzed limbed. Certain cases of acquired athetosis occur
[without any accompanymg jxiralysis. In congenital athetosis, and in the
i&oquired t3>rm without paralysis, the symptoms usually begin in the lirst
Pathouxsy. — The pathological condition which exists in cases of athe-
ttosii^ 18 supposed to be a chronic cerebral irritation in the neighlM^rhtMid
[of the basal ganglia and in the internal capsule* The condition as we
it clinically, therefore, is wholly a symptom of some organic lesion of
f the brain.
Diagnosis. — The diagnogis of acqmred ciihdmis is made by the charao-
[tor of the movements. These are oontinnoas, and are distinguished from
Itliofie of chorea by being vermicular and less spasmodic.
The diagnosis in c«ses of congenitfil aihdoms is not difficult, as in no
other disease does an infant present at birth these peculiar movements and
,i this grotescjue ft»rm of flexion and extension of the fingers and t<Jes. The
1^ disea^ calltnl mngauki! ehorrn^ m which involuntary arhythmiaxl mr>ve-
B mentd exist, m distinguished from athetosis by the character of the move-
V rnent^, which rc^scmble thf>se nf ordinary chorea.
il
Case $$02,
OoogenlUl AthetGtIi. Floiude, 2 yeiin old.
Prognosis. — The prognosis of athetoRis in r^:ard to recover}* is un-
fiivorable. ' So far as the general health is fjoncemal, the individual may
develop fairly well and may live for years, as in the case of a man, twenty-
two years *jld, re|>ort^*d by Bui lard,
Trkatment. — There 18 no known tnnitraent which haa proved to be of
benefit in children. As they grow older the trmning of the affected limha
662 PEDIA*
may Ik» iiiidt'rtakon, but, as a nile, the
and oliH-trioity have pnivoil to be of m
I have hen* a little girl (Case 3C
dition of eongi'iiital athett)sis.
Sht> U two yean old. She has never h
noniial lulx>r, uiid hai^ received no subsequei
niurh intrreKt in hi*r i^urroundings, norhaa she
tuit MipiHift. Th(> ImiwcU have alwuvK been
dovi*I«)|M'd. and, as you 8i.h>, well nourished.
Tho diwase U charactorixi'd by the contii
the brad, trunk, and extremities ; these mov
^tant fl('xi(»n and extension of the hands and :
ward and a^isununi; nw>!:t grote>que positionf
The expn-snion <»f the faee, as y<»u sw, is not
cannot <letennine the reflexes, on account of
She iii usimlly irritable, but occasionally smilei
who an* iH'jir her.
Till- pr.»j;n«Kis in this* ease, so far as reco
no es|H.'i>ial reaMin why she should not live.
INTRA-CRANIAL TUMORS.—
of many varietiis may o<vur in the
common inrm of intra-<»ranial tumor
an' ^lionuita, sarcomata, and glio-san
ciirehioma, ]i|M)ma^ myxoma, and tei
^nmmata, whirh ixxv si» fn'<|uent in 8
and early eliildluMKl. Tlie i>anL^itic
fiiHjiuMitly ill individuals in otiier |)art
are s(»ldnni met witii in tiiis eountry.
These tumors may Ix^ either of int
the tulHTeuliir is the most <*onmion.
Pathoixkjv. — The tufjrrrutar tur
as i\ rule, secondary to a tulx^rcular gi
or to tulx'rcuhir disease of some j>art
Tli(»se tulMTcular tumors may Ix* siugL
connnon viiriety. They may Ix' fou
meuiu^^es, and occnr with es|M*cial fre<
vary in size from a small colKvtioii
inass<\«^. When one or more cheesy m
in ditlcrcnt jiarts of the brain, the c^>n(
(jHuinnfn ^Vi\\\ most fn»<juently in tl
sonn'tinies develop in the irray matter
raj lid ly than sarcomata, and never
usually primary, l)ut may develop a
(Starr). The sanM>niata are hoth of
celle<l variety. Altlmuirh not (juit<' so
are uvvn^e Vwhyvh'wV vV\v\\\ \V\v^ 'gLV\v\->'A.vvKNr
ORGANIC NEBVOCS DI8EA8GB.
648
I
I
round in shape, and develop both in the nervous ti^ue and in tlie cerebral
mcmbnineiii, and m lioth the white and the gray matter of the cerebrum and
cert^lM^lhitn, Tlie fithtT varieties of tumor of the brain are so rare that they
neinl not Ije eon.sidered h€»re.
In counection with intra-cranial tumcFrs, I mij^^ht mention tliat inira*
ernnial aiinmsm^^ acxL-ordin^ to Stiirr, aiH? rai-e in rhildhrxnl tiud an^ never
verj' larpe. They inerease in size rather num* rapidly than aneurisms else-
where, and show a tendency to rupture. They are found upm the larger
arterie*? of the base of the bruin and on the Sylvian arteries. The patho-
logical *xmditinn of the brain in the ut^ighborhood oi* these gi-owths is s»ieli
as would result from the imjxxliment ti:» the bltMxl -current in the small
vessek, or from compression of some of the larger arterial trimks. The
oondition Ls usually one of amemia* The anteniia may Ix? suffi(*ient to im-
pair the nutrition of the nervous tissue. As a still later patlio logical con-
dition in these caees produced by pressure, nrem of atrophy of the brain
may occur.
Symitoms. — The symptoms which result fmm intra-cranial tumors are
very numerous, and are rendered all the more difficult to recognijie in in-
fancy and early childhood by the pronounced nervous phenomena which may
result irum even a slight degree of irritation or pressure in the young and
undeveloixxl brain-tissue.
The general symptomi^ var>^ verj' much in mxiorflan*^ with the sixe and
vascularity of the tumor, and ac<Y>rding as it is growing or has l>ecorae sta-
tiouary. In the for nit* r ca.se the symptnuis are nt\vn apt U> 1j<» more severe
than later, when, the tumor having liectuue stationary, the brain-tissue adapts
itfielf to the new ee^nditious pnKbiced by the morbid growth. Intnw^ranial
tumors in infaut«t and in young childreu are often latent, present no symj>-
toms, and are s^jmetimes discovered only ailer death. A certain numl»er of
ca^e^, on the other hantl, present only general symptoms, sui'h as hcadarhe,
cerebral vomiting, attat^ks of vertigo, c<:invulsions, and optic neuritis, which
oiuse us to suspect intra-cranial disease, but give an indefinite idea of its
lix-atiou. Again, these tumors may pn»duce lf»cal symptoms in addition to
tlic general ones. These local symptoms are represent!^ by paralyses of
diffcnnit kinds, anomalies of sensation, affwtions of the special senaes, and
staggering. These later symptoms arise according tti tlie site of the tumor
and the parts of the brain whi<'h arc atfected by it, and by means i»f them
we tan more or less approximately judge of its situation, size, and mj»idity
of growth.
1 shall not enter here into the various c<»mplex ipiestions of brain locali-
ion, but shall reefer you for further in f format ion to works es|»e<nally devoted
to that subjcvt (Keating*8 "Cydofwidia of the Disease of Children ;** Starr).
I may, however, say that paralyses of the extremities are caused by an afleo-
tion of the motor i?ortex, the intt^mal capsule, or any portion of the motor
timi on the opposite side of the brain above the cnissing of the pyramids.
Staggering or cserebellar ataxia is suggestive of cerebellar disease, while tlie
<»t ataxia is to Ik' (listinji;uisiic»a trom that \vliK*ii is found ;
ami wliirli is due to an inability to coordinate the mus<
oxtnniitios projKTly. This latter form of ataxia is much d
tli(» foriiKT, each step IxMng insecure and unsteady, but wi
and sudden rei»liiig, after two or three steady steps, whi<
(vn'lH»llar iorm.
In youn*!: infants a tumor may cause a protuberance of
skull by i)usliinjj: one of the Ixmes outward, as was seen in a
ei^hi ninnths old, of teratoma which was operated u|x>n h
the City Hospital, and which is one of the few instances
tuinop on HH'onl.
I)iA<iN()sis. — The diagnosis of tumors of the brain m
majority <►!' eiu<(s Ik* made by elimination. The variety c
determined most readily by amsidering the history of
whrtlier it is tulnTeular, syphilitic, or otherwise. The diag
can oftrn 1h' made by the slow and grachial development
When severe headache and vtmiiting exist, followed by
moiinpleoir or liemiph'gie, esiKH'ially if this paralysis dev<
shnidd sns|MM-t the pnsenec of s<jme form of intra-eranial
siispieioM is iniieli stren^thentnl by the presence of optic i
atrnj)liy. The presene*' (►f IcK'alized convulsions in such ca
linn the dinirnnsis, while if marked ataxia exists we are jus
inu' eerelM'llar disease. A normal or only slightly elevated t
thoe syinptonw whieh I have just mentioned also points to
a <'erel)ral tmnor.
I*k<m;n()sis. — The j)rotrnosis of tumors in early life is v(
no matter what th<' variety of the tumor may l>e. Altho
ORGANIC NERVOUS DISEASES*
665
In regard to what I have said eon earning the latency of tumors of the
in^ the case which I showed you in the wards some dajrs ago exemplifies
be ejctent to whit^h this latency can exist where the tumur Ls tuliennilar,
I have fciiMlay the opjK>rtimity of presenting to your inspection the results
i>f the autopsy on this case.
You nmy remember my telling you when I wm exftmining this in&nt (Caae 804) while
*■ ftliye that I could detect nothing ftbnormttl exti«*pt a mtjdenitely raited temperatun? by
which I could di^tjn^ish it f>om the caae of infuntile atrophy in the next bed, which hrid
*^' an almost ideudejU tompemturp and fiiniilar eymptcma*
The infant was thirteen months old, had never had any especial disease, and entered the
llioiprttal weak and emaciated. Its mind wa£ clear. ItA puUe wfts weak but regular, and
1 neither »low nur quick for its age. Its temperature was at times somewhat rais^, varying
tlh>m 87.2**-88.4** €. (99®-101° F.). There were no convukions, and no paralysis or con-
|tnictut«s, but merely progressive loas in weight, and finally death.
An examination of the bnun of this infant shows miliar}' tubercle of the pia mater at
I the base of the brain without acute inflammation, which accounts for the lack of acute
locrobml Fj^mptotns. Of especial interest, however, in the caae are the patches of solitary
[tubercle, i.2 cm. (| inch} in diumetcr, which you see in the left temporal and occipital
obos and in the tight frontal lobe of the cerebrum, and also in the lower left cereb^^llum,
[There IJ also caseous tubercle of the pont-bronchial glands, tubercle of the lungs with a
1 plight amount of bronchi»-pneumoni»T miliary tubercle of the pleura, liver, and spleen, and
^ caseous tubercle of the mesentenc glunds.
* Through the kindne^ of Dr, Bullard I am enabled to show you the
[result of the post-mortem examinations in some cases of oerebral tumors
which have just occurred in his practice.
A boy (Case 805), four years old, of healthy parentage, but with a history of tubercu-
loai* in his grandmother and an aunt, was perfectly well until he was ton months old. At
that time he had an attack of general tonic convuI«ions followed by paralyfils of the right
[lower leg. After that the right leg slowly improved, but never entirely reeovered. He
[ to walk when he was fourteen monthtii old. After this first attack he remained per-
f Ibcily well until two months before his death, when he was found to have ptosis and acute
^ oo^junctivitk on the left side. Three weeks before his death he began to lose in weight
and U> be very sleepy and stupid j he wna feverish and lo«t the power of walking ; he also
\mi his appetite and his bowela were very constipated. There was no history of his ever
I having had any disease of the ears*
When examined by Dr. Bullard the head was not retracted, and no tenderness wm
found anywhere over the cranium. When the left eyelid waa nuied the eye was fuuud to
be turned upward and outward. There was some swelling of the eyelids. Both eyea r^
acted to light. The tongue was protruded stnught. The heart and lungs were normal.
Nothing ubn^nimi wa« found in the abdomen or spine. There was a flaccid paialyAii* of the
I right lower extr»»mity, with tWtt-tlrop. Nothing abnormal was found in the urine. A few
days lati<r then? waf found to be some loas of power in the left upper extremity and left loe-
^drop. The knee-jerkf were present.
He was treated with iodide of pota^ium, and his general condition improved somewbaL
The drowsy condition, however, returned, and, although for a time tmpnivemenl t*»ok place
in regard to the movements of his Umbs, he gradually became more stupid, and flnally waa
• in a Uyrphi condition. He swallowed with irreat difficulty. He had stmbiAmuA of thf left
l«yu. Nothing nhnormal was found in the urine, but it was passed, as well n<* the fit?oe*, in-
f rolunUnly. UU tem|>eniture varied frtim 87.2® to 37.7* C. (99* to 100* F,). and hi* pulsa
I between 80 and 90.
An examination during the latter part of his life showed thai ihe thoracic^ epigastrUk
iiL'iii. I iH' piii^t' iiirnMistti in iriHjuency, aiiu hi uiues wits ueiween loo
iii«ti was D'tractiMl. \h- n'liiaint'd in a stupid state until his death.
Till* }Hi^t-in(>rttMn «>xHnii nation made by Dr. Bui lard showed rigo
ni<»<lintt(> (l«'i;n'c. Tin* aUloinen whk retracted. The head was la
prMpiirtinn to thi* <»iz(' nftln* Innly. Nothing else ahuonnal was notice
nuiiiiii.
Till* pit'um and }M'ri('anliuni, with their cavities, and the heart 'v
ftM-tly nnniial. Hi-hind and to tb«' right of the trachea, at or just ahov
iiiHiiilis ahoiit *2.'i cm. (1 inch) in diameter were found; they were
lyiiiph-irlarid-*. On scctiim th<\v were found to be composed of yellow
t«'rial. Niithini; ahnormul wiu< detii'ti'd in the right lunge* In the
o-ritn- nf ihi- iip|MT 1«»1m', was u t'uvity alnrnt 2.5 cm. (1 inch) in the
(A lurh) in thi* >h«»rt«v-t dianwtrr. This was filled with cheesy materii
n'Hh>\«il. Till" livtT. ."pK-vn, intestines, gall-bladder, and bladder p
n«»rinal.
On i-xainiiiinir the In-ad there was nothing abnormal noticed extei
^liii.il ami lattral -iiiUM's contained u verj' small amount of blood, clot
4liira niat'T rv»rv\vlirre seemed normal, and was not unusually adhej
Til" pia rnat«T -r«'iii.'(l ni»rmal ever}' where except in the neighborhood c
n«r" ii \va- iiiop' a«lh»'n'nt than elsewhere, small pieces of the biain i
wht-n it wa- tnni n\]\ Ruth lateml ventricles were enlarged.
On thi' -iipiri'T -.nrfaei' of the cereMlum there was a projection i
part of a nia^- wliicli i»c<upied thi* anterior portirm of the central lolx
f'-uiid t-» Im- y«'ll.i\vis|i-i;nM'ii and much firmer than the rest of the o
<*l-i- alinniTiial \va> dt'toftrd macro.-copically.
rii«- tMirii-r wa- «\aniini'(l l>y Dr. Dunham, who reported that it ai
pi« ■! ill'- aiit«ri..r niiiitllo pDrtions of the cen*hellum, and to l>e about 5 <
;i -S . 111. I ;j iM(li«-i rmiii in fn>nt Imckwnrd, and 2.5 cm. (1 inch) ftxi
It w.t- <ir.iiin-»ril»iMl. and it-^ substance was more consistent than thi
It li:..i twM ^I..l.iilar pn-Jrciinns 1.2 cm. (J inch) in diameter, one on
f.-iwunl. pn-I.Hl.ly on.- towanls each side of the upper part of the four
niiiL; ..t' tii<- M.|u.Mlu<'t nf Sylvius, but not far enough to invade the pon
tjirtli. 1- l.;i.k than tlw limits "if the quadrate lo>)e8. The cerebellar
inv..l\..|. 'rii.. aiiiyplala-, which w<'n> almost directly below and in
^\•■r.■ i...t :.tr.-.T.-(]
OBOA^IC NERVOUS DI8EA8BB.
667
H|ng the nerrous tjTBtem In the family on either side. There wa« no history of phthbis. The
Hebild WW born after u natural labor, with u head presentation, and without the aid of for-
HMpt. When she wai eightec^n monthi old abe had an attack of pneumonia : she 14 said
■ lo have had iKime '* head trouble" at that time, and was never well afterwards. Up to the
■Age of fix years she had earache, aeeompanied with a discharge fmm the ear. According
Hk> I^. Bullard, there waa ftome evidence of hydnjoephalug at or before this time. She waA
HiQver ae strong ae other children. She did not walk until she was twenty-«even nicmtha
^b)dt and fihe wa« more liable to fall than other children. She was always of a nervous
Hk*uipenitnont| restless, and unable to sleep well. She could never bear any exciti*mcnt.
BWhen #he wm *eveu years old ahe had another attack of pneumonia, with a complienti ng
^f' Thrve yean^ ago she bad a ievere illness, of which the inoet prominent symptom waa
^fcaln in the head. Thid pain was intense in the temples, especially in the left one^ and
Bihe would hold the htkck of her head with both bands. There was much severe vomiting
^ut this time. The tompeniture was stated to be about normal, and the pul^e natural.
BThere was nUo pain in the neck and in all the timbs^ but tt was slight in the right ex-
K^«mities and more severe in the left extremities. Thi« illnew la*ted ten weeks, and she
Huever cctrnpletely recovered from it. She, however, became well enough to go to »ch'XiL
I A little later she was found to be blind in the left eye, and three weeks later the right
Bije aUo became blind. The blindness was supposed to have come on gradually.
■ When she was between eight and nine years old she had another very severe tUneai,
Hcliat«ctensed by pain in the head and vomiting. At this time she was first noticed to have
H^mvoientary **ap>isms/' in which she would scream with pain and would then Iqm oon*
HMioiiBne»r but without convulsions or rigidity. There was no heightening of the tenipeift*
Blure during this illness. During this attack .'^he ccmld not move any of her limbic
H A few mouths later ^be bpgan to impnive, and a month after this was able to walk
Bslone. After this there waa gmdiial improvement.
^ Whtm she was ten years old the headaches became worse, and she had a third sevefre
attack, with vomiting and pain in the head, lasting four weeks. Since that dme she hat
g* L'en able U* walk alone.
)n entering the hospital she was found to be totally blind. There were paresis and in-
ination of both lower extremities. There was considerable incoordination of the left
f while c^tordination of the right hand seemed normal. There was no atrophy any-
where. The sensation was unimpaired. The knefr-jerks were alike and normal. For two
wet'ks she was unable to go to sleep easily, on account of pain and restlessness. While in
tthe hospital ^he wnuld have nausea and vomiting at timea, and headache would occur four
or ilv(« iime« a week, but not so severe as to make her scream. She was unable to walk
without aiisit^tanee. When Aome one held her hand she walked with the feet quite straight,
»ftriking the ground first with the heels, and tilting the pelvis more than normal Her
Appetite wu good. At times she would have constipation, foir:rwed by diarrh(»a, with in-
voluntary dejections. The vomiting and headache continued. While she was in the hos-
pital she was for a time quite comfortable. Her temperature ranged from 86.9* to 87.7' C.
J (06. 5* to 100^ F.). There were do other symptoms worthy of note. Examination of the
urina showed it to be normal.
After having the hospital, when she was eleven years old, she had less headache for a
abort time, but then became worse. She had sev<?ral severe attacks, reported by the family
M ^* fairtting-spellfl,'* in which there was loss of oonaoioiitiiaaa without convulsions, and she
died quietly in one of these to-day.
I have here the result of the examination of the head and a statement of the patho-
at conditions which were found*
On removal of the external tissues the eranium presented a translucent appearance,
Mting extreme thinness of the cranial bonns, and large white bands 2.5 cm. to 8.7 cm. (1
inches) brc»ad lay in the ptiAition of th« larjjuf cranial AUUin<«, a« though the*ie sutures
[ bad long bwn held open by intrn^rnnial pressun*. The bonr# of the cranium worr unuvually
itbin, th(»ae forming the calvaria being not much mttre than (K6 cm. (f inch) in thicknesft.
lTh» oalraria was very elastic, could be readily c>ompr«ii«d, and when the pneasun^ wai
On in>iH'otinn <»f llif cerebrum, a gelatinous mass of iv>unded lobu
a cyst, was simti pn»j«fclim; fnun the external surface of the left lobt
wiis toiiml to cniitain fluid, and t*> be connected with a hard maes
Thi^ muss wii* examined by Dr. Mallory, who reports that the cyst wl
tiiuu-d wii> em}>ti«'<l and collape*ed. On section vertically through t
IoIm' of tho ccn'Klhim, extreme retiistance was met with, such as w
cartilaire. Tbo -cction showed a globular cavity 8.7 cm. (1 J inches) \t\
u thick, irnMiii^h-yellow, jiemi-fluid niajw, resemhling: pus, and sum
In.rxirr. :^7 rm. (IJ inches) broad, of a yellowish-white color with t
lari:«'ly tnn»|wis»Ml ot* rin-ulur mai^M^ like liago-grains, separated from
of nrjirly th*- ^ame c«>lor as ihemtielveB. These circular masses gave ;
u|»|M*aran(«' to tiii> iMirtler or capsule. The tumor occupied the larg
h»lic of th«' ci'nOM'lluni and its whole outer two-thirds.
Tin- H'port of the microscopic examination made hy Profess*
f..llow^:
Thi' tumor is not so sharply circumscribed as the macixiscopi
iniiicai*'. The >triirtnn^ of the tumor itself is somewhat cc»mplex. 1
of ri'IU. th«' pn-vailini; ty|)e l)eing similar to those of round-celled
t-piciMlly -•M'li in the portions of the tumor apparently the fhwhef
irrowtli. In s<iin«' places the cells are rather irregular in size witl
^iinihir t«» th«' ^pider-ci'lls of the brain. The principal extension of tl
1\ inj»l»-.Hlieath> of the ve>sels. Thcso are filled with round cells in i
^i(^■^:ll)l^■ (li.-tan<«' from the main body of the tuinf>r. There is more
ill.' rtjl^, cnii-i-tiiii: in part of a n'ij:ular formation of close connective t
v.iv 1....^.. r«'ti«iilar ti— ue. Thn»ui:hout the tuin<»r there are numoi
ti"ii. tli»- l;irir»'>t «•!* whu-h eorn's].>ond to the circular masses described
iiuiiM r..ii- |.l:ic.- in iIm- tum«»r then* is an entire infiltration with p
ihi.f cliaiMcttri-tio .if the tumor is the hyaline degeneration both o
l,l.H„.l-\. «-,l.. La tl'c 11 lav^rs nf a perfectly h«)mogen€?ous material iri\
..f liMiliiM' an- r.-iiiui h.ith in and aloni^ the course of the blood-vo<ifLe
tli.- niin-T. Kr-.m tli" .-!/..• and pf»>iti(.n of many of these hvuline ma
r«ll- ai-M have laki-n }iart in their fonnation.
Til.- tinn-.r i- t- 1... ivirarded a-^ a ^lio-sarcoma, with hyaline degei
1.1 r..
..r U.MTn
ORGANIC NERVOUS DiaEASES.
669
r
^Kieoui^ly. When the dilatation reaches an adv^anced stage a thinDiog of the
^pbrteriul walls resulti!i, which may lead t*_> rupture of the blood- vessels or t<:j
,- heniorrhaj^s More tiommoii than tlie hemorrhage, however, is the oct'lu^iim
tbe bltKKl-vessels, which cuts ofl' the blood -supply and act^ in the same
as ill iither caj?es of thrombosis of the arteries, causing more or lesk*
vfteniDg ami disintegratiou of the cerebral tissues supplied by them. The
of the l>ase of the brain are the oue^ that are mot>t frequently
1, and there are secondary legions of the j»art.s of the bruin supplied
by them.
Symitoms, — The synii)tonLs dependeut on these legions vary in accord-
^ * JUice with the fMitlnj logical condition,
' In syphilitic meningitis the principal symptoms are sevevQ headache in
^■Tarions parts of the head, more or less constant, lasting for many days or
^■evcn wwks* and fre<|uently iu^companied aftc*r a time by ]jaralysis of some
Bof the intra-cranial ner\*es, especially of the thiixl or of the seventh* As in
other eases of meningitis, the optic nerves may also be affected, and the child
J., eliows the general symptoms of a severe intra-cranial allection, such as
vomiting auil dulness.
The lofmlized tumors or gnmmata present essentially the same symptoms
io the f>ther forme f>f tumors of the brain in childrcD which I have just
\ The symptoms prodnciHl by syphilitic endarteritis are the direct result
either tlic h^cnl dilatation or the local ocelnsion of the blrxwl- vessels,
>■- which I have just mentioned. The symptoms vary accxirding to tlie areas
"^ of the brain afftH^tt^U but the most common ones are tlie various forms of
» paralysis of tlie extrtnnitk^s and sensory disturbances.
DiAGNOftis. — In regard to the diagnosis of intra-cranial syphilis in
WW children, the sympti>ms differ greatly in different t^ses. The most charae-
H;teristic gnmp of symptoms, and one which is exceedingly suggestive of
^ intra-cmnial syphilis, includes attacks of orgimic ftaralysis, central in origin,
occurring at interv^als of days or nmntlis v\ itliont known cause, and without
[marked symptoms of either tnmor or tuberculosis.
The diagnosis of cerebral meningitis may l>e made from the occnrrenoe of
vere headaiJies, fi>llowed l>y paralysis iif one or more of the motor cranial
(res, and octnirring without niarke<l rise of temi>erature.
Gtmimata present no symptoms sufficient in themselvcB to distinguish
them fr«»m other intra-cranial tumors, so that tlieir existence t*an only be
|8Usj)ec*ttd.
The presence of syphilitic lesions elsewhere is our princij^l ground for
[making the diagnosis*
Syphilitic endarteritis may be suspected when an acute affection in the
neigh lxirho4xl of the pons or medulla not produced by traumatiam ocxtotb
in a sypliilitic subjc>ct, or where acute symptoms suggestive of hemorrfaage
tor emfxdism occur, and where no r>ther pn^bable eauie can be ahown^mieh
cardiac or renal disease.
tm^
670 PEDIATRICS.
rR<MiN()si8. — The i>n>gnosLs of intra-cranial syphilis is said to Ix Lik-
ixuW favnrahh'. The rarly sta^>s of syphilitic meningitis, and 5«rfL-ri-
v\vi\ ^iiinmata, may U* favorably influenced, or even cured. Oi'iLk.-
<'V«T, \\v havr no ilc^'ichd proof, and in the more advanced tas^, «»r ^i-:^
(Mulartfriiis i-xists, tlir projr"*>i>i?* i?* unfavorable, as no known Pfm«lit-i|:»5:
to have iiinch iiitlurncv (»n the seeondar}' changes in the arteries.
Treatmknt. — Tlie trtnitment should be with large do^*e»^ifi<i^i^:
potassiiiin, usually i-ouihiueil in tlie ix^ginning ^'ith niercun'. F'Ta-ii:
two nr thn**' y»'ars ohl the initial dose of the iodide may lie 0.0 ^niiD'
^rrain-i) ilinv times daily, gradually increased to 0.6 gramme il" ltl--
inilr>-i ^astrif di>turi»auce (K'i'urs.
IDIOCY. — Hy the t<Tm idimy is meant a condition of niarktil jtli
<liti«irn< y. 'V\\i< mental detieieney may be of different gradt^.
Patmoumjv. — l<li<My is, sts a rule, the result of imix-rioet nr ini>ir
inain <lrvrlo|)nirnt, or it may Ik» eaustd by actual destructinii nf }• r_ -r
ot' tin- lirain. This «HMi»litiou nmy U» pnKUux?il by (1) traumatism, i j-
t ram Mali*' iiitlannnati<»n, and (3) meehanical pressure.
( 1 ) TraMniati-m a<*ts usually by causing hemorrhage or distnirtl on -c -•
It'll! nal ti->Mi' in ntJit'i* ways.
(^2) Tlir nin^t <*onnnon I'orm of inflammation causing idi«>f'v is a a- r^ •'
h--^ dilVn-r I 111 ■« J ilia I it i--, which ends in sclen>sis and nicninp>-eiuvpLal:i.*-
{:)) Mydnnvjilialus apjM-ai-s to cause or to aec<im[xuiy certain 'i-^
idiocy. In sonir ol' these* iiisi's the distcndid ventrick»s cause atPn-h-'"
till' «f'nl»m] ti--iic iiy ])n'<sure, while pn)bably the distiMition ('fth— •?-
ni.-lr- i- -oinrtimr-. H'l-ondary. How far the cU^Micnitive ciWl:!- ;i* -"
l»riiii:iiy and liow I'ar tiny fidlow pre-existing inflammations i> ai p^--
ini-«!!l« <l.
rill- iv>nlt ol' these pathidogieal conditions is usually atmpliv. I-
jiti'M|»hy may In> of intra- or extra-uterine origin, and mav be l-i '
;^rl|r|'al.
SvMi'n»M-i. — The synijitoms of idiocy vary acc^onling a* theimM-
FV|.iv..Mt- a hiLih nv a low jrnide of this cimdition. An idiot mav ns- =
Imil;.' h«:nl (Voiii hy<lro<vpiiahis, or he may have a small head In-m -""
l»i-:il ii.»ii-drvrlo|.nirnt or from c<'rtd»ral atn^phy. Again, idiots mav ^.i-
ii..iim:i11\ ,l.\i|Mj»(.d i-rania Ixith as to size and :is t<i shai)e. Intik-l'*
uiadr- theiv i- often -onie physical malformation in connection wiu -
iii'Nial iinpaii-ment. In the mor(» severe c:ases of idioc^• there ir^ fW''^
al.lr in<'<M)rdina!ion ot' the limbs, and the movements of the child an- ::"*•
ward anil invnnlar. In many eases the S{XKK.*h is almost unintellr':
Thi- idint due- n.it taUe notice of surrounding ol)jeets as does tht- iv'i^
rhild. and even when the siirht and hearing are perfectly normal theimpr^
^i""- •"•I'l the -en-es are deademxl. Kpileptiform convuUions "T
rornnmnly aeenni|)any idiiKy, and play a most important part in the g«^^
condition of th«' patient.
'l'\\e >y\u\A^^\u^ \\\\\v\\ v\vv> w^vxaiW met with, and which enable i»^
ORGANIC NKRTOU8 DISEASES.
671
Hliagnosticate a pronounced case of idiocy, are the vacant expre88ion, the
■Doc^isioiml presence of strabismuSj the drooping liead, tlie drooling, and the
Black of all idea of cleanliness. The teeth are usually decwtJ. SonietimcB
Btbe child i.s ?mi Umi> that he Ls unable to bear Im weight at all, or will .stand
Hield by his parent's hands, with hifi§ feet far apart, his knees bent, and his
Kirunk leaning forwartl The \vhole IkkIv sways to and fro with an uscil-
IFlating movement and absence of ct|nilibrinra. When able to walk alone he
,. walks in a stiiggerin^, uncertain May, and falls easily. In many cases,
g however, the child cannot even sit up alone. The muscles of tlxe neck are
l»» often so weak that the head falls over on one shoulder or ibrwaixl on his
cheet The vertebral column fails to supin^rt the trunk and l>ends to a
marked degree, and all the muscles are ieeble and oompamtively useless.
^I^ck of the power of attention and lat^k of memory exist in all ca'^es, and
the higlier grades an^ often the mt»st prominent synii>toms.
Diagnosis. — We should be careful in very young children not to oon«
use slow ur retanlcd mental development witli idi»xy. Thert? is so much
irariatii^n in the time at which children walk and talk, that a delayHl de-
velopment of these functions must not be considered to represent a con-
iition of mental impairment. Some children develop s<:* slowly, l>oth Ixxlily
^and mentally, that they apjK'ar very Imckwaixl in tx>mpari8i»n with otiiei's nf
the same age. Chitdi-en in the first year of their lives may be so stTiously
|ifiV*et«^ by simie grave disease that tlieir development Is preventixl fr^jui
advancing normally, and in i"c»mparison with other children of the same age
hvy may lye iar Ih'Iuw the nsiuil grade of intelligent^. If, however, we
camine this class of cases carefully, we sei* that, although they arc very
[*kward in their deveh>[>ment, they are gradually developing^ and tliat
bey do not represent the LH>ndition of complete arrest of dev^elopmcnt which
BXLsts in idiots.
It is well to rememlw^r that in rhacl litis we are apt t»» have not only
irded mental development but a weakness of tlie extremities simulating
ilysis. When both these ct^nditions occur, such teases may sometimes be
dstaken for idiots,
Treatmekt. — The treatment of idioVi is essentially aimpHsed under
be cpiestion of their edumtion. The tHlucation of this class of casixs should
begun €*arly, usually frrini the ftuirth to the sixth year. Mnch can Ik?
done to impriive the various defects wliich exist in each individnaL He can
usually l»e taught to cHtorrlinate his mt>vemcuts, and by attending to his
■^eoeral health his physical condition can of\cn be mneh impmved. In
Knany cases if convulsions are present they can Ik? m<»re or less mntnillccL
^hlal formations or |iaraly.ses am be treat^^l witli benefit by a[)}mi*atus or by
Bl^peration, The l)est results in thet^e eases will be attained by placing the
children in institutifms devnte<j t*> the tniining of idiots. Parents can be
^told that tlie ass^x'iation of their children with others wlio are ft^ble-minded
not a disadvantage, while it is often a great dlsjulvantage for the children
Elf Monud mind in a family to be a^dociatcd with one who is idiotic. lu the
672
PEDIATBXCB.
largt> Diiijority of eaaes, hoM'ever, they will always have to be
daring tluir livi^, and, in mi>gt instaiioea, aAar they have adnneri^
ocrtatti jKJitit tiiry are* liable to retrograde;.
I tkftve hoiT R forblc-minded or idiolic child (Caae S07), three yem oM.
1 nball flT>t catl your Attenlion u» lb«? child'* pecutiar TAcant ejcpfQaioo. tod^^l
thai it WhKves motv like an infi&nt than like a child. Its mental d<>tt not ofm^*
phvfeicat d«?elupmcnt, for it is able li> walk and to use Its arms and haod* fitc^. I^iii
however, wa^ riot able to »uppori ita head nlune duiitig the flr^t year of iu iiie^miMi
loum to walk until very lately. Tou aee that tliere Sa no mpeciallj unnatmml ibfi l»i
ht^ttil, which ha» the clr\.^umferenc6 which would be nannal fbr m child ot Htm^
Cask 307.
Ml<« V
ThiB child presents tho usual variations in temper which are so oommon j: ;> '
the very severe gradeti the temper is apt to be happy and quiet, while b thi* avjt- 1
the physical development haa not been do much interfene«d with we find thai «iiiN
Leiniier are quite frfM|u©nt. The child U not able to feed itself, and, althoujfh tlwfll
bly develop into an individual of fiiir 8treng:thT we can have> hut little hop^ uf lujh
meiit in its mental condition. Yuu will notice that it drooU eontiuuouslT.
I shall not atteiTi[)t to di^*ril:MP the varioas forms of idir>rv i
prodoainl Ivy hydnxjephaliLS, crt*tiiiism, epilepsy, syphilis, a«*nte fel
eases, traumata, and other eauses, but shall simply mention a
which is represented by mieroceplialus.
MiCROCEPHAr.us. — When the he^ is imder a Lvrtaxn ^w n is«
iiiicTwe\T\ia\\e. IV Mfc ^Vvt^Sa \is\\3aiVy oucce^ted as repi^seDting • »
r
if ceplL
ORGANIC NERVOUS DISEASES. 673
ceplialic head is from 40.o to 43 cm, (16 to 17 inches), Aoeordiiig to Broca,
^ niicrut't'jjliahis exkts where the brain weighs 1W9 grammes (35 ounces) io
the male, and 907 grammes (30 ounces) in the female. It is generally con-
h6idcre<l that this mierotephalic condition is due to a lack of intm-cranial
pressing'* Together with the lack of development of the cranial bonea
^ there exists in these cases a lack of development or atrophy of the brain,
wljich may l^e considered either as the vaasi* of the lack of intra-cranial
;. pressuiv iir, as h Htill believed by some writers, as the result of the external
pressure cau:*ed by a premature synostosis. Microcephalic children ai^e
ieeble-minded and usually present the ^ymjitonis of a S4>mewhat low grade
[of iiliocy. They ntjt iiififquently show signs of want of tK>wer oi" the
I limbs. This child which I have here is nn instance of this kind.
She {VniHi 3(^) i!!. thriH> and a half yean old, and U the eldest of tbree ebildren. H«r
porentfi are hetiltliyT ft^n arc the other children. She hiu never spoken. She can feed her-
«elff and the wit Iked when she wil^ two and a half yeor» old 8he has incontinence of
[^'YUine^ She hm nevi»r learned anythinjEf, has a violent temper, and aometimet hiu nerrous
ttttncki^ which art? prohably of an epileptifonii nature. The cranium li normal in «hnpet
cuteept. thill the forehead u very nam^w, with a median vertical broad ridge. The fnnta-
nelteo are ch«ed and ^how no depre^jdon. Thert^ are no marked prominences about the
akulL She U decidedly feehle-numled, and her attention cannot be attracted or fixed
readily, The eye* are apparently norrnal, and her teeth are in |^*jd condition. There t»
i oonditinn of paresis and incoordination, but the t^en^ation is normal. The ebfeit mea«ureft
49.5 cm. \ 19} inches), and the head 43 cm. (17 inches).
I ^how her to you merely on account of the gmull »\ze of tbe head in comparis^m with
the hydrocephalic hettdit of which I buve ttlre«dy apokeo^
The treatment (if these eastrs hy eranieetomy has up to the present time
not proved Jsatisraetory.
MIRROR WRITINGh. — An unusual and Bomewhat .striking .symptom
wliieJi at times ofx-urs in sc^vert^ and, as a rule, clinmic txi-ebral disease is
one whieh is called ** mirror writing/' This symptom is usually fonnd
wliei*e there is cvreliral degeneration or amon|r the fa^ble-miiidcxi. The
actual pathology *tf the atlwtion has not yet Ux-n deterniineiL Thn.ntgh
the kindne?^ of Dr. Acker, of Washington, I am enabled to describe to
jou two ea.se8 (f'aflc»s 809, 310) of this kind whieh I had an opjx>rt unity
of examining witli him, and I shall quote frtvly from what lie ^md alter
carefully studying the^.* eases.
The iHinditicm repms<>iitf><l by eases of this kind is designated *' mirror
writing'* bt^^ause the individiud writes in such a way that the letters eau
be deeipheix^d only when they are n*fle<tecl in a mirror, when they assume
the api>earance of ordinar)^ writing. These specimens of writing are similar
ti> those which apjiear on bl<itting-pa|>er on which the impressioD of an
onliiiary 8]K^inien of writing has Un^n taken* The affection Is usually
found among left-handed children and in adults af\er right-handed paralysis.
I There w^ems to Ix* a physioiogiful tendency for leftdjand<?d children to fall
into tJie habit of " niirnir writing/* The tendency of the leit hand to write
te this wav is, according to Erlenmever, due to the fact that it is eaaier to
: __ ■
I
674 PEDIATRICS.
US4* thi* anus in a <vntrifiigal din»ction, the left from the right andtbf r^
In mi tlir left. Ixitiiunlo (la Vind was a noticeable example of ti- if-
tion. The «irli(st ntimlcd case of "mirror writing*' was in 16*^*, br
rpilrptii' irirl iwrntVHMie years of age.
I)r Arkrr^ tir^t ou^o (Case 809) was a mulatto boy, ten years of age. H *ir:"
pp niMtimlN ill alMiut thr eighth month. His father is a nervous man, unddr.--. :
plaiiil\. I'Ui i^ Will iNlunitcd. HU mother han tuberculosis of the lungs. Ou-.zj^-
uim1«- \v:i«« iii<-:iii»".
F-T ill'- lir-t ffw wi'fkh «»f his lift* he was in a very feeble condition, hut finiUv'> :■.:.
li.iiltli\ :iiiil -tiMMLT. WlMMU'vtT he wa*» >lighlly sick he would have convuUi-o. ^\- ;
\\:i- t\\.- :iii<l :i ii:tlf y«ar* old h«* fi'U u distance <»f 420 cm. (14 feet) upon a W f .
A il" j" uiuii.l ill iln- tViinial n-i^ion wa^ caused by the accident, but ihi-iv- ws- 2 :>.•■
11. ■ lii'l ii-'t l.'*«' f«'ii-« i«iii>in>«., and imnu'diutely after the fall responded iut«'Ki|:t..L; :
i|in-ti"i:- ilisii wtn* put U* him, hut he did not cry even when the 6titohe!» wi-r ]'l: 1
(lit. Fp'Iii tin- tiiin- «»t* tin* Hcrident tho »)nvulKioiii9 became more severe and inn^ Lrv-.:
Tlin-.- y» :»!•- :»-:•» ln' hrican to huvt» chorea. His intellij^ence U about the saue a? ib: :
av*i*:f^f> cliiM. At one time it stt>nu>d as though he would develop into a kli'pi.n:^ > -
at pn-.iii 1h' «h.»\v- thi^ di*«pi>i»ition at inter\'al8 only. He is of a mild and d-v.1' i.->>
iiit-iit. li:i- \rr\ littli' t«» >ay, and n*sp<jnd8 usually by a nod of the head. U** l-l. :-."_■
I. ri-li:niil«-«l. and hi- llr-t attrmpts ut ^ritin|^ resulted in this form of miiT«r wriiii:. ;■
li;i- m1-.» l"-.n tnui:ht to um* his rii^ht hand, and he now writes with equal dexicri:; l :t
\N;iy- willi lai-ii liand.
Fio. 9G.
^i^^j^^^i5^ ^>J^Nb.^\C^>^^^^^^
Mirror wrltini: of a l«»y 10 yvam old.
11. r. i^ a .-.pi.ii,;. II I Fiir. 'M\] .»f this N.y's writing, and if you will hold it in fni* '"
til- ii:irr..r y.-u uiil .... that it n-prvst'iibi a child's writing, the upper line being" AUeaV'
liiii-ui.i Ml- ai.'l -a-l."
Til.- n.\t .a^.- Ca^. 810) was a colored hoy, nine yeaw old. His father and re-'-^
OBGANIC NEBYOTTS DISBA8ES. 675
are healthy, but of a low order of intelligence. He had two sisten who were fairly intel-
jjUitf and a brother eighteen years old who was idiotic. The boy himself was not bri&:ht,
id hia mother could not trust him away from home. He did not talk plainly. He had
OTulsions during the first year cf his life, but was considered to be in fair health. He had
wmyi been left-handed, and writes ** mirror writing" only.
Fio. 97.
'^K-^Vs^^-sr^'^-^
>^
'^^^>-^^^^5^'-3N^<R>^
Mirror writing of a boy 9 years old.
Here is a specimen (Fig. 97) which represents some very poor writing of this boy's,
be upper lines are ** Monkeys live in the forests in warm countries."
MYELITIS. — Tlio term myelitis denotes an inflamn]
n»nl, whctluT of tlie jrniy or of the white matter. Acuf
us(h1 to <h'si«j:iiato iin acute diifuse inflanunatioii of botl
wliit** inatt<'r of the (^onl of i. on-traumatic origin, and is
unknown in cIiiKln^n. Considerable confusion still exist
use of tlic trrni tran^rcrtic mt/eit(My which from its dei
einploytil to ilcsijrnate an intlammatiou of the spinal con
v<i*<4ly over the jrreatcr |>ortion of a section of the cord
hnwrvtT, Ih^'u cni|)loy(Hl to denote the results arising fri
thr conl, whothcr from injury or from caries or from 1
tlic'H' < iiM's tlirre exists (»onsideral)le doubt as to whether ;
ti m r\i>t-. I shall theri'fore discard the term transverse
'I'hc \rvm iiu'nln(jo-m\jcntlH is used to denote an in
iin'iiinLrcs and of the spinal «)rd.
As (iciitr iiiffr/itis^ nwninf/O'mi/flUi^, and hemorrhage
rxtninrly rare in early life, it does not come within m
(Mi-s thrin. I shall then»fore begin by speaking of ihi
n'pnsrntcd by |>oli(»niyelitis anterior.
POLIOMYELITIS ANTERIOR.— The most freqi
the in(»>t iinj>Mrtant disease which affects the spinal con
j)araly-is in infan^-y and early ciiildhood is called tK)li<
Thi- disease oeeurs most eommonly in the first three yean
in tlir iir^t >ix months of life. It may occur in later ch
rarely, in adults. It is met with more commonlv than ec
The dixiwe may Im* primary, in which case it is w;
cause ; ni' it may Im' a}>|>arently secondary to other disease
exanthemata and <'rv<iiM'l!w '^rrniiniJitifim nv'kv'k^^n**^^ 4.-^ l ^
OaOAKfC NEBVUDS DISEASES.
67:
•which have Ix^cn examined a number of months or yearg after the prcxlut-
tion of the iiiitiiil lei?if»n* These later pathological e»>iiditioiis are» however,
quite charaeteristie. The cireumference oi* the limb gmws small in C5om-
parisr^n witJi that of the opposite one, the re:?nlt of an active mn^ular
wanting ant! i>f n-tanUd growth. The bonw of the atftx^ti-il litnljs are often
shorter than those of the other side, sometimes even to the extent of several
inches. In certain ciL^es, however, the lengths of the bones seem to be but
little affwtetl, though the atrojihy of die musc^e!^ may Ije very marked. The
onttTior eorniia of the rejrion atli?cted, which is usually in either the cervical
or the lumbar enlargement, are found to be greatly atropliiitl and many of
the largf* motor wlls to have been destroy txl. AecjjnJuig to Osier, the
affected half of the c(jnl may be ounsiderably smaller than the oilier, and
the anterii»r lateral column may show slight sclerotic clmngeB^ chiefly in the
pyramidal tract, Ac(H>mpariying this f^rnditi(m the tM:inx^}x>n(ling anterior
nerve-nxits are found to Ix* atropbicil, and the muscles ^'omu^-ted with the
region of the cord which is affected atR»phy and gradually undergo a fatty
and s(*leTV>tic change.
HYMKroMB, — The onset of the disease in tlie great majority of cas€s is
acute. Its course is chronic. In tlie acute form the onset may be preceded
for some days by fever and restleesnesB, but it is very apt to ap|M>ar sihI-
denly, with, at times, convulsioug which, as a rule, are of a milder ty|i€* than
tho^M? whicli orx*ur in cerebral paralysis.
In addition to the cases which are manifestly acute in tlieir origin there
have been mcTitioncHl fx^rtain suljacute and chronic cases. There U gome
doubt, however, whctlier tht*rte ea*^^s do m»t originate in the same mauuer as
those which are called acute. The probability ib that in most of tJie cases
'hi<*h apfH^ar not to have had an acute onset an<l in whit h tlie paralysis
nis to develop slowly, the early acute onset has been overliMiketl. This
Bubaeute variety of poliomyelitis anterior does not ditler from the acute oaaes
in any way in its symptoms, progni>sis, diagnosis, and trf*atmeiit.
Following the acute onset there are at timt^ umvjns^'iousness, lasting
sometimes tor a number of days, voraitincf, general nervous disturbance of
tlie Idmlder and iutestioes, and a varietv of symiitoras of nervous irritability
which may rcpresc*nt the prodnimata of a numlM?r of diseases. The terai»er-
ature is si^ldom very high, aS.S*' to 38 J^ C. (101° to 102° F.) ; it may, how-
ever, in certain cases be higher. At times there are no prodromata, but the
paralysis is noticfd in the morning after a night's rest, although on Uie
evening lietVm^ the child was si^miugly j)erfectly well. The severity and
length of the prtKlroraal symptoms are uo indications of the gravity of tlie
lesion or ofilw prognosis as to rc-covery. Pain in the [mralyzetl Hmb is not
an unttininKin synvpt4)m, but rn-^nirs only very early in the disease. Th^
dUaoiBe is primarily a motor disturbance, sensation remaining intat^. Cere-
bral sympt^mm, if prtm^nt, jwi.'ss off rapidly with the apj^eanuice of the pand-
ysis. The paralysis is usually aj>t to affect more tlian one limb in tlie tie^in-
ning, but, as a rule, soon becomt*s monoplegia The leg is more freijuejitly
iMflM
♦)7S PEDIATRICS.
iitliM'tMl than tlic Jinn. Paraplegia in the beginning is not unojinc'E 2
all runns ni* |»anilysis may <HX'iir. There* may al:*o be dijilegia, -t^;* >
raly-is, tlir atlW'tiini of lj<»th arms, and paralysis of the miislfs o: iL:
and alidoincii. Ilcnn'plegia, h) c*<»mm<)n and almost characteristic <.fo?^'A
paialy-is, may 1m- prt'M^nt, luit i.s ran* in j3<diomyeliti.s anterior. Tkn\.*j
u\n<{ t'ntintntly atlr<*tHl are the extensors, addiietors, and supiiiat'^. ;
di^trihntion ot* th«' paralysis is usually in groups of muscles. Tbt p?:>
tory nnixlrs may U' atlW'tetl, thougii rartdy. Facial iiaralyrf? i? •
that it (-an alm«»t Ik; siiid never t4> <K«ur in uneomplicarerl pilinrjy'C:.
\\ Inn thr pr<Hlri>mal symptoms have {mRScxl oft', as* they iijiialK i »^-:
«|ui(lvly, tin* iiinrtinn> of the child aw tarried on as usual, anri ihe j»>:
^mwth and mmtal activity art* unim|mirLHl. The tendon reflext> il>ay:
in tlu' alliitiil liml»s. When the i)anilysis has reached its? height it Rtii
stationary t<>r iMThajw fn)m threi* to six weeks, and then gradual iap-
mriit U'lrin-. and pK»s on in (vrtiiin groups of the paralvzed mibclfc5<*j
or ri^ht months, h-aving t»ther groujis jxiralyzed. These gnnvf^ k-^
tinus nruvrr cntin'ly or n^main disorganizetl, and thus lead Liter ti) •>
tia<tnns and dt lormiti<»s. When contractures occur they appear later:-:
<lo tlin-r <if n'H'hnd oritrin. These eontractures are to be distinguiaW^:
tiu»-r uf uTchral paralysis, whieh are always s(>asticy while tho** of i'S-
oriiiin an* paralytic.
Wh«n par.dysis atVe<'ts wholly or chiefly the gastrocnemii and J^^r^^'?
til»i:il nniM'lf^, the other jrroni>s act predominantly, causing dorsal flexi-*
thr foot, so that the child walks on its heel. This condition is tonc»J'-^"
pi- r:il,aiirii-. When, on the other hand, the tibialis antieas anil rJr:.;
imi-rl.-^ (►!* th<' Ir^r arc most affe<.'t4?<l, the deformity of tali|)es e«iiiinu5<*v^^
and i\' ihf pirmici nnisclcs n'main unaffivttHi, there is valgus, wh lit i: ri;
an- atl'rctMl with the anterior group, talii)es ec^uinus varus mviirs. !>>.•>
tlMii ,,t" the hij) may occur in (N'rtain oases of complete paralv.-k of in- : .
Svcre ea-ies may >liow complete flaccidity, and not un frequent Iv tiu.:>
m.iits al.oiit the ji.ints are so w<»akened that the joints become t-.o m -v:: ■
and ihr ennditinii i-ailed Hail-joint results. This condition may be 10^-
at the hip, knee, «»r ankle, and stmietimes at the shoulder or wrkt. il^^
atrM,,|,y apprar-; in a irw weeks. Muscnilar atrophy, rapid and t-xtwi:-: *
tip- rnlr in p..linnm'iitis anterior. Shortening of the bones from am< ■
-rnuth may aUo appear. The surface temperature of the affertid lini :^
l-u-nd. ihr liml) feels e(»ld. relaxwl, and lifeless, and the ein-ulari. ^ '*
'nL-i<h. Spa>nnKlic movements, except the primary Lv.nvifct
li<lli'|'al|y -
aiv al)-cnt.
I )ia(;n,,sis.— In the stage of onset, and until paralvsia has api^eaml.-^
<hM^n..H< nniM In- held in alM.yancH'. The salient points by whidi adi^^-
>i> «Mn nniaily U- made are (1) sudden paralysis ; (2) loss of tendon wdtx
(.>- rapid atrophy; (1, mil flan-id limbs; (5) absence of impairmrDt--:
.-n>at,nn: (.1) pre^M.rv of the reaction of degeneration and a dimiii^
reaetinn to llu. UvvAdve evvvwut.
ORGANIC NERVOUS DISBASES,
G7y
^^Hk h flIwayB diffioiilt to diagnosticate poliomyelitis in the initial stage of
^^Btsease. At that time pain and sensitiveness^ of the affected limb may
present, and may lead us to suspect that the disease ia rheumati^sin* The
ionvulrilMtis and unt*(jnseiousness which may apjx'ar at this stage are so
ften pres^ent in other dkeases that they are not of much aid in making the
iagnosis of iKtliomyelitL^ anterior,
Tlie mfhst ri'liable test at our (Mimoiaud for making the diagnosis of
liomyelitis anterit>r is the ek^'trical reaction^ and whun ttils can Ix- obtainc^i
clearly characterizes the disease. The normal mustdes react to both the
radic and the galvanic cnrrent. In applying the galvanie cnn-ent a rjuick
Udoiilar ctmtractiou is noticx^d both on the ujx?ning and on the closing
if the negative (cathodal) and of the positive (auodal) pcjle, but is greater
beti tlie cathtxlid pole is closed. When tlie galvanic current is [i|>plic<l
I rhe moscli^ aftecte<l by poliomyelitis anterior, tlie eontiiictif»ns continue,
>ut are slower and less sharp, and the reverse of what takes place in normal
iisoles occurs. Thus, the auodal closure causes a ctiutniction ecjual to
ir greater than that (ansetl by the cathodal closure (iTm-tion of dcgcncr-
ion). As the miLscle^ rfvover tliere is first a return to the normal galvanic
taction and later to their norinal faradic excitability. Tlie diagnosifi in
onng childi-en, however, by means of the galvanic current Ls practinilly
Jess exw[)t in the hands of an exjiert.. The fanuHc exf*itability Ix^gins to
iminish within a few days after the onset of the paralysLs, and disappeai-s
ntii*cly from those miisw'les which are severely aflecied.
PlFi EHENTiAL DrAGNOKis* — Poliomyelitis* anterior is most apt to be
istaken for cerebral imralysis, and can be l>est differentiated from that
disease by means of the symptoms which I have already described, and
hich are represented in tlib table (Table 104).
TABLE 104.
'fttholopy
Mi®
OMibimLBu&liriL
Foltoiiifitllitt Jkaterior.
Ht'inorrbttge. EmWufi*
Alritphy. Poreneephnlk.
Under three vears.
InflammAtloD of uitedor coiv
ruiii of cord.
Undc-r three y^n*
Acute febrile.
Acute febrile.
Faraljsb. If oit oommon form , Pjiml yi^it. Most common form
lotor dititurbance ,
Spastic risridity.
All the luusdei of a Hmb
atfetrted.
nionnpU»|;tM.
Flaccid.
Groups of muaclr4 in a Hmb
alfeeiidt oiuaDy tbo exu^n*
>}ntnicture«
"''th'e"i.:^rr54::s:s!'"'i ^ ^ ««- '" »»•' -«'•
Kli'otrical n-aotinn
T.'imI.mi n>rii-x
Noniml.
Exa^^rated on the paralyascfd
sidf.
Sfx-rcl) I Liable to be impaired.
Ivzed I
Reaction
lMt«llii:«-n<»' Often impaired.
Absent.
Unimpai
Normal
OtluT all(H*ti( MIS which maybe mistaken for poliom^
(1) the paralysis following multiple neuritis; (2) prt
atropliy ; (:i) i)s<Mi(lo-hyi)ertrophic muscular paralysis; {4
|>araly>is ; (.")) scorlmtus.
(1) The i)rinci]»al |)oints by wliieh multiple neuritis is
ivimi |M»li(nnyelitis anterior are (a) the symmetrical afiect
the iornier and tenderness over the nerve-trunks; (6) tl
ti|>le neuritis is not so severe as in cases of poliomyeliti
course of tlie diseiis<' is different, cases of multiple neuritis
reeoverino:, while severe cases of poliomyelitis do not rea
(J) Pro<rressive nniseular atrophy, to which I shal
lecture (i>ao:e 76o), is so ran* an affection among childre:
he alluded to. There have been a few cases^ however
lM'::an iu children in the legs, and the paralysis Ls to be
that (»f |)(>li<>inyelitis by its gradual onset, by the ealv
tiuuiuir uonujd, and by the fanulic excitability usually re:
there is auy muscular substance left. In this disease al
not \ii>i until th(> TTUKr'iilnr vnlwfiinnn lina rlico-r^vw
ORGANIC NERVOUS DISEASES.
681
fhildren are affected by p:»liomyelitU anterior. The condition in rhmhitic
fhtldren is one of weakness and not of paralysis, and can be diBtinguislicd
f.»y tlir normal electrical abaction of the nitii*cle5j and the lack of proiiount*ed
1(5) The psendo-paralysis which is commonly seen in cases of scor-
ns 18 often nil^tak<*u for some oririinie disoitso of the c<:»ntral nervous
ky£^tem, with its re^ultiug paralysis. The ditferential diagnosis from poliri*
ayelitis anterior^ however. Is not difficult to make, for the involvement
if other joints in addition to those of the legs, tlie presc^nce of piiiii
^nd teiiderni^s to such a tiegree that the child cries whenever tfic limbs are
juchi'd, and the normal tem|>erature of the skin ilt^rly diistingiiish tlus
jndition from poliimiyeUtis, in which dkease normal sensation, free<lom
>m pain, and a oold feeling of the limb affected are found.
PitiKiNOSis. — Si} far as a fatal issue is (x»n<x^rued, the prognosis is very
ivorable. If deatli ixreurs it usually takes place at the end of one or two
V'ceks, and is the resnlt of interferenee witli respiration* which mflv U* caused
rhere the [laralysis Ls extensive. Where in the initial stage i»f the nttiw*k
t'bnd s}'mptoms are prominent and continue for some time, the progn(»sis
grave*
A se<t)nd attack of the disoa^ is very rare, and when it cK-curs it usually
>mes a few days alter the original attack, anti manifests itself by an in-
■<? of the existing paralysis. The paralysis, as a rule, will nf>t inereiL**e
^\i'hen it has been stationaiy for twenty*lbur hours. The teudeniy of
piliomyelitis is for a time to improve. Some of the limits affectetl iTmver
the first few days, but in thofle which remain affected longer iKTfe*et
HK>very is rare. Wlien there is no im|jrovement after six or eiglu montljs
lie priibiil>ility is that entiix* recovery will never take place, though under
[►roper treatment a slight improvement may go on for years*
We must ri'memlwr that, even when ontreattHl, a ram of j>c*liiiniyeliu!* is
en" apt to impn:>ve for one or two months quite rapidly, then rather shiwly
br two or three raontlis, and tlien, at^er a stationary period, contractions,
loseness of the joints, and mal|M>8itions may begin to be evident and may
iDcrease intlefi u itely .
When |>n»^M:T treatment is (^rrietl out, the prognosis is much more favor-
ble, and tiie j^eriod of ])os>^iljle impnnement can be extended tor s«»me
■years. According to Brail foixl and Ixivett, there is certainly no leg, h<»w-
i evfr wa^tinl and contratltnl, that is not amenable to H4»me iinpitn-i'mcnt by
■0|»erative or mechanical treatment
■ TtiHATMENT. — The tn^tmeiit of |)f»liumyelitis by means of drugs has
■jproilunil such unsjitisfactory n^sults that it may be said to \w nah'ss. The
Krery mnltiplieity of the remedies which have been exjierimented with proves
tlieir ifiefficiency. It is doubtful whether any tn^atment by drugs can l>e
beneficial to a eentral lesion of this chanM'ter. Altliongh a numl»er of reme-
lies have been recommended to be given in the onset of tlie attack, it m
proliable tlrnt none of them are of any eei^etual lienefit ; tliough it is wise to
i\S'2 PEDIATRICS.
Ml- that tilt' lx»wrls arc im'ly movt-d, ami, if tin* attack ha^ Km i-. *
l»v cnhN ul>i«»ii>, to tn*at tliosi* syinptoiiiath'silly if they o^ntiuut.
Altli«»ui:h wr knt»\v of no ratitmal uu*iiiis of tr(«tin;r tin* prir:i^r •
ol' jMilininvtIitis anterior, \\v know tliat tlie rc?sults of thi*; L-Il. i--.
l>v paralysis of tin* ninst-li's, aiv snch that tlio j-Miralysis sluniMU r-^r-
nn.c. Tlu' intli^-ation is to cMnnlnit the rapid atrophy which i- [.in
tliM'M-r, aihl u* prrvrnt its inm-iisc*, and it^ later results from j»no4,
a tli^n"*' wliirli would iiit4Tfrn* with subsecpient rei>air. To aivq'l- ■_
tlir atl('<-t«Hl liinl) should Ik? snpiM^rtitl hi a normal positinii ai^il .i:
truanlMl :iLraiu>t the strt'ti'hinjr of joints, li^nients. and mu^'.-le^. 1l
tioii In tills, ir«iith' niassiijxt' and the faradic current appli«.-d nvr ! .1
miuutt's at a tinir at h'a<t four or fivo times a week are inrtit-at^i] * ■ l-
thi- all^-t-ittl Miu-rlfs in tho Ixst |Hissible condition and to e» >mlwt th: in .
wiiitii t«» a irn-attT or Uss (h^ree oc-curs. The regular applicaii'3 .; :
i- ai-«» I'nund to U» us«'ful wlu»n' the limh is etdd. According to Brj:
an«l I.<»v(tt. inu-rlfsarc inurh hns likely to contract and dotorraitiirX:-.-!
a|>t to rtsuit iu pn>|M«rly suj>|M)rt<d linil>s.
Tln' later inaiiifestations of club-foot and other deformitits sb-i'! •
<lralt with hy the orthopa'dic surgeon.
it may 1k' well to nientii)n that I have adopted the name inJi'iL; '
antirinr m- in-t re|>re>enting the diseases as >ve now know it. It Ll? >
ejijjiii witii les*^ reason l»y various names, such as infantile y/f/mW. >-
///// intr'tljisis nj r/iihirrn, tirtifr atrophic spinal jMiralf/itiit, «i//'W- '/
antrr'n,,' Jicrns, iitj/nf/mlc jtftntfi/siM^ dental jxtru/i/yiA^ and jjoliomif*-lif '"">'•
Urilti' ,
\ h.i\f -oiiH' ea<es here sueh as yon will 1m» likelv to meet wiii: iu .
piMitiir. Mini I -hall imw examine them iK'foix* vou.
T'.;- ::!t!. -ir! ,<':»-.' '.\\\ . paiTf V,K\\ is iiiiii* years <ild-
>!:■• w.i- p. rtV.ily w.ll i]|) n. till' liiiH* of an attae*k. which cnme on Pudil-r.Iv iv;
.11: ;.■ wi. ...11-. >li.- i> siitl t.» have lallon while sho was phiyinq:. but no iir-iv
'■ ■ ■ 1 i '" i- '■■ :.-.l. tli-.u-h -hr \va^ can-lully oxaiiiiruHl under ether. Th*- •■\i.: '
i'-i- ■.:•..... i- :...! k!..u:i. l.iu it wm> m.hh. tiiiit? api. U«-r treneral health i> n'|v'::*i'.
1 ■ •• ■ ". . ■ i. M- I -li- -.■■•ni> t«) !'•' hriirht mentally. Shi- is, a* vdu 5«v. w-'i-i'" .-
■•■' i ' '- ' ■ • • ■:"■■ N-'iliitii: ahnoniisil has boon deteetiHl <iii i>hy>i«i] ♦?xa:iii::i:'. ■
i'l ■■ . >. ■.!. i-M,. -1. .-r otli.T ..riran>:. The piil.Ke is roirular and of iro'ij >Tn'ni.':"'-
., ■. .1. r.iM- atr-.|.hy. hriii.i:4.37oni. (1 J inelios) smalU-r than ih.- nV- ■
• - ' ■ '■■ I •■• = ■■'' '" '•»'■ thiirh. The leg is Poniewhat oyanoiir, aiul i? oO.'.
■ . I ■■ i...:;v.l \\.;ikiM'<s of the niiisolos KOow the k-m?e, c»?:jv»c;a]k lb "■
' ' ■ "'• ' - \\\\^'n she is lying in bo<l the moveniem-i ef tur :!■:-
I '• ' :r.!Lili. On walkini; she rotates the lejr ,»utwani. ••' :*-
1 ' ■ ■■•:■.•■, .. . - 'A.:!. tli<- line of motion, and she dratrs the to.-s. Th-: j i'-
!' \ ■■.!.: MlrMTihal has been detectt.K.1 in o.mnwti..n with ihr oin- -^
!■■ ■ : • ' ■ ir. :. . !■ :. .....x .-.hie laleml ciirvatun^ due t<» the ^hortenin:,' -f "lb- =:-'
i ■■ .
, . ^''" " ■■'■- ^••' ••'■■' ^'.^ ",-,-s.-.. rh-otricity, applications of hot cloths iwi^v- d..;:
'^' ' '■• '■■■ ~ • -^ *'■ ' ''"■'•-' f' r-liomyolitis anterior of the left lee, and, ^C^^v^
i..- ii.i.i l-.-lli nviu troatment, the probability is that she wiK »1^ -
iii:i;. V' ■•■■■iv
i a : I i
ORGANIC NERVOUS DISEASES,
oy (Ca*e 312) is twelve vcara old.
18 »Hid t(» havt* hiid rhfutiiatic fever when he was thirteen nidnth^ old. It wa§
i that ho dragged his rie^ht leg when creeping, and this leg bjLB evideniJy boen iillect*Hi
I he iK^uran to wfilk. The* \e^ i> almpbied* and there is u condition of viiliEruB in
There is slight permanent flexion in the knee, and the hip is aUo fli^htly flexed.
1> 'iny^ntl^ unt^^rior. Left te^. FijouIa, 9 jrean old*
bovsmfrnts of the limh nm otherwise i^ood* The adductor* nre lo jj^ood oondition.
:iductioii IM chiefly accomplished by meant of the tensor vaginjv fomoris.
hh ca»e is evidently one of poliomyelitiji anterior, with valgum of tbi^ ri^ht f<Mit
liU infant (Ciu^e 318, page ^SSI), twenty months old, b an untutial ond intemting
' Infuntile panily^9 of the abdoniiniLl muscles,
^i fttated to have alwavi been healthy until flv© weeks ago, when on coming inUi the
Kvomtted and two days later limp*>d a little. When the infant cHe» you m^ that
IKminal wall* bulge, <%pedully on the left nide. The motion of the left leg i» vwy
Ul «li|^htly tlaeeid. The pateltnf n^fli'X l« ab«entt and hi^ sit^ up very feebly.
hi* little ^trl (Case 8U, page 681) i« two and cmt^h&lf yea» okl, and prvM*nt> the
condition a« the previ<Ai.s ea*e,
be haii a 6i«ter who is said t** hjive had an attack of polioruy«»lltiA anterior when ^h©
Lponth^ old. No other hi«tory has been obljuned about this cum% except thiit *he
nd ttrtrng until thin attack, which occurred nx weeks ago, Th^^ on^ct of thv dii-
^g4 PKDIATRK^
pgimlyli of ibe mutfltt **f vb*i u^ip^^r Aud lower eattremldes af tli« b- dy ^^^i
mrtm nod b«id iooii fteoircmi, Sbc b uti»bl«« U^ «it up alui*©, «i>d tlii»*yMiM^
■n* psmlyiod U* Micli an «&U*nt wi» Uit l«ft ftidu Uiiit, »« yua see^ Ifct-y ar* daidi \
i X!^K 318.
Ca*ii .:ii
F^jlfomareUtli ftntarior,
left side
mod do nol re^ct normaJlj. The left l«g i* petfectly aAccid. Th* kdce-jctls m
Tbe titrfai^e tempeimlure b ditniaUhed, and there Ib atrophy nf tli« hft^
(S^beequent histary. ) Urtdf^ troatflMiit with elscuiciiy artd mmMmg^ ^^^^^
took place.
The next case (Case 31S, pagt* 68$) Is thai of a bojr (I«), «u and oM^tf 3
who was ai>paieDtly healthy at birth, and who has narer had any iHnwi
Whea he was one year old he was noticed to have aome mote
kg. On ezamitiation of tbe 1^ the tnrlbce tcinp^mturv U fooitd to be «
hnee^i»rk U absent, sod there it an atn^phy of 5 etn, (2 incbtt) of the t^b sal <
(21 inebes) of the calf There is ako 3 7 cm. (IJ ir^chea) sboneoing ia the k^ T^^l
walks, as you 9ee (II.), with a marked limp of the U*ft le^, ^ad theie It iht <
ttail-joint in his left knee snd ankle.
These symptoma, without any ftirther history af the csise, Jastifjr os la ms^"*^
noeis of disease of tbe spinal cord rather than of the hrain. This L a tramX ^^*
appeatanees presented in the advanced ttages of a aeTeve e^e of poUomydisis Mi
^^f ORGANIC NERVOUS DISEASES. 685
frl (Ciise 816, pftg«» 5Sft), sixteen yean oldt r^prefieaii Tery wvlt the resulu wUicU
fixjm nn iitUick of poliomyelitis anterior.
«Htct to have liud »oiije di^il urban ce in her left leg following » full fnini & bi^h
lalie WMteren tnonthi old. She did not walk until hhe wiu liight yuiir^ otdt »(><)
Ime evw nince. 8be came under my observation at tbt* boKpitiil wb«?n she wju
%n old, ond ttt thill time prpsented the evidence* of a long-* tending piimlyMs »tf
In. The knee-jerk was iilwent, Thi^ left leg was cold and atr(»phied, and the
Ga8I 815.
L IT.
^^^^^^1
t ^^H
1
^^^^^^^^^^^^H
^^^^ Folium) s-Uii^ liiijcrlar.
In the valgus pof^ition. 8bc
slei of one »ide of the buck.
bho la^t three yeara.
Ili a litUe girl (Case 317, paj
!««».
^pA wi^ll and ftrong: until Abo
B During tbi» attack she ab
wain in the back. The loftt <
Wktu j^nidunl. 8b4« h fiiirly
Fthit;h« iu wiill b« the p^oud
MS an* aWnt
Mr»ticc in tbi^ case that the It
ftbral {lanily^i^ tliere would
Ki« of the lhl|^h, which wiiu
FlaU leg, leftside, m
luif, you see^ a hiter
She ha& shown only
^ 586)f Ave yt^n ol
ut he? third year, wl
lo had Minie other illi
of |K>wcr of her \cf^
wtW develo^teil, and
and tliati Qtuacl«a.
mltfl an* hr*ld apart a
be in place of this t
Id have been apt to
lie, OH yean old.
nl curvature, due in pamlysi^ of
*ligbt improvuinenl under tn^it-
d, who, as you see, has pamlyali
^en she had an attack of wborrp-
Fie!«.4, which was characterixt^ by
daU*s from thii« time, and \* *aid
ibf panilysi» ha» ulfei'UHl tH>tb
There is marked atrophy, and
nd are flaccid. If tlic case wcr^
laci'id condition a c«*ntmction of
hold the limbs daM*lr t<«9<«iher.
1
-^3^^
«se
PEDIATRICS.
Ai ilm«*« ihi* cscmtmction womld pcrluip be m auoa^ ms to prairctii ibt Ui»^ Si*
dn»wo Mpiirt
Til© |w>gn<»ii for complete neo^^ry in thw emse i« ttnfiivymWe.
Tlie trPHiiii^iit will l»« i.^f ft geiien^ nfttttre, such ft« J bavu •irwdr npe^'
•bould be idoptcd in vumv» uf tUU cli
CAi»K 815.
ca«c si:
I'uLloiuye litis interior. Tuiii^t^ \ara£,
Lftteml curvature. Fcoi&le, W ytwra
old.
Thi.s little ijirl (Cft«e 318, page 687), five jeart old, U a cue oi poiio»ij«!W« ^
which hus aftW'ted the right leg.
Wht-'ii §ho wtts thi>-'e years old she fell from n st^|>, i^rid whs fcizrd wftfc*^
attack of parulysts of the right leg. A month Jal«r Uie witlked wii-h tii«Mli*>i> «/ »• *
foot imd slightly of tho left. The skin of the limb U not es|t^ctally ecild of U9
riirht thigh meusurej* 24.1 cm. (about 9J itichea)^ ^ht^ left thisfb 24.S cm (1H hid*»'
right ciilf oietisut**^>< U.2 vm. (Of mches), the left 17,5 em. (7 itii*h«). Tbr wltOtf^
h iihsent on the right 3*i<le and very alight on the left. The rtgfat ler Is 13 c« Q'
fhorter tbj*n the left.
Under the appliration of massage and the use of vanoua moobftaiaa mma»^
liM been dight imprnvement.
Tb\s h^^ I^Ciiae Wa , v^%*^ ^'^"l^t iA«^«ti utA <iiMs-lialf yeap» old . has • good h^} ^^
OBQANIC NEBVODS DISEASBB.
e87
i to have been swung about by his feet when he wma s«ven months old, to which
lly attribute thw present condition uf his right tooU
» anterior p4>rti<iD of th*f AkjI \m tiexed, a» yuu sih', at a sharp angle at the medio*
nnt. The fo(»t can b* ♦-•uf ily bent to a right ani»le, but not beyond. Tense banda
ff fa^'ia can bo felt when the focit t^ stra)ght«'n<?d nut, but it caD b** bMUght into
w the uae of coneidemble fiiree. The length of the le^5« is c?qual. Then? is I oin.
CAf^F 31ft
Case 310.
•elitb* antinor. f^iirftljn*!^ of right
)ilg, Fuumk% 5 yiani old.
liflit skiff, Ualii, 1 1 !t% yeai» uld.
repfww»nt8 the condition of talipes equinu*, the result of a orintractioti at %ht flexor
Ibllowing an attack at infantile |>amlTsis.
IST0 also hei« a boy (Casti 320), twelve ytMfs old, who illusttrntas m case of jmiUo-
t witerior »jei'«»ndary to erysipelas*
had an uttatk of t^ry^ivelaM when he was fourteen months old. Th(^ m-sipelati
IT about *>ne month, »irid vra» followed by an attack of dlnrHMfa wlHcb 1h»1*'<1 for six
It wa* noticwi that the infant was weak and had little p»w«'f in the left lejr about
ik aftt^r the beginning of the emipela*. After reot-it*»nnK fhtm ib^ diarrluea he
O walk a little, but with a limp, which he ha^ had over since The leg ha* ^iriee
tiwing *malleri and he bm^ bit»*ly whown no impPDvement whatever. There ha*
I any ^min in the Ic^. He walkf^ with a decided limp, and the fi>tt i* t^f^UKbi to
r with a ilap. The knee bends backwartl beyond iu proper position. Tb« V«|,>fc
<)S8 PEDIATRICS.
inii. h iiiP»phi«tl, tli«* riirht thia:h iK-ing 11.2 cm. (4^ inches) les«» than the left, ir^ii -
7,.'i .111. i:{ iiuln-i !♦•<}* tlmii tin- left h'jr- The leg and foot of the afleclKl li2:^ > .:.
o>l(l<T u> the touch ihai) tliiis<' of the othor. On raising the foot of th*; a1ft-.:-:!:ii
siM-n ihal hyiMTi-Mfii-iou can bo pnHlucixl to an angle of 140**.
In ilii^ ♦a-"' I shall ailvUr a p|mrutu:i to prevent the further formation of iliI-;-:i
thi- kii««', wliich is oviJenily now pri'sent.
PARALYSIS CAUSED BY CARIES OP THE SPINB.-h-^
4)t* |)aralysi.-* «'jius4h1 by c'arie:* of the spine the lesion is esaentkllN a :■
|)ns-i«Mi of tlu' i*in\l : tliis Is usually slow in its progress, and it i-d'ji*:.
wlu'thir in it a tnio inflaniniation iKXJurs even in the beginning, llr^i-
Wit ion H'siiltin^ fnmi conipnssion occurring in the ix>iirfci<.* of t-arhsfi
s\)\\\r may Im- found in any jwrt of the «)rd. It is most fre([iK^mj:'
with in tli^'a.-^' of tlu' dorsal rejrion, though it may t>c<?iir in thewniiiii
lnnil>ar n';^ions. In carit^s of the spine the coni]>re9Nsinn of the tvnl;-:
oftrn th<* nsiilt «»f pn'ssure from the vertobne, but usuallv i? cau^l i-'
by an al><<t'ss in the vicinity of the disea.si*d vertebrae, or niort i.\*nui'
Uy a tliickrnin^ of the nieninjres.
Whrn the Irsions of the cord are of any considerable extent, a^wL:
and drsniidin^ sc<'ondarv de^Mieratious follow after a time. If iher-P'^
4taM'<, it Iravrs a (trtain amount of scderosLs of the c«.)nl at the ?«t ♦•:* t-
<li-.'a><'. This may U' very sli^lit, or the cord may l>e oonsiderabh ^^te
io >\/.r and yrt may transmit normal nervou.s influences.
Symimoms. — Tlie ons<^t of the disease is sometimes quite ^^uddef- c
mnn- trc<|nrntly it is rather gradual. The symptoms varv aavrdiii;:'^
part nt' tlir <*nr(l whicli is at!(M^t<Kl.
Wh.ii tlu' Irsion is in the dorsid or the lumbar nnridii the -d^: ■
r<'|)n'-«ntM| l>y numbncs,< and weakm»ss in the lej^. This is fiuukl^!--
l)\\ri\ l)y a |.araly>is wliicli may In^xMue <-omplete in a short time.
If tlir h-inn is Inflow the level of the sixth dorsal vertebra, iIk' '^>
alnnr arr iiWrrU^l : if on a level with this ix>int, the abdominal miw^^t-^
iiivMlvrJ. S'lisatinn nj) to nearly the level of the K^ion may be Jimin^-J^'
orrvni l.M cntiivly. In n^^iims above the luml>ar enlargement tk r*'
n ariimi- ar<' ('\aL^i:'rratc<l and ankle-clonus soon appears.
Wlu'U \\\r (li<ra><' afUn'ts the (-tTvical enlar^ment, or any prtiont i
<*<>r.l :ilH.\r. all the cxtrcmitit^ are apt to be i>aralvzed. In seven= ■*"
tli.iv will 1m' ivtnition of urine, with subsequent inwintinence. TheM*
:iiv iihimHv rnn.ti|>atcd, but in<*4>ntinenoe of fawiies is sometimes pre?fnt.
Ill l.-i..ii< ,,f the lumbar enlargement the knee-jerks will be >■
'ri-..|»liic .-liMimv. in the limbs are not marked, but the muscles aiv ^.>i»-*^-*=
^\:l-l.Ml. aiHJ ri-i^lity may <h'velop. Bed-sores are apt to form. Tht^n*"''
<•! <l«Li'n«'raii'Hi i< not present.
riic <'liaractrri<tic |)ictun' of Unions in the dorsal region causeil byr-T:^
ol tli«' >|>iiu' i^ ]>a raj »l( 'ilia.
I )i v(;n,,si.._T1,o tlisrasc is to Ik? differentiated from poliomyelitt in^-
nor, \\\ \\\\m\\ d\<v'v\>v' v\\vAv>\Av'^^vc^ \<* more common than paraplegia, a»i=^
ORGANIC NERVOtm DIBEASBS*
k^hu4i the reflexes ai^ lot^t aritl tlie action of de^uemtion h present. la
Idition to this mean.s of making a ditfbrential diagnosis, the absence of
Initiid fever and pnxlromata, of dlstnrhanee:^ of sensibility, of paralysis
>f the sphincters, and of a tendency Ut Unl-s^ores in poliomyelitis anterior
of grt^at aid in di tie i-entia ting it frf>m the results of caries of the spine,
^*herQ rigidity of the limbs, inci'eastd reHexes, and contractures are prt:)mi-
aent symptoms.
The diUcivntial diagn(3«is from oeii^bral paralysis is more diffictiH, as
lie condition of the limli8 is similar in U>th. The diagnosis is made by
be al^scnee of all oerel>ral sym|>toms, and by the presenec* of such S|XN'ial
^ympt^mis as rigidity and i>ri»mincnc'c of the vcrtcbnc in (*arics of the sphic.
Prognosis. — The prognosis in these cases is in gt*neral favorable. A
prtain ntimtxr of cast^ ivmain nncni'ed^ but nearly all recover under treat*
aeut, although the ctmdition may pci'sist for months.
Treatjiext. — ^^rhe ti'eatment of these cases is, as a rule, to be directed
llo the caries, and consists essentially in perfect rest on a rectangular \mi-
frame, ^[assage and ele*^tricity are sometimes of assistance when applietl
[in the paraly/Anl lirnl)s. Where no improvement owurs at\cr several nKinths,
laminectomy nmst Ix' i\>nsidered ; and tiiere has Ytoen a case? (Case 321) at
the Cliildrerr s Ilnsjntal where improvement IStllowix] tliis o[»eration. In
this ijistaiHH^ an ahM/css was prt^-^iug u|M)n the nnni, and on its l*eiug dis-
jvertxi ajid t*mptietl re<H>very took plac«. The o[)cration was |*crform(tl by
)r H, L. Burivll.
HEREDITARY ATAXIA (Friedrei<?h's Disease).— Hereditary ataxia
I m very rare disease. It is an organic affection of tlae spinal cord, usuall}^
rarring in several members of a family and developing in later childhood.
[The names family ataxia and generic ataxia have aLs«j been used,
I'atholooy. — The pathology of the affettion is a slow, progressive
Jcgeneration of the [x>sterior and lateral columns of the crird.
Symptoms. — The characteristics of this diseai^ are its slow develop-
at, staggering gait» loss r>f muscular |)owerj nystagmus, sometimes loss
nf knee-jerk, fn^pient disturlnmee of speech, and finally complete helpless-
with mental impairment.
Pnooxosis ANJ> Treatment. — ^The prognosis of hereditary ataxia is
always unfavorable, and there is no known remedy which is of In^nefit
LOCOMOTOR ATAXIA. — In cfmmx'tion witli this dt^neraticm of
lihe postcricu- atid lateral ci^lumns of the tnird which octnirs in hen?ditary
taxifi, I shall men»ly mention the dt^?neration of the jioetcrior (x>Iumii3 of
[the ciini (k>comotnr ataxia), as this disease is almost unknown in childhood.
The disease as it o«x'urs in chililriMi usually involves the lateral a'^ well as
tlic posterior columns of the oord, and Is thus closely related t«5 Friedreicli's
IxKNimotor ata.ida is to be distinguished from multiple neuritis, which
lit sometimes closely resembles* the pain, ataxia, and loss of knee-jerk often
irring in l)*>th. The diagDoais from multiple neuritis is to be mud^
090 PEDIATRICS.
c'liiHly hy the pn>sem« of ocular symptoms in locx>m(>t4>r ataxia. fO'ik
Ai>ryll-liol)t'rtson pupil. (In thin oondition the pupil dfX>M>j'
li^ht, hut (hn'H Tviwt to accommodation.) In aiiditiou to this m^'ii
IcTfUtial cliajj:nosis, the tenderness of the nerve-trunks in miilripkic
<l<K»s not (KH'ur in I<K*<>niotor ataxia. You must also rememlxT that U-.z--
ataxia is ineunihle, \vhik» multiple neuritis always recovers.
Ii<M'onint<>r ataxia may he differentiated from Friedreich's jasn
(1) the fart that it Ls not of hereditary origin, (2) the absence of Dy?i4f
and t)f mental symptoms, and (3) the ataxic and shuffling gait.
SYRINGOMYELIA.— As defined by Osier, syringomyelia 1. 1 J
niatous new tormation alwut the central canal of the spinal w«in
cavity fiirmation. This disease is so rare in children that I shall »>
state that it is now rejrarded as a gliosis, a development of enk^^]
neuni^rliar tissue in which hemorrhage or degeneration takes pUf t^'
the format ion of (»aviti(^.
In this disea-H* we iLsually find a diminution of sensatioo to bes
et)ld, acconlin^ to the site of the lesion, which is commonly a point k a
uplHT dorsiil or tiie lower cer\'ical region. There is apt to be a w«kK^
one or lH)th arms, a<x'omi>anied by marked wasting. There is akn»:
S4nn( wrakmss in the legs. The reflexes are increased, ami a s[ftGr irt
(lition is likrly to nsult. These symptoms are usually acwmpmis'
inarktHl lateral s<'oliosis.
In typical eases the diagnosis is easily made where there isaDHf-
troplii<- paralysis of one or both of the upper extremities, with reteoWi :
tactile s<Misati<)n and loss of thermic and painful sensation lielowthtd%
nMri,»n, and a weakness of the h)wer extremities, with a tendemy ti> ?!*i:
riiridity.
Syriii(r<)inyelia is an incurable disease, and the treatment i:? tbifli^
usually liinite<l to eornx'ting, if iK>ssible, the lateral curvature wLid !>
<|Uently accompanies it.
ORGANIC NERVOt'H DIHKABBS,
(J91
LEG TURK XXXIII.
BRAIN AND CORD.
MlTLTIFLK ClEREBRO-SpJKAt ScLCROellB.— CrRIBRO-8P19AL MlKIKOlTIi.
MULTIPLE CEEEBRO-SPINAL SCLEROSIS.— By multiple sele-
3ls iif tlie brain juhI etntl we memi a disea-st^ id whk-li the aen^e-e lenient^ of
in arexii* in the brain and i^nxl are more t*v le^s re)ilaeed bv omnecrtjve
ae. The seleiTWLs \vhi*'h 4Xt!Ui*s in tliest* ea^s, however, iw not a di^tinc-
ive lotion of mitltiple i^rebi-o-gpinal sclerosis, m it is the name that ijccnrs
other sc4en>tie f*ondition8 of the nervous system. It is simply the
multiple diHtribution of tlnsi:' areas whieh is pathof^numonie of the diseai^.
(The di^as*' ha.s al^o been described under tlie name of disseminak'd selero-
Bis, insular sc^Ierosis, Dm til selei*osis, henlsklemsi% and s<'I^n jscj en platjut^.
Etioixhjy. — The etiology of the dLst^ase is obscure ; but hereility appears
be one of the causes of multiple sclerosis, and traumatism, sh(^>ck, and
.various acute dis<^iises^, especially those of an infiK^tioos character, have an
;>logical significance.
Pathology. — Only a small uumlier oi' autopsies of this disease have
Pbeen made in children.
The ehariicteristic filature* of the disease by whirh it is distiniruished fn*m
other sc'Ienitie distuses of the brain and eon! is the erratic ami multiple dis-
trilmtion of the sclerosis. The scderotic patches may cxcur in the brain or
in the coni, or in lit^th, and they are pc^'rfectly irregular as to the parts of
the cereliro-spinal system which tliey involve. Aci^>rding U> Osier, there is
ati increase in connective tissue of the sclerosed jjatcbes, and their fibres are
densiT and firmer than nornud. The gradual gr^jwth destroys the mi'dnlla
J of the nerves, but the axis cylinders pc^rsiint in a remarkable way.
Symptoms. — The onset of the disea^^e may be rapid or bIow, but is
more likely to l)e rapid, Accr^rtling ti\ Pritchard, the child is noticttl, aftt^r
|)erlia[>s a Idow on the head, tir a shock or fright, or without any ap[>arent
causc% to tnruble. In some cases the dLsense may l>e ushere<l in by a ctinvul-
sion. In <x>nncvtion witli the tremor, nystagmus may ap|K-ar a,s an early
symptom, but, as a rule, it Ls a later one. The jrait is usually affected early,
the movements Ixmiih c4umsy or stjiggi^ring. Among other early symptoms
iiismus and dtphtpia may be menticmed. Hea<lac4ie and vertigo are
prtibably not infrecpient, althinigh in young children it Is somewhat difficult
to determine the prrx-nef* of these symptoms. Exaggcnition nf tlie reflfXt-s
|.-which dejK^nd upon the kw^tion of the let^ion b an early 6j'mpt4»m in some
les, anil may be Oiiieociated with ankle-tdonus. The later symptoms are
lifiturbanee of speech, mental weakness, slow muscular wasting, and paral vsin
sf the extremities.
only a cirtain prn|M>i'ti()n of cjt^^s ; in the former disoa<40 i
tiirv ty|M\ in the lattor it is of the choreiform variety. Ajj
ataxia the atliH-tioii of tlu? Mj}eivh ot«ur», as a rule, later
On tli<' otlirr hand, nftwia of the extn^mitied is less ooi
than in hcnnlitai y ataxia, and tlie inabilitif to stand with
and the cyts rloscd, wliile (*omnion in hereditary ataxia,
in >rl( rosis. Various )»iinesthesiie which not infrequentlv c
ataxia, ('S|MH'ially the (/irdle sensation , are not oomnion in
witli sc'ltTosis.
In ad<lition to these otiier elinic*al differeiK^js then; ar
w hit'h alVord a iuarke<l contrast in the two diseas^es. The
dition of tlic rrtlcxcs, tsiMvially that of the ]>atellar tendc
^tatr ; and (.*>) the tendency to «>nvulsive seizures. In
the kne<'-jerk is eoiniuonly exaggerated and rarelv ab
hereditary ataxia it is oft<»n alndishcd. The mental coud
<hdl«-<l at >onie ^ta^re of the dist^ise in multiple sclerosis
the t<)rni of a sinij)l(» dementia. In hereditary ataxia on
intell<><t is nnin)])aire<l, nienUd weakness being exoeptioi
are <|nite e(nnni(Mi in sehTosis and are rare in hereditar\' ai
A ditlenntial dia^^nosis should also be made from ch<
eliiniiiate<l readily hy th<» al)sen(X3 of tremor, bv the presen
niovcnirnts, antl hy the al)sen(»e of nysta^i^mus and of true
1*i:(k;n()sis. — The j>rognosis in multiple ccrebro-spina
niancnt n-eovery is very unfavorable. The disease mav I
rnrily, Imt iiii|)rovenient in the general condition of the
incnly inarU^ a remission. The child rapidly becomes so i
i< a <(»rr< <jHMidin;r liability to complications and to death.
TiiiiArMKNT. — There is no drug which ap]>ears to ha'
tlir «li-<:i~<-. tli«' treatment Iwing wliolly symptomatic. T
ORGANIC NEItVOUfe DH^EASES.
mi
8piiTal tHKrd. However closely it may in tlie future be pnived to l»e
iateJ with other dUeases, siieb a^ |3ncfaiiiotiia, aD<l however tirmly we
y believe that it^ eaiLse Ls a uiieri^be as in tlie other disjeases of the infec-
s cla-^s, still the siilieiit syuiptiimiJ by whirh wc can make our diagno.sis
Uutne prixhittHl by t5eiitral orgaine iiervoiKs le^iuu.s. The disease does? not
►pear to be eoutiigious. It may be atnite or chmnie. It may occur a** a
iinary dist/ast* or in ct:iDneetion with some other iufeilioug disease, such as
^ute lolmr [meunmuia.
Etiology. — ^Cerebn>-8pinal meningitis at time? occurs in wide-spread
pidemif*^. It is als^i met witii iu a isjMiradie form. Although there ha^ not
fet been made a suffieifiit study of* the ejiidemic* form of the disease to allow
to f^tate mtieh that Is defiuite alx>ut it?^ causatioUj it i& probabh^ that it is
le same m iu the s|M)radie form. From the sporadic cases which liave
M*efijlly stutlit'd it Ls evident tbtit ccM-tain barteria ai'e the cause of the
The most ctunmou orjj^anisra which has l)ceu (omid i.s the pueu-
Enocoeeu;^ of Fraenkel, but the strcpt*xxxx'us and hta[)hylcxx>ccufi pyogenes
Rureu.'^ have als<j lieen f*)imd in a few cases. No distinction except a bae-
leriologii^l one can lje made between tlie castas in which these l>acteria are
found ; nor mn any be made bctwei^n the epidemii' and the sjiorailie ca^es,
Bn they have the same symjit^Hus, Although thciY- in supjKi#^'d to be a
close connc**tiou lx4ween oerebn>-s[iinal meningitis and pneumonia^ yet the
former dismse is frequently found without die k'sinns of pneumonia \mw^
pn^'ut.
Pathoixksy. — The pathtdogit-iil hisions which n^prcstait tliis microbic
form of cc^rebro-spinal dis4^ase aiT chiefly an inflammation of the pia mater,
with its aLt^>m[»anying sc^rous, tihrinous, or purulent exudatiiuK The lH*ain
and ct»rd may bo involved. Vim of hcmnrrhage and of encephalitis are
aometimes found. The (miminejit priniary lci*ion which pnjtJuct.'s the
typic^, uniitmidicmt^'d pi<rture of the acute variety of cerebro-spinaJ menin-
gitis in its wirly stage is a le[>t(mieiungitLs, and the diM^ase can well be
looked ujxin as a mterobie leptomeninf/ittM.
As has been well stiited by IVlafield and Pnidden, the degree of the
lesion in the brain varies gn*atly, <h*j>eiulirig u|H>n the [leritxl at whirli death
11 occurs. At times, when death oiijurs early in die disease, no macrL>sc^>pic
change will be evident. Mierosoo|>ie examinatit>n in these cases, however,
shows a m(«lcnite degree of extravasation of Ieu<^»cyt4»s in the vicinity of
the vessels. In wcll'marke<i eases the j>ia inatt-r tuid the c»<>rd iirc more or
leas densely iniiknit4.Hl with serum, Hbrin, and pits. This jiathnjogical con-
dition may U* found over the convexity and base of tlie brain^ and is fre-
quently most marked in the latter situation. In the wird the infiltnitiou
may occur over tin* anterior and |n>steriMr surfaiH:', arxl in some case*?* prob-
ly owing to the recumbent position of the patient, it h most marke<l on
Itbe posterior surface. The ventricles of the brain and the central canal »»f
the cord may wntain turbid serum minglHl with puf^-cells and sometini«*s
blotxl-ceUs, The membraoes and underlying nervotu tiasue may be hyper*
litU PEDIATRICS.
a'inic ami tin- s<':it of cjipillary hemorrhages. In i>n»tracted'^-.r:
trirlrs may Ik- dilahil with SiTUiu.
In acMit'nMi to thi-x' charactmstie Iesi«)n8 of the disease, then ar^ .n-
ol* -^-toihhirv rhaiijr*^ in <HtlmMit |Kirt.s of the IxkIv, which are m ^
hilt \Nhi<li (M-riir with siitlicicnt fmnieiiey to warrant their unnti'H.
tlicn- may In- suhsc^nuis |>iinetate heniorrha^* in the end«»car(liiim: >vj
in thf skin; hyalim* ami p^aniilar dejr<.iieratiou in the wlimtar. --
nm-ch'; (K-t-M-iniial ninUipK* abseessc^s in various parts of the Ui-h ; :
rativr intlammatitm of the joints; iwirenehyniatoiis degiiuraii u ■
hrnrt, livrr, and kichu'vs; swelling «>f the jjjsv*tn»-<.*nterie h'm[ibri-*
:in<i nirta-tati*' rliomiditis.
Tlir It'-ion- an' csM'ntially the same in the epideniie an<l .-|-»n;i
nt' ucntr (Mi-chni-spinal meningitis.
In tlir fiH-m which fi-om its hii^th may Ik» ejdled ehnmic thf {c*
li:»- nnt ln'rii (li't4Tmin<il, as a snllieient numlxi^r of autojwts of tL> ^i^t:
lia- not yrt Uhmi nhtain^nl. It is, Imwever, ]>ossihle that the\-irii:'
-viiijitoMi- nt' (H'trjuiic n-ntral disejiM? whieh <Kvur in some of tL-^
:in<l <-|)rrially in tlion- wlii<'h do not ixx?over, may Ix* pn.Kliiaxl k tlc^ !h ■
i»t' hvdr«MMjili:dn- an«l iiTchral al)S<x^s.
Symptom^. — Tlir «lis4'as4' is usnally sndden in its onsi^t. ana.b:-
tinir- IHilrrtly healthy ehildi-en. The pnuninent svmpioiiis iin n>
hradarhc, i)h.»to|>liohia, and at tini(»s c^mvulsions^ ]>ain, hv|»t»nKstik>Li':-
itillL^ drliriuin. and, later, eoma ; also sensitiveness to sound ami i- :-
r.'udrrrH-- on |in'>sure over some |H)rti«»n of the vertebral nilriiMnk
not nih-.iniinonly. Thr t^'injM'ratuiX' in tlie more sc»vere casts i> hi-:'.;. V
to n.l ('. (1(>:>'- to Km; F.); usually, however, it is ;]?<.3= to...
(hH to 102 \'\). There is no n^j^ular temiM»nUure curve; in i''
-\in|.toni-, temjM'ratnre, pulse, and r(»sj)inition varv in different rtws '•
piiNe i. ii.Hially i,niek ; the nspirations are rhythmleal, but somewb: qi-
eiH-d. Tin' lM)wel> are usually constipated.
Stral.iHnu"^ i> a eonimon symptom, and rigidity and n'traction ■ f '
n.ck and l>ack (oj»isthot4)nos) an» soon noticed. The kn«s an- '>'^^
<lniwn u|). Tiie child (Muaciates rai)idly. The pnpils are alten-.!. 1^
not uncomnion to find metastatic choroiditis with exudation of pib in:- "
vitivou^ I WadMvortii). There is often bilateral loss of heariiiir. K"^
Mon. i„ the <vni|,ioms are frnpieut. A fac/tc c^r&mh ran at tib:-
I'MMKJ. i'hc spleen. esiMvially in acute (^ses, is enlarged. If thebraii'^-
••-nl :,iv :,I^o dc-jdrdly involved, symptoms <^->rresi)ondinir to the i----
Mild d.-^iv of the Ic.i<,n apiH'ar. This is espeeiallv noticeable in tlnM-h:-.
I.^rm. Nvhcv the .liM.a>c ha< lastcil for some months. Pneumonia, anhri'i-
j)Icnriti>, and pei'i<'arditis may arise as oomplic»ations.
|)ia(;n.»>is.— Thr pr<miim«nt symptoms on which you mastnJv:!i;>
i^'ivntiatin- <v,vl>ro->pinal meningitis from tnbercnlar meniugitb. «^ «a»''
't woMld l>e most likely to Ik" mistaken, are the sudden onset, extr^mel^"
i»Hie and hypcra-thesia, opisthotonos, heq^es, and regular puke in '-^
ORQANIC NEBVOUS DIB£AS£6,
695
ipinal diseaae as compared witJi the iLsnally slower progress and
synij)tonu9 of the tubercular. In mme causes the onset is not so
len, and ditfiinilties have arisen id the ditforentiatiou iwm typhoid fever
Eld pueumuiiia ; but, exi^[>t iu the rather rare meuiugeal types of these latter
aeBse§, the dia^uoHit-^ will iu a tew days become cle^r.
In yoinitj infants the syni|»tonis of ccTebrn-^pinal nientngiti.s niay be
lerely a heightenttl tenj})eratnrt^ with elonic a>DVulsiou8, iso that tlie diag-
\mi& taiinot l*e made during life from the various forms of retJex convul-
DQS which may (M>cur at tliis age, and eerebro-spiiial meningitis t^an only
^ suspeeted. A viimj illiiiit rating this lat*t wa.s seen by me in CYinsultation
itli Dr W. L. Kkliani^m.
male inftiru [Vnae 322), heuiiby at birth, was euddt^nly attacked when it wa* aii
^y» old wiili genenil clonic cmivulsion^, accompanied by a temperature of 40** C. ( 104° F.)
the lir»t twelve Uuun, and afterward); to the time of iU death by a temperature of
0* C. (lOli** F.), TliH itttaek fi>llnwed a f>eriod of nervoiw eicitemeDt in the nmiheri
;o WEt« ijur&inpr it, iitid who in other re,*|.>ei:t* *hijwe*l no abnurmal symptornfl. There were
ayinptijms of tvivlin>^pinHl tiienin^ititi, nuch n» retraction of the head or opisthotono^i
\d iti the intiTvuls between ihe convuljuionii, which occurred about every hour, the infant
nied pfrfii'tly well It did not r<»mitf and did not have any abnoruial fiyniptoms con-
'ted with (tie eyep, TJ»e convulHioni^, which ci*n8tituted the only Byniptom, oontiout^f
id on the i^econd day of the uttack the infant died suddenly.
The report of the autop(*y, made by Dr. Whitney eighteen hours after death i wai at
MloWF :
I Rigor niorti* well marked. Lividily of the depi^ndent part« of the body, and in umall
^parnted patches ov«-»r the armi, leg*, and chejst.
The calvuriii pr&iented nothing abnonniil. The inner surface of the dura wa« oavered
fith o|>tt<iui^ yell«>wi>h patt-hMs of lymph, e^pefinlly marked over the base of the skull. Tlie
si<s»e1« of the |>ia mater wen* markedly injw^ted, and it* nici*het were filled with an opaqun
;rie<'nii4h-yf'Uow exudntitm. Thii exudation extended over the entire brttin and int4» the
ninal cannl. MicTD^'opte exnminiition 6h«»w(Ml the prt^sence of large niicmcocei, usually
PMociatcHl in \mr^t two of which were ^mieiimef united with a ctiain of four (pneuinococcus).
The heart wa^ nonnal^ and Um cavities were filled with dark fluid blood.
The lungfi w<*re not fVilly rt^tracted^ and wero nngorgpd with dark blood, wbidl wai to
jbundant as to suggest extravasation into the alveoli. The pleural surfaces were perfectly
Diooth,
The ulKttrininal orgnn»— Apleen, livery and kidneys — were markedly injected with Mood,
Hit were othiTwifie nonnah
The htornach and intailiaei presented nothing abnormal.
The pathological diafrnosi^ was, acute purulent cerebro-spinal mentngitLi, and general
wnoui congestion.
I pR(XJNci8i8. — The pnij^noi^b*, wliere the child is young and the onset ia
violent, with lii^h tem[H'ratnre and cxuitiutioiis ecmvuUiious, i^^ very serious;
►lit, even in tlio ap)uii*etitly fatal ea^^es where ecmm Uw^ intervened, a change
my take j>hu^' and the child t*eiH»Vf'r. Thi' fin*t two weekt^ an? uMially the
pritical |K*riijdj^ mt far a^ tlie ac?iite ftirm of the di^eaae k ciiticerned. The
liseasi' viiriof? in diiratiou, wmietiine?* Ia;*ling for only a few dayn, in other
tms for u nuinluT uf wc*eks; but in some cu^es it last^ for nionth.^, when it
DPStituU^ the chronic form, which hi ajit to prove fatal, botli from exhaus*
Bon and fmm the development of more aerioiis central nervous tesiona.
cxtrciiK* and so cimnuterLstic tliat the attendants shouL
to touch the child or the bed uuueoessarily, and absohi
c'iil'orc»(Hl in the n>oin and throughout the house.
I havt* alrtwly told you that, as a rule, oerebro-s]
childn^n is a disi^aso which is characterized by acute onset
I take I'nun my nottv, is illustrative of this fact :
A Ihiv (^('uso 828), tliirUH.'!! years old, had never had any 66i)ecia
niihiT di'liouU* for a iuiimIkt of months. He went to a Christmas
iind on nturninj? from the jwrty complained of the motion of the
h'tnx*. On the followinu; day, in the afternoon, he was found to
loniruc coiitiHl hut not dr\', and to have a temperature of 40. 5® C. (
140. He roinphiin<-<1 of tenderneiM and pain in the back of his neck
i)<'>^ in thi' alKloincn. He appeared to he somewhat dull.
On tln' followinic day the temperature in the morning was 99 4
pulsi' was 120. H«' WHS much more dull and apathetic than on i
the afternoon ht'canx' delirious In the evening he had involuntar
looM- distliuri^es fnim the howels. His temperature was 40** C. (104
On the follDwini^ day his tomporaturo was 89.4^ C. (108® F
varied frnrn 40 to 80 and were regular. He was unoonscious. S
pn*>ent. Tln^n^ was retnietion of the head. The pupils did not res
e(jual in >\/A\ A tac/if ch'tbrale was pre-ient.
On tlie evenini: of the f(»llowing day, four days from the onset '
TIm' autopsy made l)y Dr. Gannett showed the convex surface
eoni to he covered with a thick exudation of pus, the spleen to be ei
]»e one of acute cere]>ro->pinal meningitis.
I liavf h«re in the wanls a child (Case 324, paf^e 697), two yt^r
to the h..~pital on the 21st of the month with the history that it had h
of jiialai>e fornix weeks. Two weeks previous to entering^ the hospi
and tli<' iii'lejinite and iri.nenil sym])t<mis had hecome more pronou
l..»- ..I" app- tit.', with eon>tipati(HJ ; at times vomiting, sligrht couch.
^•be
ORGANIC NERVOITS 03
697
'be one of thb dij^eoso. It hoe boon in the tio^plul for seven dny^^ wliich would iimke
B ■§« Hm^ m\c^ it wm ftnt noticed to bf sick i^ven wt^^ks. Since entcnug tbe Luspilal
t,e U*mi>erature hu* vuri*?d troin 06,6*» to 38** C. (98<» to 100.5* F.). At iiitervuls il hm
*miied &nd htifi apparently been uucoDscious. Sometimes it bns crii'tl uut f^liHrply, im
Ugb in pain. A tacJie eeribraU hB& been found ttt tlmeSf and the n*tracUan of the head
been almiiet continuous.
The continuous retmcti'jn of the head, with at times opisthotonoii and unennBciouBooa^
ilbout the eerioui eerebml aymptoms which atVr the fourth or tlfth week would ncooni-
uijr an attack of tubencular meningitis, and the abseooe of any sjrmptonu which point
Cienshn>«t[>iiiA] menti^tlB. Hide, 2 yean ol<l,
I lowwdf disease of the thorueic or abdominal orgaogi lead me to make the proTi«ional dU^-
tioeiii in this ease of cerebro-^pinal menintcitis. From what I have told you in a previous
lectur«> in t^peakin^ «»f tuben'ular meningitUf esf>ecially of tbe recurrent form» an inbtance
(Case 272) of whk'b I ^howiMl to you at that time, you will understand thai the diagnosis
muat hv Komowhat uncertain in a sporadic ctiAe of thi^ kind until thediaeaBC ha» been under
ervution a still longer time.
The treatment of thi* case is simply the fn^juont administration of milk, with the addi-
tion of nimulant^^* when indicated by the weitkne«8 of the pulse. Tbe child ha» been in
ao apatht^tic a condition that the um of any drug ha^ be«>n unneceeeary. AUhnugh at
limdB it has cried out a^ if in severe pain, yet the»e attnckii have not been «ufBcieiitly long
to indirnte their control by nn opiate.
(8ubscM]iient history.) During the following month the child remained very much the
Mtme vm dt^H^-rilted mInivi^. The head w«i« retracted at timea, and the emaciation bocajne
extreme, tht* nMomen being very much sunken (boat^haped). In the next tw<» weeki tha
nourish mont wad tukei) more readily ^ the head was less retracted, and he began to noUce
oljectfi ur^mnd hirn, but he vomited once or twice nearly cver^' d»y. Tbe l«»mperature at
this time liecame normal.
Tbi« chart (Chart 26, page 65W) marks the lemporature from the day when the child
entered the hospital, in tbe sixth week of hi^ lllnLii, until the tempemture became normal,
ttine days afterw*irda.
Ofte month biter, which W9m two tiiontht fhom the time when the child entered tli#
am
l»Kt»IATRICSi.
luwpitAl, h** vmi mUW u* fit tif) wUbfkUt help. Then* vap no r tnrtiiM if l> tii .
CHART 26-
■-
lot*
J^>I 4» 43 ^ -1
H
::5
iilP*
kkii
1 I
r
1
J
f"'
. —
«i
I4-4..J
^4t 1
1
Vi
J
P
A
PPI
4
1
1
— ^U
•
j
1
I
— -^ — asj* 11
rin
1 Ilii ApficUtii, ftnd wljMi mftn one mociili Imtnt wua ftmnd oc rIiT.V=.
ti> tw tn » nurmal coniliduri. K>'n(> ii 11 pTvtatv (til,) of tlii' diild,
by ttip whirJj ihfiwcd him to W- in » ti^irmni cniai^i*
TiiU D«xt ehlld whutji I have iash<m y^u 19 h i^lr) (Oab^ JSS&\ Mki fim^^\
mpfwrisiiUj i«pFifi»«oU tlmt lonn f*r ci*r<^bpr»-#.plriiU i3if*filn|ciitff wlitcb k diMM^if <^*
And only ft f«w ejwci of wbkb Imvc been rt*port«>d.
Tb*' cJiil-J mx^fi^ tbi- biii^piuil iwo d»ypi agn. Hi,r put^t* mv «ia tp t^ '
bi*iiltii>% itnd tbcru ii wo pvidt'tic** of tul»sit?ulo»iii cpt nypUlH* In tbtf fiiiBllT A ^
whom I AHW in consult*! i*i« dM uf o*»rpbro-*pinal mriitn^iifB^ Wltb t^ iimlb'^*' I
iiHii«;k t>r itJi?iiHlw uiid of whnoj>iriir-Pf»**g^t 1*^*? cJulil lina ucit ly^ ^j.- olkir<^M» ^
prt9«f?iit illiKJf* bt!gwn fiiur %nd n hnlf mi*nlba ii|ff>* Tlit* clifld had nol liin it 1*^" "*
finp(* tbt^ Hltnrk of |n«rlvt*<"jt wb&cb rKTurrwl nn** y^np ^o.
Tlie opJiet of this iittiv^k wii« ^imMen, She Wi*m lo ha^ fn Htlriv imaiS '^ t
woko up in ib<^ nij^hl fi*'linrniH, M-n-Hminfft **"*! app«»ritnLly noi TMiefttjdMB to ^^ I
These ujiuploftu. coutiniH^il until tbi* f* JUnvltig w.-«k. Th«*nf' wpr« no i5mniMoK» I ^
h^ rmmiltig mmrmd pycn two f-r three diiy». Till. wn. nut dMi.-i>iif»irt o|m» W ••< '
luuE ooeuiTod at tritf»rTftI* wp t** lb*» pp»r-t*nt tUm^, Thf* btt^giU w«m omtttiMipd. tW
h«A b<*eii fnif>n» or Itsw opUtbotonos ft^ntii th*? bt^pftrtnini*: of Ui,. lUniii*, Ai&d dio lo U»^
liitig theiv wn* dedd<d fotmelion of tb<? bead* Tbu ^liflbett nf the ai^k b^ em
700
FHDIATHICSk
%ppmf* ftnm Ui«* l\imlu* *»f l^«* «*r« orito without the ift«^ of tbr 1 1 > 1
It b mny l«j (Uttiafrcittli Uml tliw rvlUra clo«« not oom^ IV* .to ih*r
I ifiwfii<^. Tim nuudiiii uf tfav •yebftlf l# tipij iiici«alk rediK^. mmA (k« •
inn i»i««iiftt<"
i*4tjwiii*. It r««urt ffuiu* rn*«]ttvrjlly In cvn^lti^w^^i^ftiU iii«miiii(itl«^ It i« i^ U <
thnn Klitiniii. H«ici»rttnit<i thU Tu11i<wi*ii timm 0lU tile %ilTv«i<ts entm^T.
im.TrU It may hav« blmnl-^wwU ^m \u mrfWt'**-
Tuu IM4' r»n dnwiiii^ tW ilij)^*'r i*vi»r Hut* H|^lii tlilt;ti t Jtiu • 4«HtM i^ '
ThU i* *'m\\ Ihv thini i*H*i^ <>lf tbU fi*WTn at i-> oiMilii^il^ liiH l» •
luidi& rnv r>t>>v'rVMttiMi. tn Inith tbi* otl>(*r c«fr« ' t*T«mtQMlUMi^i^|
l<»tig«*l li^kutM nf iiiiirty stuxithAH, ^uri&i; whsdi ibrj ai. ciiu«M iim— i Bt W ^-^
0«Pf« h«v» lmt«ti EV|»rirt<«t) bv otliifr«, •• bj Ut^ttcidi uf BcTltrt^ ii* lijivii iiuiifM»^
tlii» ii«p0<?lat eft*0 wn iiTv ritil nIiIi? t(i glvii * motv dvHiilU* |tn»|^i«T*U Ai f9«»j ^
m» Won whi**b I Imvt* iSt^tc<?tlH! ilml iriHtltl i*n!Vt*tiC tbn child trrvm f»T.iimi( t-. |
•be ^ill ilWii^v b« blinds On ibc nthrr hnnil* *1ii^ nuiy o^yonUinif j d^e firw <
CttAIIT
217
B(i{/« iu lif^ApUaL
LL
»
i
IT- *T'
_IM9^
10
-IL
i?i>-
Iff?"'
MS
KB
MC!
mi:
»m
uc
)g%
MS
we
m \
' ^- I -
lOS"
97"
L
i
1
-
f
—
7'^
1
J
1
K-
'}
L
.A
\ 7
i/
s
^
1^
~7
A^
1
\,
^
Y
^
^
^
y-
^
/
L„
n , J. _J
1 4
—
^: 1 ■
t
. 1
sj^,
ClifcwiU- rerfehr.>*piniil W(jfiltiirfil«.
(8iib#equ©nt bistoTy* ) After the i^umvt n*port tti* dti Itl r«*miiir»«d in ilAOt d^i^ *
dltion. At timea ibs scrt^tned «■» though hi pnin^ bill pIii* u*rtk h4Tr cimijMiii<#l ^' ♦*
8bt* had ono »ligbt eonvuli»lvi>«itt»ek. whU-b ifiv*»lvt-Hi in^inly thf» upprf ritiwHie*. ^
extftMiiiiTi/j? Iwhi^ niily pliirlitly c?ontm*'tod, DuriiYij tlii* Attack livr llmtitl>i ^^^ "^
ln^r Jlrtjjfnrp cUnchfd nvor thniii^ ancJ Ijhp »r»tiu, wjiich w^-rc tunmllv nxtoiKlmi ai lirf^i-i '
i]«5VtHi lit thp mUmiw K, Hit fuce nhowi'd tio iiic^ of «p««m, »nr| duHnc Uw ►U*^ li* *'"
jmUc Wfp^ (\tlK soft, iiml rcgnhir AtW a t>w RivM>n(jc tHii ti*,i«e!« n^a fcKwi»^ ^
»ind th<'ri* wiw nfi fiirih'T tt'ridt*Trej* t^» wmlrttrtrtjii, "th^ u-itul if«Mitt»»D Jnwhiik^^
during: tho nai^iwing w<*<'k* wii* with tht- tluKh* sllirhiJv tl<«x4*a nml aIhIiu-M tttl ^ •'
flfxini ttt tht' knt'f,% wifh the hi^dw iilinrwf tt»H«l»h»q v^\A\ uthc'r AI««Ut twn »*^ »^*
«5iiU«nng tb^^ hofcfiltttl the right k*£^ Inwim*." tk'JEifl cifi thv tbi$rli f^i 9Ut?li ad »tl«ttW »
kfjpe jilmoM totJt'hvd the dilii ami ibe bo**l rv^t^tnd nn th»* %*u|ym, AnTn^-M^^t '*'-
tho loKj rtmd« the t-hild rry *nit m \Xv%\i%\\ \x\ piilri, thi« |f»n W Mtir '
in b«*d. Tbii cijjidkiori uf the* right leg L*r«niinut?d JVir (»f*v»«riii liay* «fvti lo.ii > --• •
OKGAMC NEUVOUS DISEASES.
701
mnxi hiter n filt^ht eonvuMve attiick took place, which seemed to alfei^t the Hghl »ide
' than the lefL
fbu tbttrt (Chart 27^ iwg** T<X>) ^hnws th<^ temperature during the eighteen days wh«ii
ild wtt* ill thf ho^pitnl. The pukt* during thij^ tun** varit**! fmm 68 in 100; the n»6pi-
ns ««»mi.*Utiti'g v»rit*«| fri»in S4 t" ^j2, hut wen* usujilly iilmut 28.
Thf Hngeis wen* flextHl most of th** tun**, iirid ther*.^ whm *o rnutdi Hiafidiiy of the Utiibs
It tht* r«0ex«^ could nut he satisfiictorily detenidned. The p\i» etnhuluf in the right eye
:^l4i.>^tli LMiiiJiiiun of extremiUfii Tt}^ mcmlhA aller <in«et of thm ttu>c«fr.
! tt> he further hnek fiv)ni thi' plnno of tho iHa tbAO nt the prrvioUff eitaminnliofi, 11)«
nbolUH of the left eye r^maint'd tri iiUrui the Mirne plnnn with the iris. The ht^iid wai held
I in nny position in vrhtch it wBfi plnocd, nnd f.he criixl when it wb* movrd. The pulne
IfWJ, wi^Ak nnd rimipre^^ihl**, the rr'*|iir*iion8 w«^fe rapid, 42, the »hi» nH»i moved ^ime-
Kl^ and therr* wtt« nppiin'ntly a fli- "f <ly»pnrea. Tht* t».'mp**nitur(? in thu aiflla
t_dt).«i° C. (101.5'=' F.). There wa- ..no^h of tho cheek« and ilj>», and an emptioQ
~^^^m
702
PEDIATRICS.
Cask 326*
V.
of inilm on the ctiiiiBt, Apfmfvntly furuing fWni bt^r cufsti; -'l^i
Bbe l«^ in II »lii(H>r hU ihc tittie^ except whi'ii f^hc wiia > tWi
6b« i4iowc!(1 no (iij^na of undorKturKJini; nny thing tlittl was aftid to bf?r. liwir— i<
be Mi2«d Willi an attArk of rapid bn-nihiti^ liL«>tiiig MrTemJ hciiiz** Th» Wf«yii
comti|mtv<l up U> wilhiti two day*, whon dinniiOB* oecuxTKl. Thcfc «m i
Hmm Htiil urini% hut nu vumttini;. DuHng tht* lust fWw iIm js |irrviciit« t*i tl^ f
the tM*lh wen^ kopl rinsed, ami liml to \»^ forcocl Afimri wbt^ti »b«^ wi* Ud, ^mn
to have hud one week previous u» UiU e&iiiniruitkin a oociroUian, in wkk^ttuMlj
drwvrn buck, the Ixjtiy nnd oxu^niitic* worp rigrid, and lb« ^yiw ridM up. IVifcili
fhnrply jUAt bvfon* the CMiivulMtrin. A phyi»icml ^XMninatioci urndt M ita^mt
not lung iibnorniiil in the ohc^t or nbdomen.
R)^ht<*<'n day* afU>r «?nt«*ring thit bofpitil ibd
taken l«j her boiiii*^ fro thai the liaily n«ii>n1 tTdii^ai^
toinod.
An examinaliun made two Wf»^k» hH' r
tjil showed a ^pafttic eouditioo of the e$t]>
wL'en in th«H«e i)luiitratiori« (Cose 825, III u
When Been by Dr. Bullard at ihb tii:
notice of her burrouodin^, and her eyt-
H vacant eApPi^fedioii, due liir^ly to lb'-
ttlthnujfh at thb time i»h*» was midiHibiJtlly i>iiu
in'tnitiw weri» iimch wiu>tc>d» and wen* all in * p*i
spuiitio rigidity. Then? wa^ tl^bt lleM*^n <rf tb# ^k^4
tHMly and of the legs an tbe thiKbfa, while thf ini
ttndod in nearly a nr)ut;ht Tior with tlM Nql
The band, aa you see in Ibis Olufitii^ca iTA«
nlmo^st at right anglea tci tfa^ wrist. TbepoUMtf
of the fingers are hy|>«*rex tended, while Ub «0
aro flexed. The thumb is «tn>ng|y addurtid, <
phiilunx i* flexetK
Thii* i« a position of the band fW«|uentlj teii*|
later *iage« of ^pufiUc paralysijir And is dur to tb« pH"
contraction of the flexors of the writjt and wcakncsaa of the !ntem«^ji and Iviiiilwik
(The ohild jrradually grew weiiker, and died of exhaustion ■ f^-w wr^L* ]tm\
I will aim reiM>rt to you another of these rar^ v^vs of chfoiiie«!^|
spiiial meningitis whieli I saw in <»ai?ultation with I>r, TownseoiL
The child (Ca*e 826), a boy, four and h half years old, had been previotwJj wl •*
the exeeplion of an attaek of mea^Ie:^ when he was one year old«
On May ?* he was suddenly attHeke<l with vomiting, which contlftUtd it ^
for two diivii. From the beginning of the mtnck he complainoil of ^rer^ pm iit>»^l
und ttbdomeii. On the second day of the atfjick there was much c^mtrictioii ("f 1^^
und he wjiH ^sli^htly deliriouit^ ultlioui^h nitional mo^t of the Um»~ TlM tgnrnwr""
ntiiod fmni the begjinning of the iittjiek. There were no oonvMlaioftt. Tbe l*«^**
not riiitvfsj during the first week *if the di«ea>^e. When first s€«fi W lit, T • -
pulrie wii« 124 and reguhir, th*- tern p4? nil urf^, a8.8<» C. (102*' F.), and the mpini^ ' ^
reguhir. There was slight opisthotonofl. There were no euti traction .if lb* ip-- -
the limbs. Thi- symptc^m of Kernig wa* present. There w»* no tenden>r^ t^-i-
S|Mne. The cutaneouj* fteneibility was everywhere n^nnaL The?^ ^..f,. fv rta^
efiloreficencea or eochyrn(»et?. The pupils were regulnr and fn
There wa« no fltrahls in uft or photophobia, ^< 'thing abnormal wai^ r
aminjilion. The pHtient wu^ iippareiilly in gr<;^at pain, cried out a srrat d««i m<^^
continually. Th-* suffering during the next few days waa so ^nmt that rni.r^liir. -4^
of 0.002 gmmtjie {^\ gmin) hud U) "l>e given. This d(»ee had to be int-
that it wa.s found that the child took 0.015 gramme (J grains befbir r»i'-i
Chriiiiiir ren-lirij-^pimil men-
fngltlK ^i-Hi^Uc LifO'liUnu of
hand 5^^ mu(nth«i after impet of
tbe dlMaae^
ORGANIC NERVOUS DISEASES*
703
Dn of ice to the besd and spine gmve nu relief , and
timb^T of day» later it wai; ffmnd tliut there woa needed
trol the rvstlessfincss and pain 0.01 lu 0.02 grattime
■ grain) of morphine during the twenty-four hours.
n thu tw*^ntj-fourth day of the diaense the tenipera-
rhich had varied fi^m 37.7^ to 39.4*' C. (100^ to 103*»
9cat»e normal, remaininu: io until the forty 'Seventh
During this time th»* head wa^ only slightly retmeted,
le «hild 9<H«ni**d fr»?e from pain, but PF-maintxl in a
btlesfi eouditiun, nut t^peakiugf and taking but tittle
hment or ^tinuilant$. He became entadtited, paned
ntt Hnd fa^cea involtintarily, and occafrionally vomited.
ive enemata were not retained^ hut on the forty-flrst
^he diiteafie peptimized milk wa« rftained, and on the
B|i day he was able to take gniel, and at that dme
Bd laughed.
Bhe forty-seventh day of the diaease ft relapse ocv
^e t<?mperatur« rising to 89,7® C. (108.6*» F.). The
ras riji^idly drawn back^ the eyes were sianng, and the
Btumed. The symptom of Keruigf which had never
leared entirely, again became well marked. At this
[ Bftw the child with Dr. Towntfnd. On the mity-
iftj of the di^ea^e the convuli^ive movements of the
m and leg, with turning in of the left eye, occurred,
d day« previous to thi« relapse a number of eudatiiina
red on the neck and tnink, arjd an evanescent erj-
tous eruption on the neck and fac^e, laitting only a
Hin. From th»' *ixty-firjt to thf ^ixty-sixth day of
this bcnly waa c<jvered with ft macular cfflores-
macules varying in sixe. Eochytnoies were at
tie Been, and repeated eiLanii nations of the chest and
len showed nothing abnormal.
'xf>m the fteventy-flrtt day tt) the seventy*third day
mperature wa* again normal, the child to<:>k hi« ff.Hid
the neck wttp straight, ami hu general appc^aniuce wa»
raging.
'n the fteventy-fourth day he again had convuUive
nentA, most marke<l on the left side of the b<jdy. The
wtM drawn hack, and nt no<jn the next day hi^ teni-
ira wan 89.4® C. (108" F,). Tht- pube, whiih during
»tire illnesi ranged from 120 to 140 and had previ-
been regular, was now at times irregular and tnter-
U. The bowels werr* eonatipated at this time.
i.fler thii*, although the tinop»^r»dure l>ecame nonnal,
liM failed nipidly, and thtTf was *o much cmaciatltm
be flngcr and thmuh could cji*ih encircle hii* thigh,
te died quietly i»n the eighty-aeventh day from the
jl the onwt of the dUea«e.
nDugh the kindrii^Kh t>f Dr. Towneond I am enabled
Wyou hh tcmpcniture eliart (Chart 28) tt%nn the teiUh
r the di»eft*e.
^Mras Tety difficult, indeed impoasiblCf to gire a
Hi in this case, as at timra it seemed fis though hi
^eover, and then the tenifieniture would rb* ftgftin
M unfavorable symptoms would rv'turn.
■I
s?
704 PEDIATRICS.
LECTURE :x:5cx:i V.
PERIPHERAL NBRVBS.
Nki.ritw.—Paraly8I8 of the Nkw-Born.— Neuralou.
NEURITIS. — Xeiiritis is au inflammation of the i)eri|)benl ar^
It is ;!(•<•« niipanitHl hy pain and teudemeHS in the affected rcgioasaffliffl:
iiion' siVt'H' <u<*'s by imralysis and atrophy, I shall not dwell np«:
<as4-s <»f nt'uritis of a sinjijle nerve-trunk or its branches, whicii nav >
< aii>('<l hy tniuniatisni, w)ld, or pressure, or may occur in the oinw :
variniis dis<'as<'s, but shall merely say a few words concerning a fa
form of this disi'ase, billed multiple neuritis,
Mri/nrLK Neuuitis.— In certain constitutional conditions a nriv
of* nrrvt's in ditlorent parts of the body arc affected with neiiritiB,aaii
i-oiistitutcs the dis<»jts4^ muHlple neuritis,
IvnoL(KJY.— Multiple neuritis usually occurs in the course of or ^ti*
tjuciit to one of the inflations diseases. Of these diseases diphtheriai-i-
most (iunmon, but it is sjiid to follow scarlet fever and measles. Ai&
form s<»m(timrs <KH-urs after typhoid fever. At times multiple mm*-
prndnccd by dru^ii, such as lead, arsenic, or alcohol. It is notaiiiua'-
di^rasr aiiKHin children. The epidemic form of the disease Iia-teS-:
pnvalt'iit amoiiiT the Japanese, and is known by the terms kakktai^U*'
Uri, l)nt it is <juite rare in this country, and I have never met viiln'
<'hil(hTn.
Patii()L()<;v.— The pathological condition in multiple neuritis 1=^^
intcr-titiai or pan'nchyniatous inflammation of the nerves. AfevKT"^
may bt- alllMt^il, nr the distribution may be general. The nervesofiii
>IHMi;il Hn<(s, however, are rarely affected, and the nerves of the head 3&:
I'arc [ivr not usually involvinl.
SvMiTnMs.— The onset of the disease may be acute or subacute. I:a
at thr lH-innin.<r present severe symptoms, such as extreme i)ain, teoAi-n*
over thr urrve-trunks, and iever with an accompanying paralysk Oei!»=
"ther hand, tlK' |'aiu in the Wginning may be very slight/ and the i^
-yni|.tni,i. n<Mie<-(] may Ih' a gradually increasing weakness of the Kb ^
liiN- thr irn(l.'nw-> may 1m' f<anid only when espe<?ially sought for. Tl-?
■ Im- hyprneMhena, anavthesia, numbness, and loss of muscular pn«^
After the a.'ute symptoms have passed away the faradic initabilitj'iste
ished : the aeti(m ol' the nerves to the galvanic current is dimiiiisk.i5&i
the reaction of ,lep.nerati«Mi is ])ri^Mit. When the extensore of thefc?*-'^
alll-et..! there J. fuot-droj), and when those of the forearm are affected iw^
is wrist-<lroj>. The ronrse of the disease is apt to be a long one, andintly
\v
IV
(JHGAKIC NERVOrS BIHtLiSES,
705
CxnK 327,
stages atm|jhy occurs, while the early hypersesthesia nmy g^ive plac* to
more ur letis^ umrked anje^thesia, and iiinnbuf.s8 and variiuis other [lanuS'
tfCBise may occur. In mild t^sess, where only pain and leiidern*^^ exbt, tlie
nee-jerks arc not diniiiiLslieJ, and may be even slightly inereasiKl, but iii
*^ \e more typiiiil i-jLses of the dlst^ase thc^y are alj«*ent. Contraetnres and
^B lo^MitKlie conditions are absent, the paralysis lieing flaccid. The tempera-
^^ ire is apt to be somewhat rai?*cd, and is decidedly so at the onset when
kie dissease is acute.
D1ACJNO6IS. — The diagnosis is to Ik* miule chiefly fn>m poliomyelitis
■erior, wliiL'li may simulate multiple neuritLs in certain t^*es ; but in the
^ticr dis<iL^* th<* aKsf^KY' of pain excerpt during the first few days, with tlie
I igjaoit* limite<l distribution oi* tlie i^Miralysis, and tlie absence of tenderness,
[ 1*^1 11 serve to distinguish it fmm the latter.
Prognosis, — The pro^^nosis of niultiple neuritis is favorable even where
^iie disease begins with an a*'utf tHiMi u<x\>mpauied by delirium and high
I ever, and, although the jmralysis may last for many months, the eases
isnally recover.
TRKA.TMENT. — The treatment is at first by ab«?<:>lute res<t in bed, and
later with elet?tricity, inaasage, and strychnine.
^If3dide of fMitassium is iudieated in those cjises
'hich are causes! by lead or arsenic.
In tlie subacute ca^<?8 electricity and mat^^sage are
indicated IVoin the very Ix^inniug,
It is safer to wait until the pain and marked
I teiiderucHs have disap[x^ar€d Iwfore Ix^giouing the
I administration of strjchnine.
This little girl {Ca*e 827) ^ eleven yean old, repreeenU a
of multiple iK'uriiia produc<^d by dosei of 1 gramme (15
tiiriiB) of FowltT'ji H<»]uti(>n given three timet 11 d«y fur eome
weeks duringf an iittuck of ehorpii,
Tb« Unst eymptom^ which were noticed white she wa^
trnklng the aj'^^nie were that sdio vomited K«v(^rul tituivi, l>uL
tbii was not aufi|>06ed to have been caused b^' the arsenic, and
the dmg was therefore eontinu«*d. It wa* next noticed that
tlw cbild was unable to walk. Her limbi appeared to be very
w^k| and thc'tv wii»^ ulmcziee of knefvjerkg and ankle-clontu.
The »eni<atton of the IuhIjh mnt> nuniial. A few day^ later «he
was found tci have tender p>int« over variou* parts of the leg*.
The Icir* then b«^»ame atrtjphied About a month later tender
points dfvtOop^Hi in the iinii«t and she noon lost the power of
uainjt h**r nnun^ to mich • daip«» that she had to be fed. Al
timi% althuugh the Mwrnic had lx«en imiitted for leTere] dayt, a large quantity of it
ftmnd by Profetaor W»K>d in th<" urin«.
You («**« to-day that »the haw no ri»tnain§ of the choreic moveinenUi* but that the b
mthRT «tupid^ and that there i« tenderness on d«ep pr^utin* over ctTtain points in Iht
calvon of th*« legu. She has no hcmdac^io and no other abnonnal eytnplonu. She b
tn*aU?d with the fanidtc current daily and with 0.18 f;niniriM» {Z jrrain*) of lodidi»
potaf«ium three times a day. Bince this treatmont wn« begun * ihrv** wiMk(> agu^ tb«
4S
MulMpk^ DoUTitlfk Female,
UyoaooUL
th.- u f hi- liii»*»*. Fi»r ti yrar hv wHlkinl with the help of m c
1..-^^ lit* |io\v> r of iii'ition. but in* pain. The iippetite was not l(»et.
Iif:i.l:i.ln-. Alt«T ihf |iiinil\>i:« ttppitntHi it wiw notic^ed that the
at lirij.'. Thi- Ik»w«-U w«-n.' nxulur, and there wa8 no trouble wit!
w. n- -..imwhat t'MiiliT "H pH'^j'Un*. His* t<*inp4»ruuient was d
nith'-r t'ptrul. Si)iii'\\liat Iati*r h«* 1j»si th»* u^e of his leg* eiitin
t arrii-il.
U«' tli<ii I<-t\ hi'> li<»in«- and went to Florida, and after a fei
ii-»' "tf lii^ \\u\h^ tiitinly and Ui'ame jHTfeetly well. He returned
•rh'H.l t'.-r a ii»i»iitli. At th«* end of that time the ttyinptomr* of tli
-lowly lo n turn, Jind In* Hnally had to stop going to sohoiil.
On «\aiuiiiati«.ii h-- i- loiind to protrude the tongue straight, h
:iMi- 1" thi- hi'ad. Th*'n' an* ix'il t-xantht'inatouj: patches on the clbo\«
.-p. . i:tl air.|.!iy ••!* iht- h'vrs, but there is u tjiKxl deal of emaciation
• anil'! Im' rai-« •! hi'y«»nd th«' l»*Vfl of the >houlder. There ia son
wh«M ilh- anil- ap- rai-inl f,>r him. Then.* is tend«*rnesri on preiij*ur
;lixi"M i.r thi* arm- i- l"'.-1 : the i^rasp of both hands is weak, but
iiHMt. Thi- })airllar nlhx*- an* absent, and ho walks with a peculi
i an -t:i:i 1 w.Il with liin ••y«- -hut. There is no disturbance of the 1
n.. |.r....:' tliMt ih«- -ympt'-m- n>ult lr«»ni masturbation. Xo irriu
|.npn. . -Ahicli. how.-v.T, i- tiu'ht. H«- eannot gf-t up from a sittii
.l.'uri. JI.' .ipjiaivntly has l.»-t the jH>wtT of pushing with his arm;
i- -tiai^i •. ami tli'if i- n<> Mppan-nt tendenK»se«. Ue has never had
<"."ll}itivi- .. -. :i<.« r\i-.pt mi-a-h'-.
Tli«' li -' lA -•!' I hi- jKiti'-rit and the examination lead me to eli
a-.'l I'l'Mni.t' r :tt:i\i:i. Thi' nipi'l improvement which to<»k plac
tip- < Ijil.l w:i- lakrn away rn»m hi- home for some months an
>yinpt..ni- \\ii!ii:i a niMnth at*t«T hi> n-turn, justify nie in suspectii
.ii-:i-. i> A ImmI Mill- «nnn«M'ti-d with the c-hild'» home. Of such to
I'-.i-i - til'- iii'-t r'.nini<»n and prn])aMe.
PARALYSIS OP THE NEW-BORN, By pai
r
^Hknown lu a uumber oi oiseB to result from pressure by the furcepB
^Bg the delivery, yet it has also been met with alter au appan^ntU'
^^pl doiiver>% where the pnes^ure did not seem to l>e especially severe
^Hjklonged.
^^A^THOLOGV. — When the nervee of the face are affected, the residtiiig
*Idh h supjKw^ed to be from an injury of tlie facial nerve; and when the
u 18 atft'ctcd, the lesion is supposed to be an injury of the bnichial plexiiji
of the uorvt^ in the lower part of the neck. When tlie limbs are artected»
th ariti8 have been known to be |>aralyzed ; but, as a rule, the lesion 18 of
aruL
SvMPTOMH. — ^A imralysis of this form becomes apjmrent irumeiliately
IBT birth. This is a very im]xjrtant fact ti> remember, as in this way we
n differentiate the disease fnjm a paralysis resulting fnnn jjoliomyclitis
iterior, which is exceetiingly rare in the early montlis of life, the youngest
^ on reoi^rd being twelve thiys old. Where tlie face is afflx'teil, it is due,
a rule, to an injury of the seventh nen^e, thus pnxlucing a |)eripheral
cial |>aralysis. The {leripheral form of facial pamlysis is distinj^uished
Dm the c?entml in tliat in the former all three branches of the seventh
Nrve arc apt to be atiected, while in the latter form only the h>wer two
nnehes ai'e hivolved. In tlie peripheral form, therefore, the eye on the
"ected side cannot be closi*tl entii*ely, causing tlie f^indihon kuuwu as //f^-
Minlmifi, and there is inability to wrinkle the rnusi'les of the forehead
tJie atTiX'ttd side. In faciid paralysis of wntral origin the muscles of
i€ forehead are not allected, and tlie ability to cltise the eye is but V\u\v
ecreascd.
Where the paralysis atlt'Cts an arm it hangs lifeless by the side, with the
llm turucil Ijackward and the lingei's often flexwL The tingci-s and fore-
pm may be movnl^ but the movement of the upper arm to any extent is
»t,
DiAGKcisrs. — Tfiis form of paralysis U to be diagnosticatetl fixjm cerebral
iralysLs by the aljscucie of iucivasixl reHex irritaltility and by the dlstri-
ition of the paialysis. In the cerebral form all the muscles are aiTected ;
the peripheral form, tuily individual muscles. It is dt^ibtful whether
iralyses of spinal t>rigin tH*cur in tlie early days of liie.
3a8es of paralysis of the arm in the new-born should also be diag-
leticattnl frnm surgical injuries reiire-scMitcd by fratlures, dislmtitions, and
Daration of the epiphyses. These are eiiminattHl only by a can.*ful exami-
Ition of the head of the luimerus on tlie affected side, showing tlie al)senee
crepitus, abnormal rnnbiiity, caUiL^, or deformity'.
pRiXiXosis. — The jimgnosis in cases where tlie face in affected is very
Kxl, as the paralysis in tliesc* instances lasts but a short time. We must,
IWisver, \ye st>mewhat guarded in the opinion which we give concerning
icm, as in some instances the paralysis does not disappear antl the muscles
' the imv are left irreparably injured.
In regartl to the paralysis of the arm, the prognosis is gi*uenJly lui-
OnOANIC NERVOUS DlSEASEa
707
7(W
PKDIATUICS.
(ASK 82H.
lavonihlc, c'SiH-cially it' marked iiiiprovciTiont cli>cs not stK)n cKrnir, ami oi
narily when iin|)n»vi'nu'nt taki»s plai^' it is very slow. M«>?t nt' the* m*
novtT nxii>ver, and partial rcxwen- ?k)iiIJ r
1k' exiK't-twl for a number of years. Shonniifi
of the arm is marked in the later lii-tMrv ot t'j
st»verer «tses.
We can therefore state that jx*ri|>lnTjl |»araA
sis of the new-born when it aftU't- a luul- i
niueh more serious in its prognosi-^ f*»r ivmi] Pi
ix'covery than when it affects the face.
Treatment. — P^leotrieity and nia^f^'H.ij
^VL M^^M tinuously applied for a number of yt-arsLsavt:
^ ^1^^^^ iin|K>rtant jjart of the treatment of die?e lu.*
and obviates the atrophy of the nius^li^ tr-:
disuse, whieh must necessarily take jJa't :•;
greater or less extent.
IVriphrnil {>(iralyHi.>«i»f tlu'iuru-
lMiru ranily-U «it riuht Ki'Io (»f
I|MUIV..1<1.
Here is an infant (Case 329). two hours iM. wlia
a p-riplnnil j.Mnily.-is of the rii^lil ^ide <»f the face, caused by prc^ssure of the ton-ep« '■:•!;
-«'V«'iilh mrsf.
In this ca-i- tbo rlosiirc which you notice of the right eye is pr«.Kluc<'d hv the -v Vc,
«'t' tho Wwv ami rsrliii. You see thut the entire right side of the face is affectti.
I Iiavi- h«r»' aii.>ih«T infant (Cat?e 880), one year old, who presents the o-^r^drtc: :
IH-riphtral |iaraly>i^ of th«; ripht side of the fiice.
Case 330.
:i|.lK nil pariily-i- of tin- ijew-»K>ni. Paralysin of rij^hi side of face. Infiini cr>:K.
Mule, 1 year old.
Wh.M tip- iiilMiit rri.- ynii MT that the lines on the right or paralyzed side of ri-: i*
MP- » .-■..■wh:.i ..l.lii.PMi.-cL ai.'i that the rii;ht eye cannot be closed (li^ophthalraU;. Tb
liii.- Ml" Uir 1. ir MP n..ii.|,aralyzr.l >ide of the face, on the contmiy, are deepened. iX -■
l"tt .v.- can ])(• «■}(.-. -1. Tho inmith is jlrawn to the lefl,
Tho i.r..^.n....i> of thi< fa».' i. l.ad for complete recovery, and treatment of mt t^-
will pn.l.al.ly !,.■ ..f i,.. Mvaii. oNsiri- t.. the length of time for which the lesion of the rfr:--^
ii'TVe lia- fxi-t'-d.
OBOANIC NERVOUS DISEASES.
709
This little boy (Case 881) is two yean old. He was healthy at birth, but the kbor was
instnunental. When he was three days old it was found that his left arm was swollen.
He was first seen at the hospital when he was seven weeks old. At that time he was able
to move his fingers and wrists, but held his arm with the elbow straight to the side and the
hand pronated. He is now, as you see, able to make slight movements of flexion of the
Cask 881.
PeripheFal paralyids of the new-bom. ParalyRlfl of left arm. Male, 2 yearn old.
«lbow and slight contractions of the deltoid. Under the use of electricity he has been
showing gradual improvement. Ho can grasp objects fairly well with his left hand, and
can flex the elbow completely, and raise his hand and forearm aA far as the nipple. You
see he can raise his right arm with ease to his head, but cannot raise the left hand farther
than the lower part of the cheet.
It is evidently a case of paralysis of peripheral origin caused by trauma.
The prognosis in this cla«« of ca*es is often grave for complete recovery, but, hh \nu
aee, considerable improvement has taken place in this child.
NEURALGIA. — In contradistinction to the at!ec!tion of the nervt*H
which I have just described as neuritis is a functional aflTectiou of thv
sensory fibres of the peripheral nerves, represented bv i>ain and called
neuralgia.
Neuralgia is so rare in iu&nc}' and early (*hiIdli<HKl that I shall not do
710 PEDIATRICS.
mniT than n'for to it. When neuralgia occurs it may aflFect verydiS!^
Io(-aliti('s, and may Ik* Represented by intercostal neuralgia or the rirb
niildiT iornis oi' flitting pains in different parts of the body which i^} co
inonly (kvuf in children.
I havt» lonnd in most oases of neuralgia that tenipf^raiy rtJief iVrjmi
pain <an Ik* obtained by the use of phenacetine, and I liave never seensr
i-tintra-indications to using this drug. It can be given in doses of •j.«i
^raninu' (1 grain) for every year of the child's life up to 0.6 gramme !'■
grain>). I am in the habit of guarding against any ]X)ssibIe M 6fii^>
by ^ivin^ i\\v phenaivtine in a little brandy-and-water.
KUKVMtni DI.SEASf» PUK8UMABLV OBOANtC.
711
LECTURE XXXV.
II. NERVOUS DISEASES PRESUMABLY ORGANIC.
I
I
■
CflOBKA.— Epilkpsy-— Ijjsasity,
In s(>eakij»j^ of the next vlaf<s of nevyQ\\& clismscs^ which I luive cttlltid
** presumably or^iiie/' it may j^erliaps be well to explain why I have
made use of thi^ term. It is bei'ause we eanoot help feeling timt in tnie
cliorea or true epilep8y theiv must be s<ome organic Ir-si^m, and that it
merely remains for future invt«tigatioii to show what the lesion im, \Vhen
this lesion has been determined we ean relegate the dl^^aisie to the orgauic
class, or possibly it may lit* detaderl that it IwJongs to the funetic^nal di.^'ases.
Of cour>*e there <'au lit* hut a flight pathologieal distinetion betwet^i thege
ditM^ase^ and those which I have eidled functioual, but their elironic eouree
and their serious natuiv ally them i-linically so much mon^ closely to the
dii?eaw:'s of known orgiuiic origiu tlian to the iiidetinite fuuetional class that,
♦or simj>lieity in teaching, I have deeicUJ to separate them from the latter.
CHOREA. — Chona is a disease characterized by irregnlar and invol-
untary mustnilar movements without lows of t^n?*cionwies«, and affei^ting the
iiniBc*k>» I if volition.
The dist*ai*e is rare iii infancy, but may tKJCur in the early months of
life. It s€'ldom U^gin.s arter jiuberty. ft is mikst apt to lK*gin and L^ most
marked in it-^ symptnius during tlie |K^riml lA' the second dentition^ — that
l<, during the |HTi<wl uf active growth, fn»m six years to puberty. The
greatest nnmljer ot" cas<\*4 l< found araimg tlie tcniale ^*x and among those
who do not nM-eive surticiently nutritious tlxMk It will hi* well (or yon
to understand clearly that a sharp distinetiou should be mante between the
dW-ai^ rhorva, with its characteristic choreitbrm symptoms, and the same
choreiform symptoms it*sulting from variiuis dist»ases, S4vnietim«?s repR'si'uted
by central ner\*ous le^^iomt, 8ometinie%^ by purely reflex canm's. It will r^ave
y«m much nselt^^s ivading of the litcnitiire of chor*:*a and much pn>fitlc«s
diHCtLSHion as to its ctitilngA' and path* > logy if you will bear this ilistinction
in mind. Kliuiiuating thoi*e forms of chorea which are due to gross l4?s*ion8
of the nervon» system ♦ such a** the |>ost hcmiplegic and cT>ngi»nItul forms,
w*e am at omv ver%* mater inlly n^lucv the cases of true chori^. In like
manner we should sepanitc from true ch*>rea thoac* eaiMs of fieri phiTal irri-
tation in which the }isirtiat ehon*ilbrin symptoms are evidently reflex and
CUD be oni'ed by remtnal of the I'ausc*. Kxamplcs uf them? rt^flex choreiform
fiymptoms are tlie facial (*honii i'mrn na»<o*pharvngt<«il irritation and tlie
|iartial choreiform movements otxtisioually ari«ting from errom of refmetloii
an<l »»cnlar insutHciencv, The cjonisideration of theise anomalous fortns of
iiy m iiu' ivjMU'UMi (iu*t»s oi uiiiertMii oiis»crvei>4, uiie vu iiit'ir
iLs to what constitutes riunimatism. If only the t^as«>* tif
rlienniatisin an* to Ih» (dassifiiKl under rlieiimatisiiiy very foi
cu\U^\ chonii will Ik» sj)okt^n of; while if all the flitting ach
(•hihlh(MKl iiTv considertnl to \ye rheumatism, the luimlx'r c
causiHl hy rheumatism risers to fifty per cent., or pcKSsjibly mi
will in the futun' |)n>l)al)ly lx» found to lie in eonie intormetli
that in certain e5is(*ri a close eonneetion exists between eium
tisni is v<'ry (»vi<lent. The difficulty becx)nies still greater \vl
th<' relationship U^twoen chorea and endix^rditis. Of cours
a rheumatic eliMuent in the case we should ex|)eet a c*arfliac
and to 1k» d<*|M'ndeut on the rheumatism. In certain causes, 1:
<'liorea with ciuhH-arditis entii'ely irres|x»ctive of rhenmatLsn
to such an <'xt<Mit that in our cases of chorea we .should w
ler^ions jn>t as carefully as in our rheumatic cases. Hean
ha'niie natnn* may eu^'ur in clion'a as in any other disea^^e c
nature. They should, however, always be looked U{x>n serioi
indieatinjr an insidious form of or^nic endoeanlitis, which, i
evanex-ent an<l })assin^ off entirely with the n»et>verv of t
<M*tln'r H ri(Mi>ly disable the heart or lead to a fatal issue. A :
cause for chorea, as iJ>r rheumatism, must be thought of, bii
iM'en provi-il to exist. An hcrcilitary tendency to nervous
chnrcie ty|>e has lnn<r hc^ld a prominent place in the etiologv
my e\|M'ii<iirr, however, it is not very common, unless tl
poorly nouri-hed, hadly care<l for, or ex|x>sed to nervous ex<
their m-IiooI \\l\\
()vrrt:i\inL^ (►!' the <'entral nerv(»u3 system during the fscl
often IxM-n >howM to result in an attack of chorea in fho cr^ni
NRRVOU8 DISIiL^VSBS rKBBtTMABLY OROAMC.
713
I
0
\
I
mae to tbeir inanition, and 18 aec;oin[mni(xl In a t«^nip«)mrv inability of these
I centres to I'ecciver tlieniselves* Many legions have been deseribed as oocur-
^ring in ehort^, but in the pure cages (Sydenham *s chorea) which I have just
dojCTilied, and whirU i-eally represent the di8ea>*e, tJiere is no legion which
' with our pret^ent knowledge we can say is ehanK'teris*tic.
Symptoms. — Chruva may he in it*^ ilistributinn pncral or partial : In it^
course acute, subacute, ur t"hmnic. Jii many teases* the dLs<.'[isc i.s cxcct^in^ly
mild in its symptoms aud of a beuign type ; in othei's it assumes a severity
which struts U> tlireateu life. I shall pri'^^ntly ghow yon examples of both
types of the dist*a^\ The beginning, though at time.H .^udden, a-s ihnn
fright, i,s, ah a rule, gradual, at tii^t a few mu!*«'let« only Ixnng af!'c<ted. The
chihl bxxiUKiS fivtfrd and impatient, and we must carefully dif!'en?utiate
Ibeiee symptoms fmm those resulting from bad tcm|jer, for which they an*
apt to Ix* mistaken by the iiimily. The eliniail pictnn* of the disease* is a
jerky, irregular, luvulnntary contraction and relaxation of the muaclen, apt
to lx»gin iu the fingers, hands^ and face. There is an irrc*gnlar, uncertain
action of the |iart attt^-te^l, and etVort*^ of the will only partly t^mtml the
movements. As the disease progresses, the voUmtiry control of the muscles
diminishes mrire and mort\ and at times disap|iears entirely.
The movements ordinarily i-ea^e during sleep, but iu sc*vere mscd tJiey
continue during and even interfere with it. At times the child is unable t4>
walk, on ac<^3nnt of weakness. The s|>eec4i may l)e<\>me slnw and indistinct,
frtmi the atlcrtion of the muscles of the tongue and of the larynx, and even
raa^iticati*in and doglutitiou may bctv>ni<' diffitmlt. In very scveix* cases the
ditBculty in sjx^ch may Ik* cnhauoctl by the meutal wmditi*in» which niav
become impairttl, and which is re|>reseuted by dulness and apnthy. The
tendon rcrtexes ait* a|»t to Ix* lcss<»ucd in severe cases. The must^les gvuw
weak and md^ and there Is ci>usidcrablc emaciation. There is iteually los8
of api^etite, and tin* Ixmcls arf often f*<»nstipatHl. Th«' tirine and its urea
have l)een ibuud to be increastxl during the eoiirse of the diseajie. The
dj^araoraeter usually shows im{>aired muncular power. In ct^rtain cases the
musi:*h*s of the extremities on one side of the Ixniy are principally or alone
affei-tcd {hemic ho rea), The^e casi^ do not ditfcr from ttie onlinary bilateral
cartes in any way except in this i'es[>ect.
In ver\' severe ca^-s there niav be involuntary* cvacuatitms of the fteee^
and of the urine. The disi^ase is distinct from epilepsy, and there is little
dangtT of the |»aticnt bt*cf »miug epilejitic unless the disi'ase hap{»ens to develop
iu an individual who is pi*edisposcxl to that c«>nditinn.
L Prooxosis. — Chort^a is very af»t to show wdajieew and to recur every
tfmr tor some years. Though i>l'tc*n obstinate in the |jei'^Lstency of itn
iiymptoms, yet it may l)e said to be self-limited, and, as a rule, to reoovcT,
providinl rjo e< amplications, such as from ninliac disease, arise. The time
J^'hich elupsi'S L>efnre complete recovery Ls ver>' variable, but well-markt\l
NpeR nsnally extend over a priod of three or four montlis. Although,
^nou will notice, in speaking of the progiiosia of cborpft I consider it,
7 1 4 PKDIATRI05.
n-. a nilt\ a lH'ni;rii <lisoa.se, yet we must always look u])«)u it as a^:-);
tli-tiirhaiH"*' until we an» sure that we are dealing with the u?iial niiili-r:
of the atltH'tioii. As an ilhistration of how c-areiiil wc should U: iiir.t;
iTuanhHl proirnosis in the early stiiges of acuto ohon»a, I shall mfrnifl:
tMlowinjjj <*;i>t' :
A uirl tCa^c JJoL'i. u'xnv vt-ars nld (CtM.»k und Beale), began to havf «;hi»rfk d.--. :.'
•Aliirli iMMj-tantly Imtjuik' \vin>f. Dcliriiiiii devolopod, with a slii^ht fevtr. a rijij;:.
!'.i l.l.' |iuN.-, Mini !i «|uick and inti-rruptt'd ri'spinition. TX'ath suddenly i^^rurrvtl.:
• ln«l mimI thirty liiUir.* attiT tin* misot nf the diH*UJsc. The aut<>|»jKy ncvenU'd i-it^.mTrLL-..
• t' till- |M.ii- and iiHNlulla. hut im oih«T changes of note in other \mTU *tf tbi- ••■iv.
Wc njust allow that t'veii uneoiiiplieatod ohon^a is a varying di^t^irt^^:
tin- Hvcrity of its symptoms anil their ])orsisteiice for a longer or a ^i^-
timr. We alsij know that then* is a marked tendency to ivla|>*. and 2:
tlir iHiniU'r <»f i-elaps^s varits to a great degree. The length of theinsi
:mh1 tin- nsponse to tn'atment may differ miieh. Bearing th(>^ fa -• -
mind, yon will ("onipHdiend the rapidity with whieh «;rtain imliviiliiil'i*
attarktsl or the ^piiekntss with whieh they recover. You will mern^
-onx' easr- which i*ecover nijddly imder only hygienic treatment, anc »^
othcr< which are ap|Kin'ntly unatfected hy any dnig whatever. Wy
licari-nninnni>, <'vidcntly it»])resenting organic disease, apfiear. }« r^
• »ftcn find cans** for wond<T in the eom|)aratively slight diA^mfort whii"iit>
• •ardijic lesions entail. At times, a«:ain, you will be sur|>ris«d at the q*'-'
fatal c(.nisc of sonic cas«'s eomplieated by cardiac disea.-^e. and at -f"
nnc<.htrolhil>ility by any tivatment whatever.
'fKi: \TMi:Nr. — The <lisease is variable in its duration wlictlit' D^^-
l»y dnivrs or not. Thci-c cannot Ik^ sjiid to be anv sjxvifie tnuinhni'':
driiii-s for chorea, hut of the many drugs that have lx?en us«l in thi^fe*
nivcnic lias, in my <'.\jK*rien<v, Ix^en the most l.>eneficial. ArkW ^'^
however, Ih" n-c<l with cai-e, and on the ap|)earance of anv evidence": ■•
pliy>ioln;:ieal action of the <lrug, sneh as nausi'a or cedcma of tl»eevrf>
-^IkmiM :it niirr 1m' (lisi'ontinucil. It should not, as a rule, ho civonii^'
l:irL:<' dun-, as c.ise< have occuriid in which it has prvnlueed a multiple*-
riti- of iimiiy months' <iurati<m. Where any sj>e<'ial clause can ktiKinc--'
the attiiek, -neh as rheuniatism, appropriate trf.»atinent directed tothat-tt:'
-Imnld l)e emjjIoyiHl. It is manifest, however, in the unciimplieatil »*•
th.'it our main relianc<» must Ik* plaitnl on hygiene and food. Fr^fiJ^'
Miitrliioii- li.o<|, toiiir- to eontnd the anieniia and general pnKtratiwi. Uv-
iie>-, M'clu-icui to secure mental <piiet, stimulants if there is muchn^'^^
\\e;ikne». mid tli(^ l)ronii<h»s for insomnia and over-excitomeni, a."^ ^■
memw whicli I j,nvc timnd most valuable in managing this dir?**f- •
li:iv<' -erii well-markiHl cases get well in fn>ni sixty to seventy «laj* 'f^'^
-..n<j 1o(k1 and a -mall amount of stimulant constituted the entire tiwi^Jf*^
If the nttack is very severe, skilled nursing is a ver>' important *fc^
in the treatment. The child should be protected from harming i«li'?
NERVOUS DISEASES PREStTMABLY OflOANIC.
715
leans of the paddttl bed, and U^lit but well-padded spliiits ki motnjl the
Movements during Ave\i mv iudieaktl (Kvasiouallv.
I have a uunilxT of eases of eliorea to .show you. It is one of the most
pmmnu diseases that are seen iu tJie ho^^jiital.
Ht^iv is fi Httlo ^irl (Cii&e 33il), six ycure old, who repn^^eots one of the mild«»r fntTTia
* cborcfi. Tht^Tf- is nu histor^^ of iiervoii^ i>r enrdinf dii^i5H»t* vr rheumatism in the funnily,
Ikii the chiM UiTPt^f huA never been »ick bffopc.
Threu wwk« a^o ebe oomplttined of ptiin in ber left hand and arm, ami li4t<?r tlie
maclet of tbe unn U^gtin to twitch. Si>i>n atler, Ibe whoh body wn» nffecteii in lb«
[me way^ S<imcwhAt later it wfi£ found ihut the child could not talk plainly , atid it
^ Willi soin*' difficulty that .^he could feed herself. She t4>em««i n*^pvou& and jieevisbf
id showed constant irregular incr>6rdinai«) inovoineaUt, chiefly of the fac<<, tuouth, and
|i|»«!r cutrenutie^. The h'gs wen* slightly ufrect**d, and sotnotiine* the uiuiiclcja of the
link nUc^ There bai b^n no pnnktysift uf the muscles. The eym bave U«^u iiorinat in
K'ir reaction.
8incc f^nterini^ the h(.>^pit4il she hue b^n treated chiefly without drugis, and ^cpeouil
U«ntion hn^ be4.*n paid to giving her a uourif^hing diet, bath«, genlic maiuge, and rost in
id in a ijuiet corner of the ward.
On entering the honpiial, three week* ago, a phy»ical examination shoifired nothing
i»nonnal in ctmncciion with the heart or other orgaiu. An examination of the uHne
kow€>d it to Im» nonnnl
You :iee to-duy that fhe U looking veiy well ^ and that the incodrdinatis movcmenti hare
^bd eutin^ly. Mttrli«.*d improvement waa shown after «be bad been In Ibe b«ipit4il for
^fflreekst and for tlie liwt few day», about the forty-tecantl day from tbe ontet of the
(tea&et I have e«MVHidered her cured and reidy to return to her hom^,
Here ii^ a little girl (Ca^e 834, page 716)« eight ye^ri M, wham aTQiptoint torn m
lAiracteriKtic that we can at once make a diagno^if of chorea.
1 have not b«H»n able to ascertain anything conc«»ming the hiHiory of thii? child . except
)mi sbe hiis l>een subject to attackt^ of thii natun* f^r some time. There is no history of
|eumati«m, nor of ikny other diseuMv Tl>e child beeniA U* l>e physically well and strongs
[id on examination nothintj abnonnnl U found in any *tT the origins with the exception
^aftli^ht ^vNtolic Niuffie heard ditititictly at the upi^x of the heart and tran«roitled through
le axilla into the }^M»^ten(»r scapular region. Th** ikr<'W of rartliac dulneat b not increaaed.
he pate Mar reflex e* are incHMued. There are marked choreic movements of the banda^
g», and head. On in«|>eetlon you **ee tliat the Umb^ ar« flexed and extended, with irreg-
\mt incooidinate movemcnta, and that there are ftom time to time the aame muacular
^tr»ctioni« in the face. Hhe ahowna eertnin amount of mental disturbance, ehamctcH^ed
inietime« by pt^evirthnesi and sometimes by slyness ; she 1« dull rather than bright.
8he repre*»entA the diseane chorea of a mt«ierftte!y lovero type, which from it* conataat
leurrvnev and clmmic cour*»« will pMbably pnive %** Im? very intmctable. The pn>(cnoala
I to her mental condition is e*jK*cially ^eriou*, as the pn^bability ia that tbe mental im-
|irm«mf will inrreaM rathiT than decreitse.
She ban l>een tn*iite<l with a number of drug«, «ueh a» anenk, qiiltiint, (ron, and iflberv,
^ne of which seem to be tif any iK-neflt.
In r«<gard to the mitml My^tolio •on Ate to which 1 ltav# J oat referred, it U pi^ible that
li wholly a ftinetional manifeitation. You muit alwny» bear in mind, however, that
|er«f i)» ^reat liability in caM-** of chorea of organic cardiac di^eaao developing, and tliat
Itil all Aigns of cHrdiac diMturlMince have di^appeaiiEHl a ViTf guarded pr»>gnit€i» ihoutd be
ran a* to whether th<* cardiac di<>turhanoe i« of fiinctional or of organic f^rit^in.
^Hn A case of thiM kind, inpttmd of the gntdmil ditninulion of the muntuir, which would
^Vlfkely to occur, judging from the wry flight evidence of cardiac dt^turbiince present,
kocially ttA the nuirmur could l»e well nciNiuntod far by Uic choreic functional disturbance,
iia possible that an end0Clltxliti'« uilh vulvuWr iHAitiiM* may t*%ul and IuUt pnHlur«< oiorfk
■ions PTl11pt(»TO».
l.s
PKniATUK'S.
A III -Mil lati r ih«" rh-'ii-ir in«ivi>in«-nts litul lU'ciilf d 1 y lf»s^*iitni ami t!i»-:.M>
r.-.l.i\. iw" iii.'Fiili* t'rnfii ilir lifiji" whi'll li«' «'nti'nil the h"»f;j»it:il, h" a.|-:;r •.
iV'iii tli»- ill" :»-■. IIi^ iiiu-iular iii<>V('iiii'iii> un* luttiinil. tliout^li hi* k-i:^ ur>' • ■_=- . ;
l,> lia- :i u I :i|'|"iil«', ami lh«*n' an* im aluwiriiial i«> iiiptoiii> <'«iiin.ft««.l uitM;. .*.
I -}i.\\ \'H tlii- ru-i- a- r«'|in-fiiliMii «»m' of nu-urrt'iit «'ln»r«*a in ulii.ij ■.^..
t-I. : it'.i. :i!i'I IM vvlii- li til'- iinli«-ati«Mis I'mf tD'atinciit ar».« cliiflly n-t. u'-'-ii * < »
a-i'l iii:i--:iu'- Ml tin- ln-::iiiiiim^, l''ill«iwial laliT l»y tli»* adiniiiistmtioii **i -i-i- n. '.•-
i:-«ii. .-»j« li a« til-' tanra!'" ••{* ir-'ii ami (Mita^.-iuiii. Tli«» canliai; «li«.turli:in' •. ir. i;.:- -
II! all p?-.-l.al'i!ii\ Inmii-'Hal nitiwr tlian tip^aiiu*. a> in»t *nily Wi-n* lb«.' «-:ir«Jiji :..ir; . •
.ii-:i!i.' \v||. I. ill.- . tiilil \va^ wralv ami aiiu-iiiir. •^r.uliiiilly i;:n»\%in:; 1— '.- a* !.• -•■.■.
a! il tip ana iiiia «li-a|'|'«an«l. lnit ai>o <»ii ih«* nn»*l can'rul jiliy^'ifal i-\:in.:!:*'i .. . .
lir i| ii-i .N ill- !.•■•• ••!' "riraMii* ili-i-a-f. Vnii ran lh<T«'l'«»n? i.'on>iil«.T it a •■.l-- '. '■■
• li-r-a wish a«'-"iii|iaii\ iiii^ tuiirti'iiial rapliai* «li-turlMllKH».
'IM- lit!..- -ill <'a-' :i:i**i. tniir ami om<-iialt' yrars iild, in ihi* ImiI i:i u i;.-". r
ill" wanl. i- all •xauU'latiil ra-f «•!* rlinn-a.
I 'mil t!ii- aiiai-U -lif litid Imtii a lnalihy. )in«;ht, stnuig ehlM. Sin- !j:jI :i. •":
|Mrtii--i-» wlii-M -li«' \va> iwn ami niM'-half y«'aiN old. iind fine of iiiou-lc* wii'i. -:!• »•
aiiti < lit -hall" Mar- "'lil. Slii- ha-; lu'vrr had rliriiiiiatisiii. She hc-^aii to ba\t ■•. •■•?
iij.-i:*- "t" a ratli'i- -ul'a.iitf t\ pr i«m' vt-ar )in'vii>us to thifi uttack tor whi..h -l
liP-n-lii !■• tin- li'-pital. Tlii'on-t'l of this Mvund attack was whil»* ^h*- \va« ir'-i^-j:--:
a'.il \\ii»!i -li-' \\a- in t:iirl\ t;<»m| lu-allh. Tin* iiiu>c'l«»«i of the iiii»iith .inl l'.* "■• '
atl«i;"l a!.il -h.- -•■.•ni'il !•• i:«'t viTv niiu-h i-xriti-d wh«'ii at schiM.!. withi.'Ui .» .. ^:-
«au- 'I'll'- -\!i p!"!ii- rapidly itu-n-a.-fd in "•«• verity, and .kIh* wa- l'r«»U:;hl t" t: :•
a !• A •\a\ ' M-j- ■
I -ha".; !fi Ui\' V''i till* d«-tail- n\' thJ- casi'. a?* thc-y ditf'er very litih* frMii '.h > "»
I l:;«\ •■ all- a<iv ij- -<ril'« '1 t" \ "ii. I >h«i\v her to ymi as n-jireseiitiniT on^' ••!" th»":vaj.'-r-
Im Ml- '<\' ili'-r-a
Til" -viiipi-.n:- ha\<' im-n-a-.d <\\u'o i'morin^ th«- h«»spital, and tb«' nvj-.*ulir i ••
ii:- ■ '- .in- -■■ I i-ii ii!. III. ■MMi at linn* •H-riirriiiti: when >he i> a-l»i-p. liiui -bv jv ■.
Iv !•• II I |.i.ii..l i-.i >i:.- i- ai<pan:itly um*o!i*iMnu^. Shi' slffji- with ih- 1"*-"*-* -
. '. ■ .1- I • 1. 1- '••■■• Ml! i!.:- |M ,pi :iU .jin-r *li«' iMitiTiMl ihi* hospital. A: !".iu-? ">•■
i... '■•■■. . '.•■!i.'<.l. I'Ut tlu-n* lia- not .-iMMurd to \f anv «.'*j». ,i:il ri::;i:f' '
III'. ■ .• - ■ :" ; • ■ X '111" a.'va ..f.anliar iliiln«>M i< m.i «'nlnr!;iMl. Tbt-n- i^ a •licit-'--
niii!:.,M:-. !i .1 I !i--: ii-iiMt!l\ at tin- lja*t' ol* iln* In^art. Slur is ht-iiii; tn.-.ilwJ wi'Ji*lirw«.^-
aji'l a> M ;• ': '■■./\K :.- i! i- iM.-vjl,!,. tn inakr htT swallow, hut at pn'>fii! Aiv i* lakx
; li . . 1 p'.Mi ill tin- tw«Mity-loup hours.
:-. -.M"!! i.i«i..i\. 'I'll" choiiic syiriptiiiiis lasttnl for Mime wetkis. but -jra-;-
• ■. I 1. : '. •.: I 'II" cliil'l tinally n-eoviTed t?ntindy.
• -. I iM.' ■ ■■: ill" h.-aii iw.i \«'ar- lutiT >liowed that ornanie di.-— av ^a*;"^
.• I ■ \ i!.- • ■.: i!i:.iM"iit .»t' ihi- tanliac an'a tA' dulnec««, a niitnil sy»t"lic :.i"'
. 1 ■■ :... "MtMai-d -v.ind ]iiilmonic sound. At the linio of ihiM*\.iTiii-..-«::
•■ ■.■■l •■■ '.. U":.k and il.-li.'at«'. and wa.* ••vidently j»iit!erini; fr-iu t:.''^>
. •■... .l:-.:i-. ■
■ll."U!
I."
\
ti.-
Ill «'«Mm«riInn with tiie previous csis** I shall ix*jMirt t*^ voii a csi'^' ^'i-
I -:iu ill r.iii^nltMtinn wjtli Dr. Boanlnmii.
\ '■ •
. " ;:'• f 1. y"ar^ ..Id. had alway> In^on delicate, hut had I :«•! n •:
: : :.:.i-Mi. iii;til six works pn'vious to the time when 1 -awV:!:. "
I " V. > « I 1 ' ■ '. .\" ! il a;, attack r.f cpidemie influenza. He rocoveriHi ceiniiLit-iy fr •"
.1.
IM <1 a- w.U as »'vor. Thn.'c or four days hitor he I-tj-'
->:-.i I • il- !:i '11.- M -ynipt'-nis ixnidually increased in severity, and li:;.';'*
: ■ I : M . ^. ;.! u !■ i. Ip wa- a>l. t'p. Alter ho had had the chorea for em' w»A- *•
.ii.al.i. !■• a::i. ':■. .•■ . ai.-i l."L'a!i t" havo tnmblo With deglutition. He Mwn hMthrp*''
• ■':!: ::■ .: : .- ;::■'•■.•. vw \ >r\ wak, and Was confined to his bed. There waM-vn-i*-'"'
KBRVOUS DmEA81« PBIBUMABLY t)RQANlt?.
71»
[inirt. In the second week of th« nttnck the choreic movemcnU b<K;ttme so violeni it*
r hid fulling out of l)ed. Thf* tempemturc^ up to the time when 1 ^aw him, iti
inr 111 w*'rk of ibt^ ntiark, wiu nMmiaK The puUo varietl frrjm 140 to 150, and the
atione from 35 to 40.
?heii I saw hiiti, at tbri end of the fourth week fpjoi the U^ipntitng of tht.^^ chorea, hi*
dnd ivaa perfectly clear ; he had a little pain in the handi and »hoylder9| appurwntly from
he cnntinufil movt>mcnti. He wa6 unable to articulate clearly. There was ditfieuUy in
|wi4|1uwi?iG;, and he was ocinsiderably Ofnaciated, Nt«ihit»i^ ubnonnnl wait found in thr*
The ht^art wan beating tumultuomly. Tho arcii of cardiac dulnea^ was very alighlly
1, but thvrxi wi-ru no cardiac uiurmura.
Tilt? ciiAe was appwrently one of primary Hcute chonaa without compUcadon*, Although
i many of these severe ca«e6 of chorea no cvidt^uce of cardiac liifteot^e can b« obtained *m
(ihyi«ical eiatni nation beyond a flight dilatation of the led ventricle^ yet Mine diMMie of
he miducanltum or valves may often he found at the aut4j|:My. In tho»e ciiet, however,
bo temperatorci h, tui a ruk% rai^f^l. In thit* case the continuous normal tempemture and
lAbtenceof any si^ns of cardiac diaoatc beyond a slight dilatation from the appan'ut
t of the ventricular muicbsg seemed to indicate that it wa^ a cn(«e ot sitnple churta
awfihout dittcaite of any of the org^ans.
Although the child wn^ carefully nursed and reinedie« of various kinds were employed
||l» Hrvn/L;th»ui the nation of the hi^art and Ui support his geiierHl strength, he failed rapidly t
|and dit<i of t^xham^tion a few dayji after I #aw him*
I will nuw nhow j^ou tbia little girl (Case 840), ei^ht years old, whom I have bad
i ia a warm room »o that j^he can be examined naked without harm.
BheumiktJe lutbrltk. fiidoeatdltlii. Cunlii
t(L thufca. Fill.
H The hiftory g:iveti to me when the child eiit'-r'-J tin* hij*pital wa* tliul ihc mother had
^b^en fubject to attacks of rheumatism. Tbix child huji not had any especial diAeit«<^«, with
H|ho deception of an attack of measles when she wa« three or four yean old, until
^bl,tta«^k of rheumatic arthritie iix months ngo. At that time she was conlli> i
» with fever* and with pain, tenderne«f, and swellinjs: in all her joints, especially of the knt-*"*
and fingera. Although the recovered from the acute lymptums of the rheumatism, she ha«
eince then never been able to u«e her ami# and hands^ nor has she b«*n able t»> wallc much.
|J have no record of the condition of her heart durini^ the attack of rheumati»m» but iw» far
\ I can aaoertain there waa no evidence of cAnliac dij«eaj«e prior %(* tlie rheumatism. Durini;
live of the rheumatiim there were no other p^p^cial ■ympt'tms noticed, eircept that
r4iiposition was evidently much chan;^ and she became |3t?*'vi»h nod frt'lful.
r One week Iwfon* enti^riniy Ib^ h't^pitjU «he liegan to have choreic movements, Ther
I moderate In decree, but ince^eant, A fVjw dayn later the ini*iM'mJi nation of the mufcl««
aba noticed when she endoavomd to Apeak or to swallow. Then? wtre e<mtinual
720
Pf-niATRICS*
cbiit«:k iiiiiirtftfifitit« of iliu (*yvt| fiic«« ftiid ftnfimt mad^ ultlimijtEli «**»*mfTirif ^fiiila^l
lUtm, Mml U, «# /«m iHi**, mut^h *iiuari&tod. Tim will tiotlott Uan liaoodnHiuM c^^ |
(if nil thi* mii»i!lia t*f till* fc«*. ^ytf, hmd, fu^*k, Kidy, iumI cutlfvmitlAiL IV j
bum. Tlw child ff<rNl# ilmt "Iim tmruioi i^ittrr^ her uiukiuulnr ntunmiMiU^ moi <
fti bc^r GTiucti na nay objiML't xi^rllly, A1t(imi(sh Ui*'* OiM^ U « f«ffm» rtivt« thr 3d<i»|
iiflM«(i W>'(iHi 11 tUisbt ih^nHY tii hr:ht^%miA. On }ihy#ic4d amttinftAtiMn t taiiljiil
lum^ iktv nnrnmh Oit i^i^tn^Mnii ihf cAtdiuc r^Ktctn Vihj Iinti(^* tkit iW bb|bI» ^ * I
himrt u imuyi* i»f ihr luminuun Iim* htiiI in ciLnnil lli«^ »ixiJi f •< Ua (al^KMiftl
i:itfiuiu*ti(iii« t>f tht* tumrt urt- fuurid uj l«r uf im irri table ikv iiHrliiU.kB*<'
itaiDgHiiioftiiitL At tinK"« tb'n* Ik m ft'i^lint; ma tUfHJ|;h ihi» vinuniruliir i
h^iilAllfiti And Ui«*j ariTiif All invguliiT fumit wbleli «ijggifi»u thai iIm
llitt «tb<*r inuftdfw U j»y^.lo»|«iUMl Im by tb^*#fttif tbc braH^ On |»njti»ii » tL<»» ^^.^1
n^MiiiAiicff tw tbt Hubt »*f liir «kTiiutii i»n*i luiditr ll# U|jp««r pwit m fkr «* tW iki '^
iritifnifiiitw. Tlivn? U (KtlnrM ufi4«tr tb«; ^ifftittm* Wi^titiiuK ftt ib' *«e«»Qi) kft«Qer»
vttModifig lumiM Ici iliit ililnl H|?hi hilftvjiiicvf And in vulval itg t ' r pftit 4I li^ i^c^
t liAVii tsurki^l tlir ufinii iir i!iifilke dului^ In bUck. It nit • ai^ (» tli r& ^^ ^ |
ilm* aiitll K nmHit* tht* itiipuUt' uf tb«< b«.*iirl in lb** «fith lcf\ tfiii;ni|MM'tt. OntaaiMi
iTitirinur ii btuui) m>»ii ilijtim'tly witb thi* flnt touiid mt lh«« ii|t«!t tif th# b«ii mI^:
mirti'd |i> ihf h^IUm ajhI in l^^Ui fihlr^ *}f iU«» tmt'k< Tbb myrmur b UmMotiiMlb^^ I
but |crv(l^i<>lb* Ic^ifMt^nt a» tbf^ on** tit tli*' Ur^e vi*i#el^ at Ui*^ htk^n dt tJ^i* b«fli»^"^|
Kotklfig elfto tttiDtjrmji] b d'^tnet^^d an a fkrtbcr (iliyMcal i9X«tnitwti«iii vf <i(^«-^t*^'*'
TbU U «rldtmtl) A ^'^*^ whirrii during the rr^urvi* of m thvuaimiic cUaiil •
kn «J1 pftib»yiilT d*'vdnfii*d, Tb'N i-mbiairdUb hw buf*n toHifW^d bjr Mti
fvpr^onUiI b,v dilntnttfni i^f tbe Itrft vciitrkk. Ituiiii|j( Ui«< ixniive cif lb* j
«*f tbr i*J«pibiM' P«mi|ttic*»Jit.m th** rliiin^w Un* tK*v**li'(i«Hl.
Tbi' jii*j^iM>U id a fi*»** Uk*i tbii muai ha vrry gitArdu^. In 1
i»r miliKT o<mi1»lrmtloii ^if dUNi^tbt^ ifnkw* mfiidly w«w«<»p mnd tli» irlidil Mmwm^a^^ I
fH)m ii» rbi-ujtmUiTtif hut U }vi% with iii) oi^unic ilt««tiia«s of ib« Ecsn frm&vMt^^
rwoavi^ni. T\w mrtliiM: ditiniiM', tu>wiw«>r, cau in ifta*i i^Aur* b^ mtaob bciz*tfiu4 ^^
irefttmcntr t'tp^duU.v by n^t m b«4. In tb<Mi(! cnaisi tbe dflnlatiiio i^nmv (in%^^
wbi)# thi* bcart bc-oonic* Atmngcr^ iknd^ ai ibo dioi^ pMM9i »w»v. tbawi a ^vnali^*''
dutfi«n.
DitHni? tbt* i?uuhit^ uf n cii«)«« »r tbl» kind wr mtist Hi any timtt »*t|M!y?l in plici«f p^
ui]|»ruvvmt*iit It ditoidf^tj inr.rfiu*^ ht rh«^ NrviTity of ibe »ymuiiMii«, Tb* TiHili^^'''^
tb# fasaH nmy lM«(n»m«^ itiiK'b ttiun^ L^xk^tintvf't ii«ifiumii|g tlio uloemtivB ftwm ^Ir^^^'^i
(lampUitntiiM^, T AhuU ihrn'f**f*^ biivit ti» tol) lb« pfttifsibi of ihU c^biM tbit^*^^
4Mit,i>«mt<lv tTUicHl wtidtiinti, liiid tbut for vuizic diijni <>r wi»le4 It will ^ taftviUiW^
tvbt^tbcr ebo wiU lire or not.
The tn^utriifml nf iti^ cm^e Ih witti milk and vilmiilMitte. fi b iDpoailli I* ^'
f&kp liciUd fiHnl, jhud lilt* inUk 11 witii tb« gtt!tttie»t difiiuuUy itiimdtAc«*d tulo I
will iinw hnve tbu nuniw fr.»>tS |jf?r (IL, j«Mr(*r2t), »o ibut ynii rrAn mtt bi»w mlnoti
it IE tot bf^r to uvkii tlw niiik »u her mouth or to irwiiU*»vr ii, AllliPugb ilti tftotfr**
1 hiivo triL^d Torimift mnh^td»< at lidmiiilftterifij^ tho milk atiil MltnulABto b dkbtf^^
haw fcmrKJ tbut thi* jw w* clo4o fo •iMwm<»diciill3* whi*ni5TPr m tpntm t* blfodiwi U^
the teeth thni tliu tiulk is ii^ually Kplll«d befi.>rfr sbn ni«;«fivf^ It. Tli« »«lk^ *^^
bav€* frnihd to he mt>ft siKtwttfbl i^ by tbi* f.*odtn|r-(ni]i witli a mbl^vr ukmAt9^^^
nmk of ibcs cup. Th« niblw nippk* ia pttiforatod wlUi » ]aff|^ HoIil Tbe fiiA nw#***
sot incltj> ihw t^hureid mr.vcroi?r*t^ r»f th^ Jaw tv* the do^m* liiAf wiyibUic l»«i^^^
You upe ihiit by n httlr* fiUbrt of ruckini,- ^h« Utkm ihm tnilk fulHv well,. ItefOC^ 1^ ^
cHhy m swuUnwbjg mnthiut^. The umaunl of mUk i^liicli ww vnilmf^ !• prtwie*
NERVOOT DISEASES PRl-BUMABLY OROAXtC,
721
I twenty-four boui^, and which I think u sufficient to support her ttrength until the
cut*' ^ia*^^ ot the dttseufe shall have pa^^^ed by, U 1419.33 c c. (8 pint*). She is iilfo ticking
ibout GO c.c. (2 ounces) of port wine in the twenty-four houra.
(Subsequent history,) The child remaineil in lihout the same condition fur the neict
^rtscof fourduys^ when the temperature roie to ZS.B^ C, (102** F.), and on the following
ay to 40«* C. (104"* F), and she comphiined of pain in the precordial region, On enatni-
on, in addition U> the cnrdiuc murmur* it frictiftM*4ourid was beard all over the cardiac
, but especially in the neighborhocxl of the left nippb. The area of percussion dulntaa
i the *am»*, and did nut extend to the right of the slermim. The child inuaned con-
r during thtiday, and wils very n*^tl*'«^. The choreifonn movemenu becoming inord
AdrntnWtrnilon of milk hi s
cxiggeratedi the port wme was increased in amount and S.7o c.c. (1 drachm) of infusion
of digitalis was given once every eight houiv. Under thiA tr^tment the pulse grew m
little stronger and the child^s reMles«neA§ iH^came le^s. The temperature aUo fell to 88.6^
C, (101.6*' F.), and on the fMllowing day to 88* C. (100.6* F.)* The pain continued
during the next few days, and there was a certain amount of diarrbce*. The stimulant was
increased to 120 c.c. (4 ouncc>s) in the twenty-four hours. Tlie child then became leas
restlcBSf took more nourishment^ and hlept belter. The diarrhwa c<*a«iHi on the seventeenth
d»y 6wm the time when she entered the hf»iipital» and at ihi* time she liegan to swallow
better and to spe^k more diatinctly. During the next few days her general condition waa
improved, and she seemed brighter. An exiiiiiinHtiMn of the knee-jerks at this time ihowed
that the tendon reflex was abs<?nt« There was gn>nt atmphy of the mviH?IeK. The liver
was found to be somewhat enlarged, and there wih flif;;ht dulne^ under the left clavicle,
hut n<»lbing definite was detected on au^'ultation. Tlie lyntph-glumU were ♦iiilarged in
both axin«. The temperature at this time varied frtim 87.6° to S8« C. (U9.5*» to 100 5** F.),
ih^ thirty-flr*t day from the child'» entrance into the hospitjd, and continued at thi« height
for ilie next wtick. During this time the child remained tn about the same condition, but
grew much weaker and showed more hebetude
Fftnn ihe thirty-seventh day from Uie time when the obore» began the child grew
much wmktT. hiftd incontinence of urine, reftised to take hn nmuiihment^ and on »*ime
|M*rt win« beitii; given tfi her vomited. She thou wtis attacketr) with dyi^pncra, wh»cli
oatiied her Uy cry out hiudly. On examination, dulne«f and diminished vvjo»I resonanoa
wen found tn various part« of the chesty and a f«w hours later she died,
46
TJ'J PEDIATRICS,
Til rliari- iClmrt- 'J'.* and 'M)) ^huw tho c-hild's teniperatupe frc-m tb*- :.■..■-..
tMit»T»'ii til.' hi-pital until h«T di'Uth.
ClIAKT 2y.
2>»» //.s fif Di sense.
y - ' . ' 10 i il I 12 ,"u . 14 "i5 ! 16 ; 17 I fd ; Id I 30 j 21 I 22 ; 23 : 24 ^
. M i: \I I. M K SI i: M i: M E M E Jkl E M E 31 1: M E M E M C M C M E X C M E M E M E ME 4Z
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;mf..j»,-y wn- jii;i(l<- by l*n»fo-sor Cnunoilinan.
Ikm'I \sa- l;..t ..)|.'Ii.»l.
}>• rit'-rii'iim wa- imniiMl.
liv.r w:.. .r.Iaixn-.l. .■xt-rnlinir 4 cm. (IJ inches) below the margin of U« ril»
".til |.l.Miml .aviti.-^ th.'iv \vii>u considerable accumulatioii of blood-^tuned fc'^'
'ri..r !iM'<li,i,tir;inii wa^- tliickiTird.
l'<fi.ar.rm,n ai tl„. a p.^x of tho htnirt was adherent to the left pleun, tni »^--
th' ti«H..-^ w.-n thirkcn..,! aiul (LHlematou*. The right lang wu ilightk ifr?-*'
NERVOUS DISEASES PUBBUMABLY ORQANIC-
723
I picuni hy oiimpumiivcly bte adIiMlom. The pU*uni of the lung wii« smooth ^ with
exwptifiri «»f ilii* iwlbe«ion« just npykcD of. The Ivinjihatie* over the surface of tht*
iJwim wcrt' gtvtttly diliiUMi, Th<? upper leH lobe uf the lurig wa« coii^e«t«^ and gave u
Etnsuiion c;f tttiutU iniiluUir ma^es in it. On Aedion tbern wuiv n dUtinet lohular vouioUilu-
[on thrttughout tliu upper lobe. The U*(i lung wa» of h d»rk-red eolor, coinpumtivfly
mixith on H^^tion, aud somewbut solid. Muco-purulent iiiutU^r c<tuld b*; Kjueext'd uui i*\'
he bronchi. Tin:' chi<»f fbamcterUtic r>r th** lun^r %«,<* thw ti-xlreuie dilatation of the inter-
gbulur !<p»ii^-*. The lympbtttici all lhr«>ugh Ui*.^ httig wvw visible. In the bronchi ihfpi*
^Kponaidf* ruble asdemfttouai fluid. The blixid- vessels at the baie of the lung: wera fkvi*.
^^krouchiul glands were eulnrged and reddened.
^■The left lung wa« not m adherent m the right. Over tlie pusterior portion uf iho
Prii there wiw u filight fre*h pneumonia. The lung wh« 8nm«?what eouippe*&ed hy the
Jtudatiou of blotxi, utherwi*e it wim> in iibout the s^ame condition a* the right lung. The
^rirnrdial envity w»u* oblileruU^I. The adhesions wero eHhily broken down, exet*pi at the
|MJX, where the perieurdium was greatly thickened, Itfi surfaee wru* eovered by a thick
•of tlbrin Aud eitudalion.
The hetiri wn>i ♦'tikrged. Over it* surface wa* a don«e layer of fibrin. At the api*x of
he left ventriele, ut n jwiint corresjxmding to the lulhe^ion of the perie»rdium, the niy**-
Kuni fell (*ufl and had a whitifh iutlltmtiun. Beside Ihif^ ctirnwponding to the intm-
Eieular septum, there was a line of rather Urm^ thick ^ whitUh tiodule«. The interior
le right side of the heart contained m*>derately firm fre^h clot*. The surface of iht^
ayocardium on the right side of the heart w»w pale and soft. Along the free border of the
iiricult>ventrieular valve there were n tVw fr\*jsh vegetations. The left *ide of the heart. wtiM
ilated, and the ventricle wa* thickened. The edge of the mitral valve w«« thickener] atid
roded, and there was diiitinct lo<a» of (substance in the thickened [portion of the valve, which
md irregular and erfjdeil edgi:^. The mttftcular euWtunce of the heart wa« pale, with tmmW
rbtti^h h[>t)U beneath th»» endiKmrdium. The*»e ipoU were very slightly elevated, and were
iiore or leiie cireuinscribwl, r^iinilur spots could be steen in the cardiac muM'leb. The »ur-
ice of tlie left auricle wa^ thickened, and bene4itb the thickened area were numeroutt finall
rbitiah points. The aortic valve* were intact, save f«>r a few fibrinous deposits at the edge
f the contact. The beaded ntvr of elevHtitms described on the Mjrface of the jK^riciirdium
orreeponded to the course of the descending branch of the left coronary artery, and was
tivbably due U> thrombi with Atippurution around them along the course of the artery.
Tlie spleen w^a^ enlarged to the size of 10 X ^ X ^i tin- (4 X S X U inches), and waa
ftmtively *oft. Over it* surface were a few small adherent thrombu^ma08e8. On
I the Ma]piju;hian bodies were extremely prominent.
( myenteric lymph-glands were enlarged and fllightly inftened.
Fhe liver waa large, the bile-duct« were free, and the gall-bladder was ilightly di*-
The portal vein was free. The surface of the liver was dark red. The lobtUet
irere prominent, and on section were slightly congested.
The pancreas was apparently nonnal. The suprarenal glands were m^rmah Both
cidneys were of the #ame general sine and app<'arance ; in bt'th the cfsrtex WM extremelj
Mil€, and tin; capsule wa« easily toni oif. In the cirti^x there wan a alight difl^we staining.
rhv glomemli were palOi but otherwise abowed no change. In the lower ileum then? wa* a
light enlargement of the follicles and of Peyer'^ patche«v The ghuuU at the root of each
ung were enlarged and swtdlen. The lett jugular vein was tlkd hy a rather Arm, slightly
dhoiivc thrombu««tnas^« which eiiended downward into ibe vuLiclavian vein and acrtjii
hU Ui the superior cava, into which it projected , and on the end there wen» a few aoft &esh
dote.
he anatomical diagnosis of thia <
Cbrcmir ^»eri« arditi^ and medkilinltik
5 AcHite ulcerativf* endiM'anlitipi,
^4Riri>Ribo6is of innotninate and led jugular veioiu
bo-pneumonia.
I congestion and adema of lungi.
Adhf^ona of p^ri«ftnlium.
>\>t<'ni in which the patliolopcjil k»sion has not yet Ix^n (ieurn
11 ir rhar.uici'isiic svinptonis arc* attacks of uiioon?!<'kiii>i
without <onvnlsi(>ii<, with a jrn»at liability to a reciirrviioe ot" i
thnni^h a hnijr |MTi<Kl of tinii'. The traiisieut los«? of coii:?<.*imi:
ronvnl>ioii- which nccm-s in ('i)ilci)sy is calltxl jj^iit tnaf, whil<
<(»iiMinnsnc>s with trciicral convulsive man iit^tat ions is calUnl
( 'oMvul-ion< prccisi'ly similar to thosi* oc-c'urring in true epilq>:
in organic jiTciiral (lis<»as4» as the n^ult of external traumat
other caiiMs : such coiivulsions have Ix'ou tenueil eplhpt[joni\
Jdrl'snnhiii rjti/rjfsif is a|)j»lic<l to Kxiiliztxl convulsioHS which :
ot' tn'^anic cci'cl>ral atrections. Th(»se latter forms must not U
with true rpih'psy.
It i- important that a sharj) distinetion slumld Ix^ made Ix^t
vnl-ions«»t' true cpih'i)sy and the many reflex convulsive attack:
tVom a variety ol' <'auses and arise from the hy|K?rsensitive a>ii
infant'.^ nervous system. These rt»Hex c*onvulsions so eloselv
eoiivuUion< which o<rur in epile|)sy that the grt^at importance ol
in;: iKtween the two diseases i»an hardly be exaggerated. Ir
rapidly ;rrowin;r l)rain the irritability of certain motor centres i
eally far greater than in lat4T ehildho<xl and in adult liie. Th
i- tiie >ourr<' ot' nervous explosions pnKlue<?il by raanv cauires
ill their nature, and it is im|M)ssihle to differentiate these exples?
clinieal -ymptonw alone from the eonvidsive attacks of epilep>i
lvrn)L(M.^ .— It is usually granted that the initial lesion
h|)-y lie- somewhere in the eorticid motor centres of the bn
thi- epilrptitiirm convulsion is an irritation of these centres. 1
may <*{' eonr.-e oriirinate in early infancy, and does so ui a lars
e.iM-. W'lietlier. hnwevcr, inliuitile eonvnlsions niav br* thp oam
raivh fur it, the diild Htujis fur a nnnaeiit in itn mtniputioii^ whether
ing, eating, or playing, while \Ui eves become fixed and it a^umes a
it expn?s&iou. This tijndihorj inny hunt for only a few flCHxmdB, when tlie
• a^ttmes its former otfU|jatioti a,s tliougli ii iiad never been interni[it<il,
pisually h not aware tliat anything has happeiie<l. In other ease^ thii*
litioii lasti^ a little loiigfT, an4l slight twiteliing of the lower \niH of the
id of the extremitie.s may oeeur. In other cases, again, the attacks
severe, the child a>mplains of being dizzy, staggers, has slight
Isive movemeiitj^ and turn.s |)alt\ this coudition lasting for a minnte or
h| and bt^iiig <piite markiHl, but withont any total loss of aiusciousness,
pientary attacks of staggt-ring S4jinetimcs occnr ahme io place of the
^kj§ alM>vc d(*Hcribed, At times these attackn of petit mal are the only
ifestatioas of the di.sc»ase, but in ncverc* at-ies they are apt to Im* a*^^!™-
^1 by otxaisiurml attacks of gmod mal. They may <Hvur as id^cn ii^
rty or thirty times a day, or, on the other hand, they may be noticed only
[in four or five days, and sonirtimcs they art* absent for longt*r intervals.
Ib the gntnd ntal the attacks an* of mucli grt»ater severity* Thc*y are
Himes precedtJ for several honrs by a feeling of malaise or general dis-
R)rt, but this is not always pres4^iit. Patients s^mictimes have notice of
luddcn ons4't of the attack, and such notice inimitl lately preceding the
blsions and forming {>art of the attack itself is calletl the aura, Tina
[may lie of ditli-rent kimls. It is most comnicmly a seiiise of fidness or
is?tsion in the epigastrium, tiY)m which something seems to rise into the
It, and micr»ns<'ionsness sujx^venes. It may bc_% liowever, a jiain or a
Ition of numbness, tingling, or other form of pariESthesia in varions pait8
be b^xly. S>mctinies tinnitus h the first symptom. Ftx^ijuently the
Int ha« no waniiiig whatever of the attack, but falls unfV>ns<'ious with or
lout a t-ry. The face l^ecomes congested, and the eyes usually turn ujk
l an that onlv the whites can be seen. Atler this follows the - '*
PKIUATHU-S.
I»i:i •IK- ;i!!:u'k iiKiy -nf«*f«il aii«»th(>r with litth' f>r no iiitiTiiii^^i r.. '■
till :iii:i«K- I'ollnw i.nt- anntlirr in {U\< \Miy tJir si'Vt»nil hnur'» :"!iv v: •
-;ii«l !•' !»»■ in iIh" 'iti/ififir shtfus, ii\\\l hi- (Niiulitioii a- n'^iiinl- i.^ •
••ii.''i-. At"i»r thr r«»nvnl-i«»n cra-i- the* rhiMV l>rrathiiiM u-,-. il--- -•
r..!i- :i!m1 till' linih- arc nlaxtHl. Later, aiul lH't«»n* <n»n-.-i .ij-n-^ :
tiini*. ili«- •hilil «»tt«ii tlill- into a iKh'|» shs^p, ami i»ii wakin.: ha- n- ■
t'..»ii ..l" tlh :iii:i'iv. imt rMiiiphiiiis i»nly ut' h<-a«lafli(* ami «»t* in* nra. •-••.: •
\if.i Ix- til'ii II Mrriir ill ihf niiihl. and in thi-i I'ii-t* may 1m.' nvirl-i.
..ii!\ i\ uliiur ot' fhiin IhIiii: that thi* rhihl ha** \v<*t the Unl. Ii .._i
• .I-- wh-rt onlx ii«H-!iiriial alta<*k> hav** Ih'^ii pn-xMit wo otuii li;r.> •^^.•
t» Im lirv that ihr «HMa«' ha- fxi-ti^l for <-on>i*l<Ta1»h.' |)iTi««i* !•' : '
jiii-. iiri' \\:i- -n-|Krt««|. In >nnif ra>4*> in CH>nm'«*tion with tht uti^.k-:
i- a (If -ill- t«» walk t»r tn run, h> that tht' |mti('iit must 1m» i/lo-^ly v./.- -
In tlii- •iiiMlitioii ihilihN'ii may walk straight a«r:iin<t an 4»lKa'l..*!. .
iIh \ :ir«' in«ni- apt tn >tnp when soincthinii *i»im»s arii)**-* their jkuL **^". ■
iini« - ihi \ walk t»r nm in eireles.
The ea-*- nl" part»\y-mal rnnninir (les<TiljiHl by Biillai"*! art' :it th.-'
• .irly inaniti-ta!i«»ii- ot' an epih'psy which will ilfvclop later. th'Si.'.. '
ni:i\ aU«» I»e only {\\v -yniptonis of hyst«?ria, rhun»a, an<l oriraui'* •*'>
ili-i :i-e.
I\|>ilejiiir rhiliheii an- liahh* to hnrsts <»f iin^ovcrnahlt' anL!:»Tui!:'
Iiiite la-tiiii! ti»r htnir-, in whieh they may t«»ar iuwl J^'strov thini:*. i'V '
niMtlur ni- niir-r. and are apparently fur a tinii- under the influeii'.r " i
-jon^ and haUiieinatioiw.
rih- r..!idiii«'n ot' patients Iwtweeii the attacks; is in the liLrht'T •--*
in flu- iMjiiiiiini: «»t" tin- di-ea-e ii-iially ipiitc normal. A"^ the d-.-.- -
ji.--.-. Ii..\\r\rr, iIht. i- a t«'inlenty to mental inipairmont. an«l it '!. -
-. \. r. .a--, ill e..ntra-t i«» the liirhter t»nes, wc arc apt to find jionir • 'j> -
ns. 1:1 ..!' int. lle.t. whic'ii at tinie< may ;ro on to an a<lvanc.-c<l dein»ii!!a.
It li:i- l»'iii e.in-id<retl hy some of the in<ist acute ohs«*rv»r- tirii ' "
..i-- in \\lii.-!i p.tit nial exi-t** in eonmn'tion with the nmn* sewn •.::. >
:•!. iM'.n li.ilil. to nn-ntal im]»airment than those in Avliich the unir.'i:
I>i\<;nm-i^. -A- the eoiivnl-ive attacks <K»<Miirinir in epilep<\ ui!..- •
di-iin-.vii~!i. .1 .•l!iii.-:il!y iVoni -imilar attacks due to other t^iu>«s '••• i.^
i:.i'''<d lo diiV. r.-nii.-ite . pilep-y Irt.m other distnist^s by carefuUv rliuiici!.:.
■ .il:'i- .•.iii-.- Cr ilir rnnvnUion-. We nmst also wait to s*.-*- wiHl.t: *
.•iM:..L^ will .-..niinn. ind.'tinitely. in which <-ase they aix; nion- likv".". i" '
• pii-j-v \ \.rv \''A\\' ilhiMi-ation of the difficulty which mny Jiii-
diujih.-i;. .liin... i-iiiiinil" .jiilep^y is rej)ivscntiHl by thc??e two iulimt^'-: ■•
I li;i\i' li:id !»r«.iijli1 \nn- to -how v<»n.
\\
11
.|.|-
..n v...^ .tiM.U.-.I at til.' :l^^^:. nf u.,i months* with i:'in..
•: • '"' it »"•'» »»••'•" liieiitaUy briirht. It wa- llvL ;'-
•'!■ •'..Ml, l..t.r it :,-ain bad a convulsion, the inoU-r^ l.^ -
•V :w.. an.l oiu..l.:,ir y^-aiv old, and the i-..nvuUi.:=^'^ '
I'
NERVOUS DISEASES PRB81TMABLY OBGANIC.
727
Qtlnued. vnrying in inler%*ah and \n severity. The chikl k now tomewliftt impiunsd
bc^iituTly, but there have lichen no other eymptonis of ci*ivbnil dift<*ttse.
The diiitfri*»sb of epilepsy can be mude in this ciiae, but thif wa» not waminted at the
tJQte of \U flr«rt cotivuUion, nor inde^ for ^uiiie time aderwarda.
This second ca^e (Case 342), eight months old, ia, opportunely for your In^tructionf
liaviiiii^ a uc^fieml eonvuUive attack. You «ee that H is unconscious ; thut the muscle of
the flice and of all tlie extremities are in active motion ; and that the eye* are turned up.
TUU h the thini ultack that it has had t<i-day. The luwer middle incisor* are almost
through thf5 ^um ; th^ gum h not swollen or ten^, and «hows no indication for Utnctng.
We must therefore bxtk further for the cause of this nervou* explofion. There i* no eri-
dence of anything in the ear, and the normal tt^niperatun? aidn us in eliminating the pni*
dromal convul^ikm* of one of the acute diaeasea with high temperature. On coming out
i»f the convulsion previouM U* this one there was no evidence from pamiyniA or stupor that
any central nirvou^ legion hud occurred.
So far as the clinical picture is concerned, this may be the begirining of an cpilepty,
but the chaaces in a case like this arc always that it h not one of epilep«y. The mother
now remombeis that sihe gave the infant last evening two or three bean» which he managtHl
to twallow. The ca^^e Is probably one of reflex convulsions iVom gastric irritation.
(An emetic wa*; given, the stomach wa* relieved of the beans, and the infant had no
tnore c^mvulsionH,)
Tho dia^mw^i^ of epilepy is made from a niatiiiuaiR'e of the attacks
niXer a iMnisiilerahle j»en«Kl witlioiit «?vidoiiee oi' aoy organk* disease or
oiarked irritaticm. WlieJi the oliild bites its tongue during the attack and
g(K« tiiskM:'p after t lie 0**11 vul.sion, or when tliere is tefD|Hjrarv mental impair-
ment after tile iHHividsioii, we liave pxid rcaj=H)n to state that the con\nilBioi]B
tire due to true eplIej)sY, espeeially if* no pyniptoms of orgauie brain dl^^^aee
foexiBt.
Epileptir eon\nil>«ions are ea^^ily distiugninhed from hysterieal ones by
the presc*n*'e of eonsiMonsuej^s in the latter, at any rate to a eonsiderable
extent. Hy^terieal convuUions in children arc* n»»t very eonimon, and
almost never exbt without the presence of other i^ymptom.** of hy.steria,
l*RO<:JNr>srs. — The prognos^is of cpilepy for life ls^ on the whole, favor-
able, and cpile[4it:s may live for many years.
Ail rj'gartls cure, the prognosis in ea^^^^ lif^nning in early infancy is
ver}' BtTious, When the diseix'*e begins at the age of ten years or later a
tvrtain niindxT seem U* ree*>ver, at leant temfwrarily. Many anthorities
tt»n!^ider that true epilt-jwy is never cured, yet undoubted cases exist where
no convulsions take [drnv for years.
Treatment. — The child should he treated at once, in order to avoid
*iiutintiourt .shiX'ks t'> its nerve-ot*ntres. Much U'nefit result*? fn*m early
uttentioQ to general hygienic conditions, to diet, and to protc^ction frtjni
nerN'ou^ dist urbane*^.
The managinncnt of tht^^ cases demands oonstant watchfiilness and tart»
H*» Hi* to n^gidate the snrrriundings of the child in such a way as to avoid all
jifiurce of irritation and nervous excitement* The diet must he regulattxl
according to the es|)€*eial indieatlonB for each patient. Slight gastric irrita*
tion api>arently prtiduoes more serions consequences than irritation of aojr
other part of the body. A veg»^table diet is usually indicated, but where
cliiuiin-: tin- (Inn* with a larp' quantity of water, 120 c.o. (4 «um'>'!-
nilf, ln'oinidr nt" pnta->iinn has Ikvii ibiiiul to lx» the most t.^ftii.'ifnt a
nf tiic hroiiiults ill tast's nf ('|)ilq)sy. In giving the broniiik- it
U'LMii witli >inall dosts, 0.12 to 0.24 jrpamme (2 to 4 grains), ihiv
tinir- ill th«' twenty-lour honiv, for the first year, and tn iloubW ih'
Ibr thi' MMMHul y<ar. The dost* should lx» inerea.se<l gradually
phy>inli»iiiral action of the drug is noticed.
Thi- trnitniciit, at intervals of one or two week.s, should lie o
for loii;^ |M ri«Mls, and from six months to a year after the i\)uvuUi\
hav<* sei'iiiiiiirlv eeasinl.
'I'lii- littl»' uirl !(':!-'• :!i:i), win* lia? been bRnitrht to the clinic ibis moniiiis:.
MTP -liali' yi:ii- .-M. Sin- \vu- :ipj»nr»*ntly a houlthy iiifunt. When she wu.> t-n
v|,,. l..-:m f> \iA\r r..iiviil.-.iiins. whioli were of a clouic type iind infrequent sit tir
'lit- W.I- f'-urt'-ii ni."Mili- mIiI iln-y lu'oanit* nion» sovore and frequent. Siru*- lli
J ••iiMil-i'Mi- !i:i\i' •■..iitiiiii»«l. ami at «»nif tiini* ^h^.• luid flfty-four o«»nviil-i-i:i» i:
li-'ur-.
S!if \\:i- ir«'ai.il wiili 1»r<»iiiijl«' nf |x»ta^>iu!n, hej^iiminjc with d^.»^t'# of (M*J
ui.ii- -■ ari«l L;i':jilii:iily iiii-n-a-iM.! !«• U.3 jrnuiimo (5 t^rainfs) four or l^w time* in
i.'ir i.-.!i> I'll..!, r ilii> tn-atiiu-ut tin* (•«)nviil?ions have become lo^s fretju*
U'l .li !i':iltli li:i- ?iiu<h iinpiin«<l within the la.«t year.
N" -tl.. r -Mi,|.:..ii,- of .li>r:iM' liavr at any time been det<»ctoti about thi." il
-i:i.p!\ I". |.r— iit.'tl l.yoMivul-ivf attacks followed by unconsciMU-iiu-^*.
-..l.ntl.l.- in»pr..v.ii,-nt at present, yet the probability i. t
:V..in th.- .-i.il.'p-y. and that as i-he grows older. *-p-.vi:illi
;i\iii-iv.- aiiarlv> may oeeur more fre<|uently. and unil«r :1
\ !..i,.'ii. mi.n- IT 1«— alfeeted.
\\ . u'l.iii I liMVf had bnMiirht to the clinic tiwiay t-h-
= ■ ' ■' '' ' P>''1^^ • i- ti'rt''- .vrars old. 8he was he:ihhy ;i
i H..- PA.. FMMiiili^ m1,1. At that time *she bo:;an to huvo
1 .-■•:■ ui.i.h «-..iiM uut be arc.iuntiH.1 for on a ear*.'fi:l »•
a
l!'.i-*i
1. i« -i:i.p!\ r-
tl
.-• 1 hi
\'.'[ -li'-w- r.-!
i!
• A.-r 1
•'I!'-
11.-: ! .1
" ■•: -ip-ly t":-.
■• '.•■1. iL. .
:.■ :■ M.i-;.l . •:
■ .'.iM (':.>.
\ «
!. -. .
ill;.- . ■ ',
NERVOUS DISEASES PRESUMABLY aRGANIC,
729
lUle that if said to her. The bead U of about Ihe nonnal sixe. The face and eyet
vacant e3ipres»ioni and she has io be taken care of as thouf^b the were an In&nl hi
rly months of life.
thii case there U no histoiy of epilepsy or of any eepecial nervous disorder in the
^ nor of traumatism or of any serioujs disease which could have produced this nervous
NUice. We i^n only say^ therefore, that it is a case of ebrcmie epilepsy starting from
Uiknown cause and resulting in permanent idiocy*
bis boy (Case 345) is ten and one-hulf years old. There is no history of epilepsy or of
L disease in his family. He has never had any especial diseases, but for the la^t iix and
yean he has been attacked with convulsions ttccurrin^ about once every thrie»e weeks.
past six m^^nths the attacks are said to have been mom IVequent and severe* He at
bas bad us manv as five in one week, and some of the attacks have lasted ftAeen min<
f more. He stiites that jui^t before one of these convulsive attacks he feels frightened
tk. He then loses consciousness and falls to the ground. The expression of bis face
irdull, ae though the continued shocks to his nervous system were producing a certain
It of mental disturbance. He answers questions, however, readily and intelligently,
fttctkl examinntiim shows nothing abnumial.
Cabb MB*
'ida
^
1
i L 1
Vlepej, 6' a yvasB dumUoa, Petit in*L Ma1<». lUS ye*« o\4.
poe entering the hospital, two weeks ago, be has had a number of convulsions and
mn closely watched^ and there seems to be no doubt that the attacks are real and not
peal. The attacks have UiiuaUy occurred at night, but sometimeii also when he has
Up and about the ward. The attack is usually ushered in by a loud cry, and he is
Emd to be in a state of clonic convulsion. He firothB at the mouth, but has not bit-
longutt. The attacks have lasted for nUmi fifteen minut^ss, and have then been fol-
ly coma and prtilonged sleep tW some hour*. In addition to the other convulsive
riiH there bas been much twitcbirig of the tm^ during the attack. The eyelids arv
half oppn, and the ey«** r*>Ued upward and inward, Tbw pupils react only sUghtlr
t tb»> utUiek, and the *y»^lMiIls are not ^en*.itivii to touch. A^ the convubive neitRUn*
[away, the reaction of tlie pupils graduallr returns. l>uriii|i; the attack there is do
, iensation produced by pricking with a pin. Some of the attacks ara pivooded by
i and an attempt to get out of UhI, <hi that he has to be i*c«ti»iiied, and sumelimas
ui'.Mi 'Jl in till' iiiiiiut'-. lli^ titii|«T:iiurL' lia." lH»fn ii4»riiiui.
'I'll-- in-.itimMt "f till* l"»y !i:is luvii with bn»iiiidt» of jiola^iiim, but 1
i..\\..l l»y Tiiark.il Ihh.-Hi. Hi* U pmbably u oas»» af chronic e}»ili.*p-y wKi
. ijn-.l. Mill! Nvhii li. ;i*»"nlini: lo Dr. HulljirdV opiiii<iii aftiT car»-'full\ v\a:
!i:i\. !.. }.•■ t:»kiii «:ir«' nt' ill un in.-titutioii for fouhU'-inindcd childrvn.
'I hi- -trii.'. li«:iltli\-l«"»kiiiir Iniy (Case 34»i), soveii yeuw old, 1 ha\'
tfj. .lii.i." t' — l'iN !.' *li.«\v _\«»ii H* iiimtlHT forrn of fpil<-|i>y. Th«-n- U i:«» i.
i.rr\.'U- .li-:i-' in till- fainily. \lo was liorn after a difli(.-ult d«^livtTy. azA
'\:i\ li I'l :i iiumiIhi- ••!' I'unviil-inns, which continuiNl at intervals f««r ?• v«
w !•.■ .■!' a «l'-iii<- L'«*iMral varioty, iiiiil wi*re nppan»ntly ri.'U«»ved by Piiuill d:-
pM(:i.-iiiin. |)nrii!i: tli«- tir^t yt-ar, ultli<>iii;h the convulifions did not r»'tur:s.
:■« tiiiM- -liulit attaris.-. in wliirh hi' turmfd pale and became alnH»>t ui:i
:iii:i. k-. li..v\<\.r. Ia-ii'«l l"t»r tuily ii fi'W minutf.". It ij» reportc-d that tl i
i.!li-. alili'U-ii lii- j»hy-l(iil il«*vt'li»pnu*!it wafS fairly normal, lie did ii'>i
.ii,.i - . ?!,. .1 :iliii.-t )»liiHl. At'tiTthat time, however, his montid condition in
:i" --■• :iM-i a liitif Larkwan! in cumpjirison with other infant.< «if th^ «aniL
ii:-i Mar ami a lialt' ••!' hi- h!«* his Irfl IcjLT MH*ined smaller than the rid.
-li.-rt'T. hut II" «-'|H'(ial paraly>i!< was noticed, and by the time that h'* u;
•i.> iliili i< iM-.' ill ih«' -iz«* i»r tin- limbs was (h*ti»cttKl. When he wa* t»n«* \f-'.
t-« -it al'i.«'. Mi- t««th wi-n- cut at the usual time. When he wu- t
!ii« a«iiP •!!• lit- i«r tin* lu'ad -hoWi'd tliat it was of alniut the normal -iz».-
.•■'■r.!a'i- 1,." \\:i- rl-.-.tl. T««wanl> the end i>f the second year he InMraii t«»
u:i- Jw- :i.m1 a lialf yar- i»M In- had cut nil hi.s teeth and was well and -i
apj" ti!' . aii'l .■••uM walk \\«'ll. Ih' had, however, hhown Mg^ns of mental
u:i- :!■ i:nl. wa- .-uhjij't to r\plii>i«.!H of temper, and had to be carefully i
M.:i' If «li.l M'.t hurt liim-«-ir «»r tlie other children in the familv.
\Vh. I! li'- wa- t"iir yiar> old he heijan to have convulsionfi of a cl»
'iriiii •; at iii-jhi a-nl n-ln'?-»'il in by a sen*am. During the^e uttuek-s
•!i ■litM. u.i- i;; ■ ■■ '
I..
,.r..:..|-.,.
■ w is--, .i i\
uav . :.i ■! tl-
A- V II -
"W- \ I r. ■. ■ ]\
i.il. .-s'.ii ■■'i-ii
. -I - i.ii-. ha.l -t.rt.Tous breathini;, and afU-r five or t..n n
|. :r..iii whi.-li hf culd not be amusi'd f*»r a numlMT of h-
w.ul.l lu' .-..nHwhal dull und fretful, but these synipl'tm-
. .•.Mil-i.ii- w.»uld ni»t return sometimes f..r u number •>f n
• lii:ii t....lay hi- i- phy.-ically well developed. His men*.
■ \i.liit: hi-*y.'- an- n«>t bright, he has a rather vacant, i
li'- ha- hariMtl ti» n-ad. he does not «iTirkw n.^ -.-.•.. ...i. ;..* n: ...
NERVDUS DI8EA8B9 PBESUMABL.Y ORGANIC. 731
%
silling, and he should he placed in some institution devoted to the training of feehle-
ilnded children or in the hands of some expert in this hranch of psychology.
INSANITY. — Insanity in children is very rare. In the ordinary forms
f insanity no definite pathological lesion has been found which would
ocoont for the symptoms presented. Such changes as have been detected
oine very late in the disease and seem to be secondary. In paretic de-
iientiay however, we find a special form of cortical interstitial encephalitis.
Instances of mania and melancholia at times occur. Hallucinations,
rhich are a common symptom in the insanity of adults, occur in children
isaally in connection with the delirium of fever, or more rarely with epi-
Bpsy, as I have already described. Insanity is met with in children at any
ge ; it is extremely rare before puberty, but then becomes more frequent
The prognosis of insanity in children varies according to its forni.
LoQte mania and melancholia are said to recover generally. True paretic
lementia is never known to recover.
PKDIATRICS.
LECTURE >::x:-x:vi.
III. FUNCTIONAL NERVOUS DISEASES.
(Oipinic riutiirc not yot ahown.)
(1) PROBABLY CENTRAL.
IIysI KKIA. — nYrN'(>TISM. — CATA.LKP8T. — SiMULATKD I>ISEA8KS. — IXslOUTIO -"
crssioN.— TkM1M»RARY Am.SKMIA. — TbMPORART APUAk»IA.->ARKE9T£D P^\ 21.
DKVKI.nrMKNT. — KETAKI>KDSPKKrH. — HkABACHKH. — VeRTIGO.— SEXMTrTE Vj.
— Tktany. — Pavor No(turnu8 (Central).
To-D.vY, ^ontleiiKMi, I shall speak of a class of cases which yriii'
lial)l(' to iiKM't with intors|)erseil among the patients with defiuifc di*r-
wh(nn you aiv calh^l to stv.
Thcst' cases aiv oallcnl fuiH^tional, and are represented by either a r»j:-
rarv susjK'nsioii of, or a ixTvertcd iLse of, the normal physiologiwl fe -•
of the nervous sy>t<'ni. We have at present no sufficient evideniv M jiv ■
us in ehtssifyin»r tli<»si» diseast^s as organic. These functional nenou- y-
noniena phiy a ro/c of «)nsideral)le imix)rtance in early lite, as thtj •■
unieh more frcHjuently at this jHTifxl than they do in adults. Tbt-vir--
funetious of the nervous system in early life are in the pnK?e» uf dtvJ :•
niefit, :m<l iirr Fi<»t so |K*rleete<l as they arc in the more mature yii^vt:
fart, they HIT in a >tate of unstahle e<iuilil)riuni : henci* shtx-ks of vr!
kimls ea>ily <:niM' tenii>orary (listurl)anet»s which, not lK»in»r frr^'^-lyr.-i
<'an |»as> away after a {mmmikI of irst.
Tills ehiss uf functional disturlwnct^ may be divided into utn'»n- I'l-
nonicna apparently resuhin^ (1) from some affection of the nervi»ih i^:'""
an<l (2) from sofuc irritati<»n of the jHTipheral nerves.
I shiill lirst s|H*ak of those functional disc*ases which are supiK»HfJ -" '
of centnil ori-^iii. Of these hysteria is j)erhai)s the most difficult to ii;P--
cFitint*' r(»rreetly and t<» understand, and I shall therefore b^n^itir^
(lisenr.e.
HYSTERIA. — IIy>teria is a functional disturbanct^ of the om-
ei-ntns reinNM-nttd, a<«'ordinir to Mohius, by a state in which iJta- «K"
the IhkIv nnd produce inorhid changt^ in -its functions. The iiaiit >
nii>nonier, l)nt it Lh- Im'cu ad<»ptcKl so generallv tliat we must u-^e it "
tlie pre-ent.
We know very little ahout tlic etiology of hvsteria. Well-Bars-
in-lniKvs ot' the di^rase occur in early life, iisimlly in the middle and !* •
j)eriods ot' childluMHl.
An inherltrd nervous oi'iianizat ion or highly exciting surrounding^.^**-'
lMne<l with a lack n\' |u'o|>cr home dis<ai)line, appear to present as ft-^;-
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FUKCTIONAL NERVOUS DISEASES.
r33
field fur tlie disease to develop in a« any conditions, such bs fright, whicli
apjiart'Utly, at timi\H, dinx^tly lt*ad to it.
Tlie nieit* pre^nee of emotional or irai^inative conditions in children
u d<»t^ nttt c^nistitiite hysteria, Ft^r the existence of the disease it is nwessary
tu have definite symptoms, either a markedly dis*jrgani/ed mental state,
lysis, aiue^thesia, or mme eerioua I066 of function (amanrosis, deafnt?ss,
yspha^ia).
Sv Minors. — The symptoms in this most prt>teiin of di-seases are innu-
merable. Convidsions and |iaralysi8 are quite common, while dysphagia,
urosis, and anaesthesia are met with only in tlie very severe cases, and
not otten seen in America. Amesihesia is es|x^^ially interesting as rep-
resenting a pure type of the disease, and is usually ou one side of the b>dy.
< liildi-en [K'rhaps only two or three years of age affected by hysteria will
s<mietimes allow themselves to tie jirit^ketl on the ana?sthetre side of the im-e
M w^itliout wincing.
Hysteria in children as usually seen in America Ls marked by die emo-
tional conditions (►f tlic child, and by the j)rest»nce, in many cases, of a fixed
I idea relating to its own physical omditiou* The child believes that it can-
not perform certain actions or functions, and hence does not perform them,
ere pr<»liably hru^ often Ix'cn in tlie Ix^ginning some rt^al difficulty or dis*
bance of the [►eribruiauce of tliese functions, such as paiu, which has
paaeed away or which is not suflicient to pn>dur^ the present condition.
The most CNjmmon symptoms, a^ide fn:>m the mental condition, aiv
(1) convulsions, (2) paralysis, and (3) auffstbe^ia.
(1) The t*onvulsions aw distinguislicil fmni thost* of epilepsy by the
noe of loss of const*iouent*ss. The patient never seriously injures him-
«»lf in fallings and dots not bite his tongue. He d<»es not slci'|> alk*r the
attack,
(2) The (laralysis is often of the g[)astic form, and may be eitlier hcmi-
plegie or paraplegic*. In this form the limlis are rigid and the knee-jerks
are exaggt:^ratwl. It may, however, lie of the fla<_rid variety, with the
knee-jerks diminisheil or absent. It is distinguished from the organic
forms of paralysis by the normal ivaction of tlie mus^'lcs to clwtricity, by
the absence uf atrophy, by the al>6enc^ of any aflwtiou of the sphincters,
and at times by the prcs4^nc<? of amesthesia*
(3) When anesthesia tx-curs it is asually irregular in distribution, wcur-
ring in patclu^, or else it has the sjime di^^tribution as in cerebnd organic
diseas<\ It is often variable, changing move or lees from day to day.
Although almtkst any symptom may occur in hysteria, yet the lack of
unif<>rmity in the grouping of the symptfmis, and the combination of symp-
iiims which Ijclong to entirely dilVerent dLst^ascs, are of grt»at aid in making
the differential diagnosis from these disea**cs.
\Vc sc»mctimes meet with an exaggerattHl hysteria in children. The
attacks art* iv(uvsentCHl by screaming, running, jumping, and a feelbg of
being pulhxl alM>ut; they may last for hours, or for days; their duration^
•:;i
PEDIATIJU'S
liowrvtr, i- ii-ually loiiir, — at times, with intervals, ov<»r a vvar. N •.
i.f nrjanif ili-«a-<' an- t'nniid in tlu-H' casi^s ; they ^ieI(Inlll iniup ',. ...
aii<l an' liFially nm-il l>y moral inHnriK**/, fhaiij^.' of sf<*n<\ ami u"--'. .
-iin^'iiFiilinL:-.
II\-t«ria •M-ra-ioiially <-aii>is cliihh'cn to |>r<*sent rr\m|»T««ii!- : •
<li-. a-' ni* tin- -|»in«* ami jtiiiits. This most otton lollows -niti. -IL:'
I»nf may utrwv -|Mintan»un-ly.
l*i:«M.N(Hi*». — TIh* |n*o»r»<»^i^ in <*as«»s of hy?*t<»ria i>. a.-? a ruk ii.v
l>i v(..No>is. — (niMrally, tlir <lia«rn<>sis is not >o <liiVn-iilt a^ ii. :•
iMiaiiM- tin- <-liiM i- not ahlr tn control its s<Misati«»ii> i»f j»ai:j ::::>!
<«.m|»lrtrly a^ i- |»o>^il»lf with ailnlts. In surtri^'al t-tb^t-s, hnw..-.. r.
hy-t« rit-al allrction- -imnlat<* most closely orjranii" ilisoa>c »»t' tii»' *«i.;-
(iiaiino-i- i- ot't« n atti'n<lc<l i)y cxtivmc (litti<*iilty. The a|i|»rh-ati«:n>'. .
riirniit- ot* electricity will nsnally show that tin* ana'sthosia i* lu'tr..'
A <oFin»lrtc «lillcrcntial clia^nosis of hysteria wouhl iK-niipy lu-n
than I c.ni nivc to the >nl)jcct, and I have thorefoiv merely nui.i •.
pn»'ral |»rinci|»lc«» hy which yon an* to 1k» •j^^ii^l^'^l in cliairntKi'-atiiu "
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'ri:r.ArMi:NT. — The treatment cif hysteria is to hreak up at q^
harmliil honu- -nrrtumdin^s, if such exist, and by luoans of ^^ikK'I i:"-
cniin»iiUi.in to make the child nnd(»rstan<l tliat its symjitoin* ;m' :r:
The varioii- lucal >ym|itom*i connect^Hl with the digestion ami p-iua i: ■-
ol' the child -h.»uld he <anthlly treate<l, as the hysterical symi»t"iu*:i> .-
larL:«l\ de|»eiMleiit on condititMis oi* this nature.
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:'.I7 . I'll \*-nr> m1<1. is ali.»ut to l».':ive ih«' !p-:-it;. .
• .li>.:i-.' t'.r whiili -hf \v:is hr«»uu:lit ht.Te fjr tivilri.*'
i- !!i:ii li.-r pa:'"nt- MD" liviiitr ami well. ari-J iha: ::•:
•!. ill th" tUiiiily. Tlii-* «:hil«l had always Ul:. u»-ii :::■
..• h.-pital. At that time -li«. coinplaiii.-..! o:* h
•.■'iii:'4 -i«k aiiti appari'iitly iinaMe t«» six^ak. S:.
. 1.. I.avi- liail -|ia-iii», aial to liav»r bt».Ti \'.v\ p-:.- • -
..! i.i.k ..r taiv in h.T li.nne liJV. and had U- w -zi'-y
i.i.rn-.' ..f thi- laik i^C caiv in tlie c.»n«liii.»n ••!* :,vr ?Aii. •
-pii.il. A ph\>ifai examination >h.i\\vl i. itLir.^' .«• *
\ :i!.l ili.l.iiMiiial orLraii<. The piipiU wen.* >*.ij:it!\ 'i .'•-
'■ :':-\'.\ 'I'll.- kiMM'-ji-rks wer«-» d»'er»?a<ed. Th»-r- 'aa- '•
= '. '.i!i..l.I.- tM walk, aii.l .-h.' lay in Inti takiuir :i.- tj- :i.'
if" :i:i\ tliiii-.r wa* iliru^t lowanls th^m. Her lu-arii.:: -.ii 1 "
•*-!i' Im\ in Im.I ill a very limp condition, with rh-I-L- ir
.. fi k. pt r..IliMir fVeiu .-id«» to >ide, and occaj?i«.njir.y -AVi-n-
• ':-..!..! ... a- t.. iiiak«^ nearly a rijrht amrle wirh :i.- '•
■•■ V. .:iM ii..t -wallow. Her teniporatim.' was ?M/iM' •
.•: f!. I»;. WIhii hoiu'j: examint^^l ^lio cri*.Ml .-ut ?. •i'^^' •
••' .:•. .1 '■mkI. aiul in three or four days her onulili-'U «v
• .1 A. II. I.iit wa- appan.Mitly unable to iV-cmI hor*«'lf A:-
■;■• I ■ ". aii.l on heinir taken up and dn-^rii^tHi it \i.i-l' -:■
:!.; v.:i:!< a liitL- with Mipport. On bc*^inning t.^ walk.^i-
••:>. »■ I.. i:iic w.nl.h.Hi <he walked much WttCT. At »:io ::.-::•• ^
•: !)• ih. \i'.itinir physician came into the ward. ando-. -
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lilmoRt uny word that was said to ber, hut !n a whisp**r, Aft^r this she impravcd
* unci begun t** urticuliite fairly wcU, but -slowly uml with iin oflurt. She also f|>t^k*'
irily two <ir three time*. She could not walk witbi>ut uMhisUnoo, ha she would put
oi too fjir forward. She had been very much cojiBtip*itt*d through the whole uttack^
\ thiA time the coostipatioQ grew lesa. A definite training of the Anna nnd te|^ wai
gun by mean* of pas^Te movements and masftiige. Under thi^s treotment ^he hai,
«ee, j^rctttly impntvedt and to-day ^ the thirty-fifth day from the time when «he
he hn<)ptul} has recovered mmpletely. She speaks and walks^ although »he is eUU
rkward.
f kave concluded that thin U n eai^e of hysteria^ a<i she has i^hown no definite symptonu
' other dificase, and on acoount of the emotional character of her ^yroptoms Mnce fthe
BD in the hospital.
Hypnotism. — Hypnotism i?* an artiBoial meotal txmdition which can
bodiiccicl in ehihlreo as well as in tuliilt8. It is 8iip(K>s<xi to be a tenipo-
I abeyance of tlic f)Owers of tlie higher cerebral crntT'c^. In the iirclinar}*
I the ehikl is throwo into a condition in wliich tlic consciousncR^ of hit?
)mal euiTounJiogs is lost. This condition in liiitwanl apjx^aranec chisely
IHbleB sleep, but is prodnood artifi<'ially and ttao U* artificially removed,
i^ the sensation of pain can bt* tenipirarily alMilislml, at Ica-^t to a con-
bable extent. For this rpiL'^>n it has l>t»i'n snpp»scd that it nii^lit be
1 in the treatment of cases rei|niring minor snrgical operatit^ns. It has
ailvocated by siime physicians as a form of treatment in various
; but our experience at the Children's Hr*spital has pnjvtxl it to be
ieot,
DATALEP8Y. — Catalepsy is only a symptom. It denotes a conflition,
Ireutly of cK*rebral orig-in, in wliicli, togt^ther witli total or |)artial loss of
laousnes^s, the limb8 assume a peculiar form of rijridity (^llcd tt?axy, and
lin for a considerable time m any |>osition in whiih they may be placed.
7::»;
I'KIUATUK.'S.
varirtir<. |ial|»itation. <K>|ni(t»a, vomiting, sjisisiiKKiir atui«k« :
kiiwl-, ami iiianv ntlu-r >yni|»t<nns aris<', and, may jK-^r.-i.-t ll«r \":\':\y .
'I'hr 1m-! tnatnu'iit tor iIh'm' c-ascs is at oiui* to .>lir»\v tlinlj!.:*..
kiiMW hi- -\ Fii|it«»iii- an* unreal and of uo iiupDrtantv.
Vnii will ri'iiH-iiiU'r tii*' Uiy ((*jl<4' -WS), t4.»u years olil. whovir:-
l.\ lii- iii«»tliir t'» my <iini<' a Irw months iv^o with a hist^n' nf r:. •
wiiirli Ii.'kI Imiii iiniim- <»ii Tor two yrars, omv or twicv in a in-'iiti;. i!
Will ii.Miri-lnil ami rolm.-t l«M»kintr. The hiiortnation Mas oliiitM: r:
iMothrr that In* luvrv hurt liiins**!!' when ho IMl clown in a cHiVi.- :
that thr attack- t'ollownl attempts to make him tin s«»nu'thiiiL: ^wiv.
not wi-h t«» «lu. Vmi may remcmU'r that I thfii sntrt;e>l»il in Li-i:
ih.it In- -JHMihl 1m' -riit t«» priniu, and that he iiinnciliately iMl "UL
ha'l a vinlint etniviiUion, inamc^l at tii<' month, an<l was a|»j>an:ntl;
-liMii-. I tlnn pickj-d him u|) and tol«l him tliat il* he ever U.'IiuvmI :
wa\ a-jain In- would surely 1m' shut up in prison away tVom hi- 'j
He iii-tantly n<ov<«re<i, au«l lias sin<H» Uhmi a ivasonahle niHulHTf!—
V«Mi mu-t Im" pnparetl to meet with all tlu*s<.» ilit!en»nt phasts 'l ?.'•
manili'-tati'Mw in early life, and h*arn to n*<*o<jrnize to whieh cla-^jn! ."••
di-ea-r«^ ili«y lM'l«)nLr.
INSOLATION.— Ileat-insolati(»n, or hciit-stnike, is a o..i>.lii;\
par<iitly npre-i iite<l hy a t'uneti<»nal <listiir1>an<»o eonnet'ted with tU'<^'
• irenhiti'Hi and produeeil hy heat. This afltH'tion in varviu^f iK-i:>'-*''
-ninrwhat tVe'jiHut oeeurrenee in eliildron, and is snp]K»s<:Hl to !»' f"
pMFii«d l»y a hyp< nemia ot' ^^n-ater or l(»ss intonsitv i>f the mrninL"*'i- ' • '
Ni'—iU. it i- met with mo>t e(»mmonly in the middle ix'ri'Kl «t*'. hi. ':.
iM-ran-f at that ivj,*^ the ehiJd is most jikely to Ix* oxi.M»>id to tIr* i:."— *
w hjrh proiliicc it.
Thr clini'al pi<tur«' «»f this class of ea<es is, a*s a rnlo. quite chan i *'"
Thr rhihl ha- jM-rhaps Ihhmi playin^x on a hot summer's dav .*»unw!i.it -'■
vi-jMrmi-ly than usual, pos^hly rompini; with an older c*hild of iiK.r^. ^L'
di'v«l«»j»ed n«rvoiis re-;i-tanee, p'ttinn: inton.^ely exeititl, and irr* iiiiv • ' *•
taxini: it- Fnu-eiilar .-treiiL^th. It may Ix* that it has \yo<.n e.xjvH-.: i "
(lir«Mt ray- of tin- mi<l-<lay <un ; or it may have beini plavinjr in ts«.ni:«: =' • "
liiit jpatnl and -titlini:- pla«'<'. The nurse of the child, nc»tieinir tlif-X"
llii-h«d •••MHlIti'in of it- fa* T and head and its exeite<l, sparkliiiir •^"'- "-**
al.ii-rn and hnriM.- il to its home. Intense headache soon e«»m»> 'M-x-i
a llw h'Mii'- d. iiriiiin may >nj)ervene. The skin is hot. drv, and niM ■•
th.-iv m:is 1m- xninitin- in thr iM-innino: ; the carotids and temi>.>ral i-.r- " *
thr-.h |"iv.|,til.j\. 'i'he heart's a<*tion is violent, and tlio teni]X'ra''.:- =•
rai^.d to ;;s.i» :;!!. 1 -H)"- i\ (1 02^-1 Oa°-l 04^ F.) : the puk i> ^
:i".-.!. rat.d. |m riiap- IK) tn 1 oO, and is ftdl, but u.snally rhythmira;. -■
.MnjimrtlvM- ar.' .-..iiu^-t'-d and the pupils ct.>ntracted. Photophohb ••
-ivat. r ..r I— d'-rec i^ almost invarialdv present, Bevond this tlu'^'Jri.
Im- II. > ^Miiptniii' .x.vpt a >li^ht amount of muscular twitching, and is ?-
•a- - a ••..iivid-^l..n tnay .Mviir if tlie temix*rature runs as high as 40--l''.t-''
the
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lis explosion where fever aud clkturhance of the eerebral curiilatioo
ent, but, a^ a rule, this sympt^jui is absent,
JN08TS. — Be careful a^ to the prognosis which you give in theee
Although they often simulate eh>sely a beginning meningitis, adiseafle
bich the pmgnosis, as 1 have already told you, is unfavorable, yet they
Nery amenable to treat ment, and should therefore be carefully differea-
I from that disciij^. In very severe ea^es the children may, of eouise,
€ insolatiou, as do adults.
[hAGNOSis. — The diagnosis fn>m meningitiJ^ Ib ba'^ied u[K>n the hii^tnry,
milder grade of the symptoms, except the liemlat*he, and finally, in
ftful cases, the quick recovery and sjjeedy disap^jtearanoe of the fever.
I^IIEATMENT, — The treatment of beat-insolation should be pnimpt and
hjue. A stimulatiug enema of salt, one teas|x»*:»nful to a quart of
^j should first he given. The child should then be placed njmu a Ijed
■ted by a rubljer sheet iu a aj^il, darkcnt^l nx>m ; a warm mustard
f should be applied to the low^er extremities, and the neck and chest
k sponged with water at 25° C\ (77° F.) tor lifte<.^n minutes out of every
5» Ijciter's coil should be applied to the head with water at 5^ C, (41°
I bromide of potassium should lye given, 0.3 gramme (5 graias) every hour
pur doses ; a little ic^l milk may Ix* taken if the child cares for it, uot
I than one or two ounces at a time ; and complete rest and quiet for at
I twenty-four hours are usually indicatc^b The child should W watched
iilly for sijme days and not allc»wc<l to play actively enough to get
■d. Great care should be taken for the rest of the summer to protect
fcild from tlie direct rays of the sun, a* after one attack the cerebi-al
^tion n^mains in a very sensitive condition for a considerable jieriod.
I have found in my Dote« an account of two eases of this kind occurring
^ practice, w hich I shall report to you.
:18
PKDIATRICS.
.'i p.M At »l r.M. till' h«':itli<'h«' WH' h-.x-;. and b».» Ml asloop. Ho awi-«kft at IH ■•y
t-Mi|" rutiin- via- f.-iiiul t«» !•«• :IS.*»^ ('. (102° F.). He then t«v»k S4»rne iovti iLuki... i
l.r..ini.lr .•!* |>..t:i>-iiini. Ljit«r m the u'lizht th«* U'lnpt-mturt^ was found l«»h:i^.':.. _• *■
C. ; UMi' K.). and tin* \mUv tn Ik* 10(>. On tho foLluwini; day tho temperatun. v.- . '
»'.«** ' K. , and tli«' }iiil-«' IH). II»« (Miniphiint'd of slight hoadaohe, but thi-re w:i4 : |.ij.-. ; .
lit- I'rli \v»alv ami dp»\v*y. and wa-s kt'pt in a dark Piu>ra all day, takinir >ni:in •:•-> : .\
On tlif iMlI-'wini: "lay In* ttll wt-ll. had a tcotnl appetite, and wa# up uH'i Ir^-.
(»n th<- nr\i day Mt't«T drivinir in an cip«.»n carriasro in the s^-un tVir an h'jr .
h'ul.nli-' '•!' tn.Ml.rat" ••■virity. but n«» ffver, and was five fn>m headucho anip r-* •
• •n th«' f.'Ili'wini; thiy.
iMirini: th«' tp-xt t\v«i or thr»M' years, aUh(>uc:h ho did not have any p-.-irr-:.- .
^••\. P- rharart-r. from titrn- t'» time diirini; the h«»t weather he shnw»Mi that bi-i - '; *■
• Mlriti'ii \va- -till in a M'n.-itivi' condition, as slight exposure to the ray-t of ili- ^11;.
«'..i,-ii|.T:il'l«' ll« aiiai'h'-.
Tli'- n«\t instanri- ••!' tlii^ kind was a Kn' (Case 3i>0), five years and ihiw* ir.vi- '.
(>i: Aui:ii-i l!t th- Wi-athi-r wa> h«'t and ^ultry. The l>oy was perfrt'tly wi-11 darn:::-.
a!i>i \s.«- n-'t ••\|»i-til t.» any I'spifial «*xt'itenient or exertion. He wt-nt t:.- •-••i '-.■... I
iiIltIi! wa- l)<'t. ii'i air \va- -tirriiii;, and the nxim in which he slept was ven* hut-il-' -
..p|.r.--i\.'.
Til" n«*\t ni'»rnini: hf aw.ik<' at 5 A.M. with severe frontal heudarhi-: ?i-i>
• ir..\\-\. l»a«l i;«' apjMiit.-, and hi> ti-nipi'ralur«.< was found to l>e 38.9^ C iKVJ' F.= 3
k'pt ail .la\ in l.«il in a r«Kil nmiij. At liint-s he would cry out fn»m the p-jinir. ■ •
11:- iniiul w:«- p«Tl'«'i'tly rli-ar. A ili»><' of bn^niide of potassium, 0.3 irRininiL' .'• jv.'*
L'ivrii at ♦; P.M. Hi- i.'nip.'ratun' at that tinn- was found to 1k» 30.5° C. .;H.V5^ Fi; :.. .
w:i- \UK full and li-'nn«iinix. In th«* idi^ht he iH'oame delirious and hud i- :• .
\saf' li'-.j, a* li«' W"iild jump out ot' brd and cry out with )Miin in his h»>ad. C'U'-i -"
u-r-- Mppliid to hi- h«ad durinir th»' nii^lit, and on the followini^ day th« ?t!i:|: •
iiji-h rili-'\«'d. Haifa K-M-ln-lli- powder was given in the morning and ^^p-it-l
li"iir-. Till- \\M- iMllowd l»y a tn-f njovonu'iit of tlie bowels. He felt dull aii'i ^ •':
..f li M.JM.li.'. but at •". I'M. the .-yniptonis wrrc much ndieved. and hi* irmj---r.iiv :•
:■•»:■"! t . I..- ;:.■.:= ('. -is^ K., :,iid hi- pul-e to K' KX). On the folb.wirL' i-J- '
: p ■!'■ I I" li i\«- Iriil a -jo..*] niL'bt and lo havf awiiki'ned p<»rfeinlv w.-ll.
!•'■ : ;\\ ...r ilir. •■ \..ir- follow imr th.- attack Iw wa« liable to bavo att:.rk- 'f ■.■;.■■•
.:•',. •• f- .n, iMi-l'i- . \p .-UP' to tbo sun oral niL'bt if the iXHun in which hf rl-i-: : :
t-- I" I'.i v.t.ti!.il.-.l ai,.l ||..t.
CONCUSSION. — r>v <Hinciission wo moan clinically a frnuip "i' *'-■
tojns loll. .win- >om<' |)liy>i<'al shock, with its resulting traumatic irr!:..:. ■
of tho iirrvoii- ivntivs. 1 have met with a number of insUm<x^ v! *>
ii<rvon«- phcijoinciinii.
*'• • ^^ '■ ''■••' ''■' '•">■ '<'''«'^" ••'»1)' f"ur years *dd, who fell fr«>m a tabl^ :■•::• '•*
I •■•'■.. h:':. :r '1 iir .nt-r. uthi f-und thai liis skin was cc»ol, and hi- puU.? -l-f. •■■" -
•'"' "■■ ••■I- J:"i--.i'i ri.i liM.l b.'cn voniitinir. No evidence of traumatic injun'- m' ■'
•■:.<ii- 1--I M .- uM I... f..un<l. Aft.-ra fowhoura the .symptoms trnidualh i^: " ■
■•»••! ':• .\.i. i..il". . tly wii ."• ill!' followinir day.
Til.-., iii.l.rmltc ^yinptoin^ arc iisimlly inscribed to the bniin a.< tii--.
ol" ii-iii.iiIoii.
'i"l'" nv:.tm,.!ii nt' :, ,,i.r oi* thw kind is simply by perfeot re^t awl •>•
in ;i (l.nKrno<l r....ni, uith hot ai)i)H('ations to the feet and aUlomtii. -'.^
>ni.Mll nn.l ivp,nt.-,l ,lo>.o. <,r stinuihmts ^iwn by onemata until th.'i=t..ra.-
i> :«i.Ii' to niMin tlnn,, the tivainirnt k'ing wntinueil until the einiila:i-a ^
n<innMl ninl thv jmU.. ^tnmo-.
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A
II
FTXCnOITAI. XEBTOnS DISEASES.
739
The n«xt insUnce of thii kind was the cuse of a Uttte girl (Caae 353), lixteen maiithB
•Id, whom I *aw in coiuultutkm wiUi I>r. Town!*ond.
The child wae perfectly welt, and was not of au eapeciallj nervous temperament. She
Id speak a number of wordi and could walk. While sitting in her baby-cnrriA|E:e one
\y at th<i top of a hill^ another child took hold of the carriage and pushed it with great
^pidity down tht^ bill. The carriage was tipped over, and the child was thtfiwn out on the
tidewalkf apparently f^trikincr on her head. She wa« unconscioua when she was picked up,
but oo sisfns of injury beyond a slight bruise on the right side of the head could be dt'k'cled.
ire wtt« no vomitinjBj. Her extrefnitie* were oold* Consciousnefis soon n^umed. und
ng abnormal could be detected on a physical examination. The pube was 1^>, jind
m temperature 36.6° C. (98** F ). Afler the accident she had no appetite, and beeatne very
and easily frightened. The bowels were moved regularly^ a flight amount of blood,
ihowever, appearing in the first dischai^ which occurred after the accident. U was diffi-
cult to make her go to sleeps and she would wake up screaming and at times not knowing
»ny one. For several days she could not make use of the words which she ordinarily did,
Ittod did not recognize her father^ but was afmid of him, while before the accident she
■tnjoyed playing with him. She seemed to have the same fear of a number of other people
is the house, but did not show any symptoms of fear when being examined by Dr. Town-
send or by me, although we were entire stmnuers to her. These symptoms continued for
•cime weeks, gradually subsiding, and were not accompanied by any other abnormal con-
dition^ such as a rise of tempeniture. The child recovered entirely.
The treatment of the case was simply to keep her in a rather dark room separate fVom
everybody but her mother.
I have here to-day a uimiber of instances of other central and fiinetional
diseases to show you.
As the eauBe?? of the.se nervous manifestations art* maniluld, atid as
we know nothing atnint their |Kithology, I can best deserilje their symptoms
and trtratnient l>y dt-seribirit; iiidK idiial instances of the various tu^i^ of this
kind whieh have come under my observation*
TEMPORARY AMNESIA. — Here are two cases whith belong to a
clflsa of nervous disturbant'e which is reprfsented by tem|x>rary amnesia*
This child (Caae 858), nr«w ten yea» old, waa playing when he wu nine yean old
on an asphalt tennis-court with stome older boys. One of the boys threw him down on
the hard court so that he struck the back of his head. He got up^ but felt dizi^y, so that
hi> did not attempt to play any more, but sat looking at bis playmates and occasionally
making foolish remarks. This finally attracted the notice of hi& companions, who took him
home. He was put b> bed, and seemed drowsy, but did not have any nausea or any other
»ympt<»ni«, eicept thnt he c»:>uld not remember anything;, even that he was present at the
wedding: of his aunt on th»* previous day. He articulated plainly and ^j^Kike naturally.
After sleepiui: for alxiut twelve hours he wt»ke up with hU memory perfectly res1or«d|
except that he bud a very dim remembrunce of what hnd happeniHl to him. Since the
accident his mental condition has been normal, and ■• joa see him ti)-day he is a bright,
well-developed boy.
The probable cause of bb amnesia was a physjcnl shock with resulting abeyance of
ftinction in the nerve-centres connected with memory.
This next boy (Case 354), thirteen year* old, is a case of the tame kind. White ruti-
cingi iilK»ut .MX months aero, he *truek hi3% head ac^ninst a tree. I saw him thrrc hours later
He bad walked home, but w^ » little nau««HtiHl, and was put to bed. 1 f^und that h« had
partial loss of memory and was drowiy, btit that he bad DO eq)eouil p«an. He wa* per-
fcetly welt on the following day, and is^ as you see, an intelligent Uiy, witltotU mental
dUturbanee *>f any kind.
TEMPORARY APHASIA. — An inttanee of suspension of th^ cerebral Ainction
eoimectcd with the elabomtion of words is lliuntnitod by Dcmmo's caM (C«ie 866) of
a tnintinnal an<l not an (irjraiiic eoiulition of the brain. Int'uii
atlr<tion (Irvrlop Ixitli niciitally and phvsuiilly for a variable j
\\i\\\^ livt' c»r six months, and then c'ontiniu' to develop ph\>i(-all
t4) (|<v<'l<»|» niciitally. This (Condition hists for a variahh* ik^tuh]
whrii thrv Inixin to develop mentally ii^iin, and, althongh tur
th<y an- liackwanl in ^H^mparison with otluT rliildren of thti
finally -iiow no tra*-«' <»!* an abnormal inontal condition.
Arnst^l psychieal development sooms to Ix? rather CNimmonl
with rhaehiti^, and may also «KxMir hi the c!ourse of i^evero il
nntliiiiLi-eUe is detinltt'lv known (nmeerninji^ it.
RETARDED SPEECH.— At varying iK?ricxls during the l:i
thf liiM y< :ir aiul the hepnnintr of the second vear infants U?t
thtir tir-t attrnipt< to sjM'ak. By the middle of the seomid v<
usually al»l<' to e«imnnmie;ite their idea.s by means of short, 1
ti'iHi-^. in tiie tiiinl year most ehildnm 8].K?ak quite plaiulv. t
<1«» not ei rn'itly nse the prej>ositions and adverbs until !?«:>mo
Wlnii (InrinLr tlu» setNind yesir the jiower of S|>eech does notd
till- ii-iinl rapi<liiy, it i< sj)oken of as retanied sj>eech.
This lack (»f jxiwer to sjK^ak may l)e from a simple lack of (
of ('. rtaifi ]M)rtions of the lirain, or from or<T^anic or functional c
tnil);m<v. It fiiay also arise fn»m abnormal conditions outside «
Tlir r.i-r^ which are caused hy a lack of development mav l)e'y
<iri:iiii, or may U' due t(» an arrest<H:l cerebral development nn
nimihcr «»r ••au<cs. These ejinses are usually connected with s
intrrtl mice with the crrchral jrrowth, such 2u» a severe illne>s.
.•iph:i-ia i- like that ])ro(liicc(l hy S4»me such organic lesion of t
c\i>t> ill CM-, -i ol* ecrehral paralysis. It may also Ix^ connect
.♦• ;.i;.
'PL., r.i
ktt«i1 nT-vl«
FUNCTIONAL NERVOUS DIBEABES.
741
^1 this amDeotioD BtammeriDg may be spoken of as a cause of retanled
1^ When a child of tlik kind is bmught to you to d<x'ide why it is unable
n speak; you should carefully investigate the previous history. In thi.s way
^u can eliminate organic disease of the brain by means of tlie alisenee of
ual syraplonis of such disease, especially hemiplegia, and by a&eiTtain-
that the child has oot had any disease suffit-iently severe in it^ character
interfere with the devel(i[)UieDt of the centres of sfjeeeh. After deter-
g that the cliild is not an idiot, you should make a physical exami-
tioD of the ear and mouth. If, on examining the ear, you find that the
Id Ls deaf, you will at ouee have a good reason for his not bt^ng able to
Even where young childrt^n have leiirned to speak fairly well, if
ey later become deaf fn>m a diseai^e like s<^'arlet fever they are very a[)t to
^come mute also. Where such lesion of tlie ear has oocuri^ed before the
lild has learned to si^eak, he almost invariably is found to be a deaf-mute,
Ithough there may be no defects in articulatiun or in his meutjil eon-
Ition. It is seldom that any deft?ct in the nioutli or throat is found which
iterferes with artirtdatitm, except in eases where very extensive lesions are
resent, such as cleft (lalate, and sometimes enlarged tonsik ccjmbimd with a
Igh-artThrxl palate and a large adenoid growth. The tongue-tie which
le parents usually t^fuisider to be the cause of the n^tarth'd s}>eeeli is
»ldom prt^*nt. Where no symptom of organic, functional or develoj*-
ental et»rebral 4lis<'ase exists, where tlien* is no physical deformity, and
here the clnld hears well and seems briglit and well develnjM'il in either
ys, you can, as a rule, assure the parents that the six!ech is merely re-
led and will |>robal)ly develop later.
HEADACHES. — W^hen pain in the head oceurs in early life it Is to be
rded niort* seriously tlian when it ocxmra at a later period, as it is more
to indicate some ^nive cc^ntral lesion. The various fijrms of org;inic
he which arise in children can be spjken of bt^t as symptomatic of
le various diseases in which they ocx!ur.
There also ap|>ears to Im* a type of headache which occurs in the later
rears of childhood irrespective of any disease aud ot\en unaccomj>anied
ly nausea. These heatlaeht*s, as a rule, ai*e in it of serious imjMirt, and are
dually classed under the term functional. They occur irregularly, and may
le in any part of the head. They an^ often s*:> severe that the cliild has t*>
ie down. The intervals between the attacks are variable, and the length
f the attacks varies from two or thret? hours to a day. Of these functional
eadaf*hes the most frequent fi>rm in clnldren Is that due to amemia.
Althnugh in many cases headm'hc^ are «:»use<l by an im(iroper regulation
f the diet, yet there is evidently some other cause which we do not ret^og-
Ize in their pr<idu<»tion, as with exactly the same diet for many moutlm
1 child will show no symptoms whatever of headache. In like manner,
though we know that headaches in ehildrt^n may depend ujjon consti])a-
I, yet this class of cases occurs whether consti|>ation ib present or oat.
742 PEDIATRICS.
Mi^niiiif aLs» may exist in t'hildren, and is characterized l>y ?e\>T» x
in till' lu*a<l, s<inK'tinu»s unilateral, dometimes bilateral, aftyjmi)a:!Hi
naiista, dizziness, and j^j^'nerally vomiting. The attacks uwur at irrvj. .
int<Tvals, and usually last the greater i>art of a day. They may lieli: v-
(in l)y apparently slight (^uses, such as over-fatigue or veiy mild iLi--
tinns (»1* diet, in those predisjKtejed to them. These headaches art ntirk
luTttlitarv.
Although all tlu»si» forms of headache are ordinarily ver}- intriii
to rni-e, es|KH'ially when? no bad hygienic surroundings exi^it whi«i u-
aceonnt lor them, and where the child does not lead a sedentan* liit. "
as a rule, the attaeks have a tendency to lessen and disappear a? the -i .
grows <ilder.
The treatment of these* headaches is usually unsatisfactory, as the jr:ii
siM'Ui to arise fi-om some functional disturbance which, irrespeeiive • 1 1
cause that \vv <tui as<'ertain, resists the best known hygienic and dk' ^
trt-atnient. Strict dinH»tions should be given as to exercL?e and i-."
ehan^«' of air and s<vne is often a valuable adjunct to the treatmnii L
many e:is*»s th(» administration of fluid extract of ergot, as re«i»iimM'>.
by Dr. Knssell Sturgis, has proved to be of benefit. I know of »> •»■":
treatment for easts of this kind during the presence of an attaik iL:
alKoliite <|uiet in a darkencnl room and the use of bromide of ptoa^
hromidr of s«Mlinm in sufficient doses to produce sleep, or at least to. sr-
tlir a<Mite pain.
Tlii- l...y i(';»-r ^.V.) i> thirteen y«?ar8 old. He has usually boen Ptn^ne ami ?• =-
i'l lii- Ii:i1mi-, ainl l-riiilit in his .-tinlior*. When he was nine years old he h:t'l i '::.'-■ ■
.■:' -.-III.' f.\»r. Tj. In tliut tiiin' he ir» said to have been healthy and nt-vtrt i..' ■
Miiy ii'TN'-M- •li-iii:l<:tn(M' (hiriiiLj th«* duntiil period. Just be f«.» re his attack ^u* vv."
Iii- iia.l :i -.-viT'- hi'Hii.u-lM*. At tir>t these headaches occurred only twice a v-.^r, :-■"- '
i- Miirick-il l>y ihfiM four liiiu's a ye^ir. All the headaches have about the ^ime di* '
i-ii. - :i« til." ..ii«- tVoiii which h.- is now sutlering. The pain is usually most inta--'
top ■f III- li'jul. Mixl ••xt^'M'ls to the front and back. The attaeks ijenerallvlasia ir-»'. /
til. -.-.■..11.1 mtii.k wlii.-h ho. had, the pain did not last so many days as in the fir*: -•■:"-'
whi. •:. li.i\.- .M-.iinv.j lawr, hut h<* wii'* U-tlt in a rather weak condition aflerwaixiv ^= "^ "
• • -111 I 11- ; UM.k. 'rh»T«' \v:i>i 11.) pjinilysin of the let's.
V. -t.i-.lny li- woiii t.. ^rli.Hil :»< w-ll as usual, but soon began to feel pain ii.h«--
a:.. I li:i i f.' ri'iiini t- hi- htnin:. The headache has continued, and to-dav, ;*? t.«ii ?-■
<:''■'■"■ -it '«!'• '•'!' l':»^ '•• 1>'' 'h'Nvn. He lins no nausea, his appetite is po*-»d, ano :b -^ '^ •
>|H .i:,; .|:.:.Mi\.- .|i^!ui'.:iii,-.-^, hut h«' has a slightly coated U>ii£:ue and a slijjhtkrai-^ •
rii' 1. w. ;-^ :ir.' r-u'ular, and he complains of nothing but such seven pi'.
.; !:■ h;.- t.. ii.. j>.rf.-ctiy still. His diet has always been simple, and thrr^f •
ii ■ ii:.. t «an-.'<, >u<]i as the use of tobacco, to account tor the attat'k. 3 ■
u:. Miiy .1. lirinni, has always In^en perfitctly conacitms during the attaik-.^ *■
. "i" :iMy i.li..t.]>h..hia. and ni«»rely wishes to be let alone.
' x.i:!ii:ii!..: hini t-.-.iay y<»ii see that his temperature is 36. 6*» C. (98**F.i,i:J-v-
I- i>" ■'liar, iMii n..t i,u.-nnitt.*nt. On physical examination nothing of if. ■::•:
natup- » .l..t.-.t.-.i iP. ,1... th..rax ..rahdomen. The heart's action is somewhat irr^iT::*-- ' ■
tlui- .- :, -li.:i.t -.uunuMv with th- lir>t smmd at the apex, and an accentuateti i^:--^
.-.'....,. I ..,M::.i. II.. ha. n.-vpi- ha.l rliarhitis. Uo i< rather anaemic, but of cou»' i-' ■ ' ^■•
unn.-ii ,1.\ j.al.- t.-l^y, .-,- h- j, in tin- ini.Nt of cme <.f th<»se attacks.
In thi- .■:.>,. th.-r.- may Ih- .nuw >li.-ht or-amc disease of the mitral vslw, bu'- *■' '-
1" r.i:!i:--
h .v\ i:
,.:.r...-l;
y\. :. ill
rUNCriONAL NERVOUS DISEASES.
743
iM is well and strong between the attacka of headache, the murmuf may be af functiotial
origin. In (hither case ihe bt^udiLcbeB can scarcely be accounted for by the cardiac dbturb-
aneOf and c&n well be spoken of under the term functional/
In treating this case small doses of tincture of digitalis are indicated, on the suppoQition
that tome disturbance in the circulatory organs exists, evidence of which is given by the
cardiac murmur.
We should, in examining a caae of this kind, before speaking of the
ck as functional, eliminate other possible cauises. One of the moat
csommon causes in children, but which does not exi-t in this case, is pain
caused by a strain of the eyes. In all caised of headache in children the
cause of which is not evident, a careful examination of the eyes should be
made, even though there be no symptoms which poiut t*j the eyes them-
selves.
As an illustration of a class of headaches the cause of which was
formerly obscure, I show you this little girL
8he (Cade 857) is twelve jeari old. She has ttilTered during the past two yean with
almost continuous headache, no that she ha& had to he taken away from sch(»ol.
A c^in.'Iul physical examlnution of thi-; child made by nie two year» aK<» failtfd to detwt
anything iibnonnal, except that «he wu« fiulfering prohnbly from the n^sulu of eye^trala.
With the ex<vption of the headache she has been well and stmng, lia^ hud a j^mni color,
good appotitt? and dige«tion» and ha* simply been incapacitated from studying and reading
I account of the j^uiiu in her heairt.
The child wa^^ examintn] hy an oculiflt and waa made to wear glasaea. No benefit
fMult^xl, and until within a few wei^ks^ her [larent^ iiupp^jsed that *hc o^uld not becun^d.
Su^pectin^i however, that the cye« wen.^ reully the source of the inmbh', I referred the
child to atjother oculUt, who haa made a change in the glataeif and the headaches have
disap^R'ured.
VERTIGO. — Vertifl^n at times occurs in children* It is a term ap]died
to a condition in whicli the individual i>r the objects around hioi iij)|M ar to
be rolling about. It is called subjective vertigo wheti the })atient himself
seem;^ to l>e turning, and objective vertigo when it is the surroimding objects
that apiM?ar to move.
Vertigo has a variety of rauBcs. It may be due to organic cerebral
diaea8e^, sneh as tumors of the bmin, esjw^eially of the cereWlbim, and to
di^a^es^ of the ear and of tlie eye. It may alft<i l>e due t*> rinndatory dis-
tiirl>ances, as in eardiat? dl^^ane, and to gastric vertigo, sl^ <rom improper
food, al^5o from t<:»baoco an<l tea.
Thin boy (Caae 858), thirteen yearn old, was referred to me hy Profea^or Blake with the
hUt'jry that li«' hail had a purulent otitia 8»*veral year* >>\uce, but that this had healed three
ytiin agOj b^AVing a coodionn of ndhcaion* and ciciitriceis with c«jn»iii»'nibl<' inipainment of
hearing, but with no tniubJo of iho hibyruiih n^r any tiympUnu.* pMntint? »hi*n?to-
Th*» child WHS always utrong and Wf*ll until he w«* <M»ven year* ttld, when he had the
punilcnt otiii*. which ProfttSMor Blake tr»*nt«-Hi. Three y^mr* ago hf bi*gan tn havi^ attacki
€d dlnrAtim*^ accompani^ by seeing whit<t »|HtU*. He at timcw had nau^a, but no fe«<ling i»f
spinning ri>und or fjitling. He ha« aincif had this f***«ling caiitinuoUMly, and lau-ly it has
ralhf^r itir leased tn severity* He ha* had no oihe? abpomuil symptom*, pxot'pt that h^ fi»el«
■ompwhat weak. He ftleepa well, htn app^'tlte U fair, and hi* boweU an; regular He baa
Thi-t lioy (Cusi* 350), thirteen years old, previous U> one year ago wa> j^rtV
but >iii(H> th:4t tiiiK' bus c'(>iiiplaint>d of headache at tiinc« when studying, bsL" Wk
titi'. iiiul bjij* iMcniih? <'i»ristipatcd. He began to complain of his back at thi-fani'
tbi* uibtrKym|»t«»in< <bfVfb)pt'd. The other symptoms have not been eepwially pp
but tbc }miii ill bi> back hH^gn)wn progressively worse, and there is seiifiitiver.t^Mj
t»V«T tb»' .-]>ilM'.
Aft«'r I bad first sei'ii birn and prescribed exercise in the open air and "i
M'inK'l and «»t' >tudy. b»' improved for a time, and all the other 8ympt<.>ni;* di>aji}^'
tlir f\(H'pti«»ii of tin* sen.-itiv<*nes8 of the spine. Although at times this 8en>iti\>:
pt-and «Mitin*ly, yot it has bitely returned, and has been just as painful as in ibt-l
I tbi-n-ton- n'fjTriHi bini yesterday to Dr. Lovett, who reports that therpji^?
tinii^ t'i>r iii>'<-baiii('al treatiiieiit. that the spine is normal in every respect, and t
diH'u-r run b«- jvoiiivfly (>liiiiiiiatt<i. The tenderness of which he ct»mplairi.> i-
w»' an* ar<M«.t.»iniMl t«» >♦•♦' in neura^thenic women. The probability is that, owitj
pby>ii-a1 ('«>M(iiti<>ii and bi< slight niusoular development, his spine has had tr>de(>
li«rani«'iit.- to maintain it en>ct, that the sensitive condition and the pain mk <
strain wbicb is l>n>iiirbt to boar on them, and that this will disappear as his
iiii|)n»vi«j. \V<* can th«*n^foro provij»ionally make the diagnosis of sensitives
d« bility. and I ^ball bav»* bini treated by massage, gymnastic exercises, and
Sniin' (.f tin—' <'a»«'- pr«)ve very intractiiblo lo treatment.
(Siil»><<|ii«-nt history.) Within a month after this treatment was carried v\
n-fMVrn-d cnlirfly.
TETANY. — 'i\*taiiy is a torm which is used to represent tonic
trnt niuscnlar spasms witlioiit loss of consciousness. The oondition
11 syin|)t<nn iA' nervous irritation, probably of central origin and
(liictil Uy or^anir lesions. This symptom is very apt to occur in
rliarhitis, Ijut it may (K'cur in otherwise healthy children when t
various <listurl)au('cs oi* th(» ^astro-enteric tract. It Ls also met wi
course ol' many of the acute (Hs(»ast»s, such as pneumonia.
The s|)a-Fu usually aflcH'ts tlie extremities and not the face and
panied ap|»arently l)y a <'ertain amount of pain. The Iih^s and
0 — UIVD Oi|J«:'V4l>CM
the te^^HBbrs* Warm baths are indicated for the relief of the
p, and bromide of potai^ium Is the most eflicat^ious drug in cases of
kind.
PAVOB NOCTCTRNUS (Central). — The night-terrorB of children
[occur from a variety of causeg, and ehonid not be considered sb one
pe, but iLs a svinptom of a number of diseases. Any nervous disturb-
. whetlit r centra! or |M^riptieni!, may produce so profound an irapresaion
be sensitive cortical cells oi' the brain that the child's sleep may be
(rbed by a cortical irritation.
I
rbe special form of pavor nocturnua wbicb may be considered central has occurred m
oy (Case 360), six jeare of age, who has been brought for advice Ui ih*- clinic thit
Dg. He has mlwayi been a delicate, thin, pale child, not caring much fur open-air
B, but inclined to remain in the house and t*> be read to vr to have exciting etoriea told
His appetite is poor. He is mental iy bright and precocious. Otherwise he Hppean^
iWell, and shows no signs of any organic disease. Last evemng he was allowed to &it
kber later than usual ^ and a number of terrifying stories were told to him. He went to
pi usual, hut in about an hour waked up screaming. He was found fitting up in bed
Bg terrifled. His eyes were staring at some invbihle object^ evidently a picture in his
I and not a reality ; he was pointing at this imaginaiy source of his terror, and kept
Ijng that it was a black dog. It was impossible to pacify him for about ten niinutes,
le did not recognize his mother during the attack. He then became more qriet; th«
'look paused frf)m his eyes ; he recognized his mother ^ and soon lay down f ^nd went
\lf to sleep. The cause of this attack, which Is typical of the ceotnl form of pavor
auif was evidently undue excitement of the cells of the cortex in a bright, nervous
efore going to sleep. The treatment of a cAse of this kind is to iccustom the child to
[«ixerdse in the open air, U* prevent his reading anything but the mo6t ordinary and
» books, and to have no stories whatever related to htm.
r4ti
PEDIATRICSw
LECTURE X3CX:VII.
IV— FUNCTIONAL NERVOUS DISEASES.— (Concluded.!
(2) REFLEX.
TAVfU N'uTTRMs (Pkkipheral).— Dental Reflex. — Rkflex Ntstig¥-j-:
KLKX nK TIIK KaK. — KkFLEX OF THK LaRYXX. PAROXYSMAL GAaPISG.-lL'.;
nK TIIK LiNii. -Kkflkx Cough.— Reflex of the Heart.— Beflu ": '
SioMMii.— Kkflkx of the Bladder. — Reflex of the Vaoixa— Reti:-
THK UnrTlM.
PAYOR NOCTURNUS (Peripheral). — At the last lecture, gatk"
I shnw<il you a cast* nf pavor iuK*turnu8 in which the symptom* we>
<lt'ntly of rt'iitral oripii. To-ilay I have to show you a little girl i**
yrars old who also has attacks of i)avor iioeturuus.
Til.' iliilil i(':t-.' o»il ), MS y.iii ^»e«.>, i-i r<»bu>t-lo< iking. She is said to be alwivri-! .:
.-tn'Tiir; tn li:ivr !i u^hmI MpjM'tit*' ; iu»t to bo nervous or excitable ; to l>e fond ••■f plij.i: ■
t.i'.l..i.r-. Mini not t«» ran* t<» liuvr stori«*s told to h».'r. Her mother also &tate^^ th»t jI---
.-tij»;ti"«l. Mini tli.it -In- lia- a triub'iicy to overload her stomach. She has hid di:::z:/.
,.f ^l.M-p t'.-r -..IIP- tinn-. an«l la.-t nii^ht .■<he had an unusually severe attack of ptv r''-
im-. Sill- li:i<l iat»'n a v^ry hoavy .-•uppi.T, and on going to b«kl she imniediutf ly fe.l i- -
I. lit --"'11 l"-_raM t" 1m- n-«tli---. to thrt»w b«.Ts«.'lf about, to groan, and to jrrind h'-: t^i- ■
litii- I.tt'T -h>- U"k«- up *«n:imiiii^. and ajipan-ntly had a certjiin amount <»f uy?^"--- *
ilil I..-I !■• (•■•mi,/."- \,>r iii"ilii-r. l»ui -at up in IhhI l«M»kint:j very much frii;ht»-nt'd :i'j 1 • :" - -
;i; I.- r tli:'-;it. II- :■ lu'.th.T niMiJi- lii-r drink smne warm watiT, which pr..<iu.-"l ;•
\"'i.ii".; J. Sli' t!i. II l.triiiiii- ratiiinal airain, n*ot»^nizod hor mother, and &«.-'rj I-iy-- '
l«. Sli«" ha- M" n-<'«ilhTti(»n i«f thesr attacks t>n the followini; day.
. \i.i.:.ily a c-.-i-i- in uhii-h tin- irritation is of the tt^rminal tilament? • f ib-
■ r\.- i'l \\u- -t-iniarh. rausiuir n'fl«'X symptoms of the nei^'ou-! centres t: •:
\\> lit t-
Thi> i-
III- '-^-i-trii- •
t\t. • J tliM! th" .iiiiil i< t'rrilifd and fi'«;ls as thouirh sh«* would stifle.
It i< ;i .-a^.', th. r. t".'!-.-. ..t' p.-rip]nTal juivmf n«K'turnu«. and >hould Iw' tn^tit^ti V; '-■ •"
:itii:i: til-- .|i.-! a; d .ill-winu' th" «'hild ti» hav*- only a light and digestible ^upjvr. V ■
tl;:i' tip- tv... , hi— - ■■!■ iM-.- ai-f di-tinrt and that their treatment is entin-iv diL'''^r:. T.
u:,; iN.. ..If. -1 !!i.'. ! uitli a iiiiMun- nf b..th of these forms in which it is col p-.'^.-ii'-
iiiaiv :i ■•!■ ;ir lii-tli,. ti- ii h.-t\M-i'n lln-ni.
I havr rullrrtr<l n minilxT of rases to show you which repreiH?ni ^'-
otlnT ill'istrativr ty|M'^ of ivtlcx nervous symptoms.
DPJNTAL REFLEXES.— The twitching which occurs in ehiWR^ :
the time when :i tooth i> tln' ap|>aront ejuisc of a certain amount of dn^'- ■
li'it :m.l i;-vi-i' -h(.iiM hr ndi-rnKl to here as a significant ilhi^tnition of u.--
vnii< |.h('iioiii.ii:i from ivHcx causes. The cuses an* numerous, but a^-vv
ot -iitli.-iciit iiii|H.i-tjmrt- to report. In certain instances, however, f^r-'i- ■
>i"ii> oi" a n-ilrx n.Mtmv occur at this time and cease when the tcioth b'
:i-um.(l it. |d:i.v al..,vc tlic mari:-iii of the j^um. I have also met with '^■'»-'
inter. MiiiiT <':i>c- of l.H-al oMlcina arising during the period of dental irritati'i
h
a tv ^^'
1
■V
k
C'Otll
the
till
IlCl
chi
IIL
la
th
<1
-1
1*1
tl
'J
FtJN(7riOXAL NERVOUS DISEASES.
747
One of these cisca wns a m&le inikni (Ciue 802), llfleen months old, who some manths
previously, wbili' cuttiiii^ ofie of the second molAi>, hud an Attack of cedemft of the hAnds,
whk'h wri.4 not iiceompiinied by irritiition c>r any uiher ^^jinptom^ and which paeeod off after
a few huur».
Tbi* &uai<? boy when th*j canine teeth were about to oome through the gum» waa agaun
atUckfd by mdema of the face. Thi* local oBdenut^ a^ iu the previous inetance, diiuippearwi
At tiraoa I have seen a local oedema attacking one eyelid, so that the eye
ooultl niit l>e closed.
Although we mniiot say that the irritation from the teeth is neces^sarily
the cause of these conditions, yet they so oilen arise during the dental
eritxl, and not during otlier periods of childhocKl, or bcfoix* the fourth or
Ih month, that we can at least say that iu individuals of an excessively
nervous temj>eraraent the irritation which Gvidently arises in certain cases
when the teeth are ileveloping may l>e sufficient to cause a nervous explosion,
which in thii^ 8t^n6e may Ijc spoken of as of deutal origin.
These are only a few instance* of the reflex distnrhanoes which occur
during the i>eritxl of dentition, and I shall speak of the subject as a whole
under the heading of difficult dentition (page 794),
NYSTAGMUS*^ — By nystagmus is meant a peculiar rh\i^limical oscil-
lation of the eyeballs, usually fn»m side to side.
It may be produced by many causes. It is sometimes dependent on
organic disease of the brain, aud sometimes it arises tn>m hx^l diseases of
the eye. In certain cases it is reflex from various peripheral stimuli.
Nystagmus of reflex origin is not a very uncommon symptom iu young
children* I have notes of two cjlscs, l>rothcrs, who during the deutal |)eri<jd
showed this oscillation of the eyeballs with no other symptoms. Complete
i«»very resulted when dentition was conclude*!.
This rhild (Case 868)^ three years old, has, u« you «ee, nyttagmua. She is rhachitic,
and did not walk until three inonth« ago. She ahow« no signs of organic diiease, and will
therefore probably recover fh>fii the nystagnius when the rhachitU U cured,
REFLEX OP THE EAR. — The reflex connection between the roots
of tlie t*x*th and the membraua tymjiani by means of the otic ganglion pro-
duces the well-known n'flex t^rache wliich occurs during the dental jxriod.
Tliis phenomenon I shall s|x'ak of more fully later (page 795).
REFLEX OF THE LARYNX.— In certain case^* n^flex symptoms
otvur in tlic hirynx. This fX>ndition is usually note*l during infancy rather
tlian in idildhfKKl. The aflection has beeo called larifngosjm&mus^ and»
although it is more usual for it to (x?cur in rharhitic children tlian in i»ther8^
it is not nc*N>vsarily wnfincd to rhachitis. It is not in my experience a very
common dWnrie, but when met with it is very characteristic.
The infant is suddenly attackcxl by a sjiasramlic eontrartion of the
lar\"nx. This cc^ndition may bc» pre^^-ipitated by various causes, such as
IVight and cxcitA^ment, I have also seen it produced by various perijiheral
irritations, such as those of the nose. At ttmes the attiu^k is so severe
748
PEDIATBJCB.
that the itifattt beeomeft tmooiificnoiii^ aiid cyanotk^ The attitdi I^Itc
a few minultts and on recovery the lufiint Hatinis afi wdl m pvit \x9i
d«ie^ not m*t*ni U% Im? ed iuiijutimiiloEy oonilicion oanneeted with ifeJaotl
and ii|iiiaivntly it w pureiyof ii rdieic oaturtL la ucmie GaN9iefii«|j
laryngfkl muud will frequently pnenede ftnd oft^i mioooed ifaMSix^'-^|
Til ^ ^no^ m cBmm of lar/ngcMiMiisiniis »t ^ & nile, m^\
altltough veiT wcsik infimti umy dift in an aitt«4^k.
Aii tbe infants ure tu<^itiilly dciicatt' ami of a Iii|;Iil%" oervnw ntfttfls^ I
lii^ tf«itmeot frhouli! be diroetad tii iiopnjviiif^ ibeir §;t*iiiffrftl hdltiiB^tl
pFQtedicig them fnim nerv-otis i»xcrtleiiK*nt until tlu^^ have ttftiniiifif |
wliciti their nen*t»uM iVtfii^iti b lc9» ijrritiil>li* iuhI ih in nion' il«l>le«|tulliQfi{
I>urtiig an attdA^k the treftUiiefii i^ to eixlca vur Ui prutlim* itja£at>ii4i|
flpasm by pertfilicral irritutiou <ibewlieiB* Thi» m tzAimlly dooebf^M*]
ing tlm child oo die chai^ atid fiioe wilb cold WBlcr aad l%lilly ii3|fK^i^|
AmoiiiE i^ ntimlii^r of cuiet of tliin kind whiob have cosit laikvl
notioe wae^ thi^onc:
ImuI » muiibvr of eimtnlaleoi wInoi h« ««* «iKtllii|| hi* llr»i laivlii . With tW unp**'
a liffat iUodi 0f «fdiiciiiie iefiiMfiJiB, lit bai bmsn w»U And *ttufi^, FnU^vti^ y^ 0*
of «»|i)iliiitik ififtwuixA, Ni wliiisb tlw qmiI iViit|icoiiM %* > ^oocti, ^* w Idt fO»
verf Mttt))l« nftiCN|iliAf3fii^ fl« then liegui to Ii»t« ai;H ^rsrteriavl a* IA«
WlMiwva- th» iktn«e, wti^k ^vimf him m bulh. «ttrm[»ti^ i^i cIcaiuk bffa MM.ai^' I
f%falj dtmw lilniMilf back pamotiinBS nlimMt Ui tlM |iM»iUati <if c«pMb(jUitt9t bttk^i
■efoof Mill i^tiiillct »d4 tlitf n ft(W » ttw tfoooife the ftpavm woolil pmm aitsj vir^ ^
M«ni p^tfi^f well agmin. TbeiQ Bllidls ooo^suBd f'.>r ftotnv mciatbi vukwt a^
liumltig lilm, «tid tbcpy than gn^w !■* ftwqaaftt *mI jikm i J » wav i
tSfo olb«r GiMiv b wftikili t^ $m^ w«« iiniifer lo ih^^' . , T bin ptV^ I
ioiib«d,wmiiffii&at»f]ilUrMecnil j«r. In I1im# gmis tl
CO %j ftftcfitfiivgt vnd wiMti Utv diOdnpfi ii«ni» ihwArtcd tu u ,
tloL 1& iddiijHti iff thr •Tinptoini w^kli t tmve joAt dMcsibr^,
iB&m ft cffviwi&g Ufyngod inaiid Juvt a« tbo ftttaek ims taking l^. . _
limit ftfW it ^ftd ccftirtd.
A« mlditioBAl exampW iif rdlax pbamineiia of the krmi: Imnfi^ I
ot%tu in the car may W tiietilio»ed the hfjannins^ which
paniea the impat^-tioD of m^uneti in the mnK, and which
imtiiedbMy alVr the removal of the ms!u», PmtismoT Blake Rp«n^
where a pe»is4ent lan-ngml ciwi*^ of aevenil nionilm* duratk^ts wm naK
aldj Ftlieved by the removal of a bold from the extemal andtoi; f^^
Ttmmm^m^ m$ well a^ ooe uf i^ex ooiigh (Oaae 308) wlueh I «1m11 ptf^
repiwrt to yofi, can be expbuned by roean^ of thi^ diagtam (Drnprn ^
po^^ 74ft), which shows tbe rAtx nitmsc&m botwt«-m tl^r <mr and tk k^
The irritation of the nxittve abfw af ^i^ auriinilo-pooiiaiof^tt*
distrihutixi in the mmtm and to th« taemhfana tviniNuii m n««3lBl M
the tuocor abrea of the mi{icrior UryiigvttI Mrr^ ttcat»g hi the I111711 ^ I
»cl«
pftl
FUNC?nONAL NEKVOU8 DISEA9£a
749
t coughing by causing oootraction of the crioo-thjToid muscle. Where
iriginal irritaut, either in the meatus or in the membrana tyrapani, by
pntinued presencx? iuvolvei5 the vaso^motor fibres aseo<natecl with the
nlar nerve, they conduct their impression to the ganglion of the pneu-
DtAOaAM u
membmna tyropanl, «nd
tic ; D, iiurieuli>pfu'umj>
I oirrillO : G, cxtcrtLol carotid ; K, l&ryugeal artery ; 8, superior Uryiig«ftl oenro ; L, lafynz.
iBtrie, and thenoe it is deflected through a sym|jathetic faaeieulus pro-
^ from it to the first cenaoal gaugliou. This again thn)ugh the nervi
m carriers the imprt^sino to the external ran>ticl artery, and by its
pes to the niueims monihrane of the lar\' nx, and a^ a result of reflected
pilator impi^eaHions we may have congestion of the vessels supplying
pucous membrane of the larynx, and j>erhaps effusion from these
e detailed description and an illustrative diagram (Diagram 10) of
batomieal conditions underlying tliese reflex phenomena will be found
later lecture (page 795),
^AAOXTSMAL GASPINQ.— TbU boy {Cnae 865), eight jean old, hA^ alwayi
lelicate^ and has evidently been ill fed and ill carvd for Ht^ is pale and thin, i« of a
in tempi^niment, and ha^ been overworked at achooL Physical examination ahowt
^ abnormal in either his thorax or hie abdomen.
^e attacks from whicli he now suffer? have ocrnrrtMl for the past monlb, and are
Ig shorter in their intervals and more severe in their chamoter. The child, fmm beini^
lite of perfect quiet, .suddenly becomes cyanotic^ rolja hU eyes up, stofM br«athin^,
[And looki Bfi though he were about to die. Tbe attack lasts about half a minute,
p is then apparently a« well m ever Since he was brou|;ht to tbe clinic the intervals
been about fifteen minutes. The seizure is apparently a reflex irritation of the
Crm^ and could be clasifd under hyitena. Tbeae cases respond quite readily to good
Il-reifulftted food, and relief from the duties ot school.
; boy (Ca^e 366), twelve yearv old, with the following history was brought to me for
I waa of a nervous iemperfttnent. He was studioui, and did not care lo play with
boys, preferring to remain in the house and read. 11 i^ appetite was pretty good;
( pale and rather aptthetio. An examination of the thorax and abdomen revealed
i; abnormal.
w(H^k# previous tony taelnf^ him be bei^an while sittfnit quirtly In school to have
attaclu of gasping which he could not control. Th«M« attucka w«r» <if a mucib
T.V^
PEDIATRICS.
!:.i .1.' u'-i.l-- ilian in lh«' rai*«' which 1 hav«« just >h«>wn y<»u, but wt-n* •iir.:« ■■.- ••
Ti,. \ .ii'l 't>'i .Mi-ur \vh«i» h«' ua> phivini; out of doors <*r i'Xercisinir, mi'l h-iii::
»'. :..i iP-iii palpitaliMM or »ly.-jnm»a.
r:-.:i!iii«ni witli v:ir,.iU' ilniix!*, >u«'li Uf arsenic, nux vomica, :ir;d iror.. ..: - .
t'. :•- -.t tinii- aii'i -••paraii-ly, ha«l ii«» t*rt«vt upon the parox\>Tii>. Tukini: ih- • .
-. !p''1. ]*•.' \. iiti!i.r Imii IVmiii >tiiilyiuir or rfadiii:^ much, unci nmkin*; him i:»t v :
-in:. I Mii'l ri.l.- a M.-m!-. l«--f!u'd thi- attack.-^ iti a few months, and h« i^ v \>p- . •
liU 111 • •.■:!jI n»"iitli'
REFLEX OF THE LUNG. — In young infants {mlm.u:ar;. . ;
rio-ily -iiiiiil:itinir the svinptoms of asthma oc*eur from iraistric irriu:
tin- terminal lil:miciit> nf tlu» imeuniojr-istric ni»rve. Thov an t'.ii
n tl« \ ill tli«ir character, ami aiv promptly rolievt^rl l>v tR-atimi'.* •
-tohiMrli. They are <p<»ken of* umler tlif torm asthma il\>|K|.tirii::i
ea^- lit thi^ kiinl it is usually foiuul that the peripheral irriiat!-.:: -::.
ari-e-i t'nmi the U», hii:h |HT(viitao:c's of tin* solid cim.stituoms <•:' tlr •.:
which i-^ •riven to the iiilaiit, nr is e-aiiscHl by tlio total amount of mii-.:.
luini: too ^^cat lor the infant V gastric* <»a])a<'itv.
The lirst -ymptnni- iioticinl in th(»s<> cases are the pallor of !!i»- iii-
larr. aiul a -li-ht eyan«Ki> aroinnl the mouth. The respiration> ni.r.lv
.jniekeiHHl, aiul the infant is evidently in jrroat distress. It l>Hv.m«.> .vi'.
luvatlu- very rapidly, and often liM)ks as though it were aUmt t^Mli.
exainininir tin* ehe-t tin* Innir is found to lx» res<inant, and tlieiv i- r. •
iilmoiiual on auscnltatiini exn'pt i-ougheniHl rt^spinition and a f«'\v - :■
An emetic will (jiiickly reli«*ve this i-oudition, whieh di^aniHar^ :>-«
tlir Moniaeji i^ .iiii.tieil. The attaek> are siiddiMi and often nnir. A
Mttark ha- pa-^Md otV, the ahnonnal soumls heard in the hini: ar '
in\.- .li-ap|»r:ind cnin|»letely, and th<» infant scvnis j>erftvtly \\A[:j.-
\n..ther ela-- of ivllex pulmonary syni]>tonis whieh ha> at tin>-'
■r my iioti.v eon-.i-.i^ of casi's in which from sinne jHTiplunjIiH::.:
I wh. IV markrd pulmonary symptoms simnlating pneumonia ari-^
T-. :-.ri.- fi : T:, .. ::.;:*. MX y.'uix nl.l, is an int«Testinic ca*o of th:^ k:rA T "
• •■ '•'■•■' •'• ■' •' '*^^"" -l'" was Imvin.ir an oxaccrbiitiun of an titta.'^ ■:*--.
■•.:••- .:...! i T-.:- li:.|.|Hn.-.l ,.ii.. war ai::o. and >ho i^ lin.uirht t.> tb- ..• iv- •-
• •. ■•. •.i:'-. :i- . '•• -". r>. iiHa.lv ..f ih.' sani.- kind, so that 1 >hall pr-btViv : ..
. •:■•• .;■ :■• .'. .. ! .•■::.•
\ • ■ •'■• !'■• • . :•:. K. .]... h.i^ M h.'iirhtfiK-d tciripi-raturo. 40= C. (104=» F.".:.:-'
■ •• ■• - •■•'••" • '•■'■■''- '•"'"• =•'=" ^'••'^' ^^^' «»-vinjr ^Hsrhtlv, and sh..- -li-A- •
. . r ; .... . II. • !;..-... a. ynu mm-, i. Hn>hed, and >hi* ha* a <h..rt, drv. ;.
..... ;.■. , = . ! ..i. .ai- On lookin- at this t-hild vou wnil li.-.::
.: ;. •. ..• . . '■••'^•■'■■^•••''»'tl>»>i> i^'ivcn hy thc^ t..mpVnituri.. il..-^'.:"--
J. . • . .i t... ..■•l,..pn...a. On exaunninfi: the hinir>. h-Mt. a...:
••• ■■•. • ■ •■! Ti.. l..;!.u..na^y>y1npt(,msun»vvidontlvn^l^.xi!l:il.•^■•
. •,,... . .... - ti... svihx ^vi^plonls an? usually priilucHi J.yti
' • ..: .Mil .1..::: U... Ku^tachian tubes with tho air^:mrh-. Y :
.. .:•. - :c r i hav uillafd the Eustachian tubi^ her U^^^. -
: :; I • . ■> u: a unmit... i\w ahc- n,isi have co.i.<ed to in.-.r., ;-. :
•'•"•* •■'^•'•■■'^•'■•^- "•■ ■'^•■•''^'' -■.wl....lnwnwitheoTnfV,rt. The icmpenilu:v *::
to
iin<
laryn:?
ntiti-
nlitv
war. t
A
'■y : 4 1 1
ui-.-r- t
' r ". :it;
rl... . ■•
::i.}
V' '
i:. :
tl*
\
IH1-
UI
,.!,
ii r
(M'
i-i
M
lu;
to
1,1
hnej.
V^
uir
-1
tV.V
1
ti
ili:
\v
1..-
:i
hi;
riirr
r Ml'-
fmtme time
' care m coDJunction with Professor C, J- Blake.
kle girl (Case 868), four jem old, bad ad attack of meafllos wbicb was complicated
||i» tncidm. She roooyered entirely fh>m the meaalee, and seemed perfei^tly Wf 11,
bt the perfotntion of the membrana tympani had not entirely healed. Stnut'what
p>ugh began. Nothing w»f found to account fur tbU ^ytiiptum in thif tbmat, tnn^i
if except a slightly reddened appearance of the latter from euuj^^hiiig The cough
letable to all local treutment until Ihc ear^ which had been in the pfooeii of boal*
ll showed signa of inert^Jt^ed inflammation, Wlienevpr the ear w»« duchai^ag,
Boeafled entirely. When Dt, Blake treated the ear and the discharge grew le«»,
I began again^ and therv wa8 an evident reflex connection between the lurynx and
p reflex phenomena enntinu**d for some months^ the child alwap coughing when
Di better and ceasing to c^mgh when the ear got wor»e* Finally, on the cliild'»
|«i to Switzerland and having an entire change of air^ it« general health wns much
i and the reflex cough parsed off. There baa been no recurrence of tbi« condition
flowing tea yean*
n there is an irritation io the na^o-pharjTix a reflex cough often
and h best ti*eated bv hmsi] applieatioas to the pharynx and uaso-
k. It is important Ibr the physician to reerjgnizc this *.'lass of
las he might otherwise be very uusui^t^sCul in Inciting thest* cases,
liildren are treated with dmgs for a ooiigh which Is uisually ascribed
bhitis, where no physiml sigas of irritation ejin be found in the
(rynx, or throat, antl where tlie irritiitiuu Ls in the* no?ie or the nas<>
k. In plac^* of the many drugs u«^ually given in tlie^' i ase.s, a ^simple
I the nost* in indieat^'tK
P*LEX OF THE HEART*— I ooca;sionalIy meet with cases of ex-
Mdpitation in children where nothing organic can be detectetl, and
ID (^use, such as tea-drinking^ is dis<f »verable. The eliildren are of
f neurotic tem^>emmcnt, and are usually mueJi influenced by exciting
4ings in tlieir homes*
ttltHlmtioD of thit clas« of caMa I will »how you thia boy (Case Hm)^ ten years
y •abject to flt« of groat cxcitpracnt br*iui;ht on by the roofit trivial causoft, aurh at
^ to go to »cboi>l c>r t«i take a jtiurneyr For ftorne \vuut% before the prt^per time for
jomei he h apt to grow more and mon? agitnted, thinking thai it miwt l»e time to
il will then often Ite «eizeil with violent palpitation lasting for several hmir^ and
Im to lie perfectly still i>n hi^ back. At iheee tifn<*« hi* *km will be c<x>l and pale,
pllfte wciik and irrcirular- Nothing abnormal haa ever Inwn detected on an oiaa)-
f the heart or any other orjfan.
^uont hi£t<»ry.) The attacks in thb caae lailml until h« wui twelve y«ar* old, and
ir occurred ninee.
atliMtioiis of the stomach. I shall therefore merely refer tc
iiistaiui»s of reflex functional disturbance.
REFLEX OF THE BLADDER. — Reflex spasm of the
vtTv IriHiuontly in young children. I shall consider it und<
iiicontineiKv of urine when speaking of diseases of the bladd
REFLEX OF THE VAGINA. — There is almost alway
to Ik* found for the reflex nervous symptoms which arise ftc
tatioii. One of the most common causes is the ascaris vem
at tiiiKs ^ivi»s rise t*) extreme and severe symptoms when
Irom the riHtum. In addition to the local irritation^ which
^reat uiieiisin(»ss, so that it cannot sit still and is continually
alH»ut, its t<Mni)erament may be much aflected. A child w
is apt to Ih» very fretful, to have violent outbursts of tem;
apjK'titr, and to jrniw thin. A case of this kind has lately
notict'.
A little i^irl (Caso 370), five years old, had the most extreme vaginal
I s.iw ixT >^\\r bad Ihhm) atlectt'd for several months and was in a Tery we
tiiiM- the irritation s«?eiiiod to bi^ more than she could bear, so that she wo
of h«Tst'it', would throw herself on the floor, and would have violent spas
of tin- I«*t:>. ll«r sleep was much interfered with, and her whole appear
child sutr«'riiJir from some serious disease. An examination showed th
niicularis was the oau<io of the vaginal irritation, and after a few days' tw
«x|M'llinir this parasite the child ceased to have any irritation and subs
♦ •ritiri'iv.
REFLEX OF THE RECTUM. — In certain cases refle
a most (•xatr.ir*'nit<Ml ty|K» art* localized in the rectum. An
plicnoincnon is this little girl, who, you will remember was
clinic several \ve<'ks ajro.
FUNCTIONAL NERVOUS DISEASES. '763
ith boogies, the size gradually being increased. This has been followed by marked
fpgovemenif and her mother reports to-day that the trouble has passed away.
(Subsequent history.) The rectal spasm did not return in this case, but the child began
* hATe incontinence of urine, finom which she is still suffering two years later.
f Another case which came under my care and which was a form of reflex connected
Ith the anus was a little girl (Case 872), eight years old.
This child for a whole year was affected by intense irritation in the region of the anus,
hloh prevented her from sitting down for any length of time and kept her in a continual
ito of irritability. Nothing could be detected during this period which caused these
inptomB. No trace of intestinal parasites could be found, and nothing abnormal, either
i tlie anal oriflce or in connection with the bowels, was seen, the skin around the anus
ing in a perfectly normal condition.
^e child was treated with bromide of potassium for several weeks, and recovered
itbely.
What I have said oonoerning the reflex phenomena of mfancy and early
bfldhood must not be supposed to be a complete enumeration of these
flfectioiis. Thus, various involuntary movements of the head in infants
mietimes ooeur, such as spasmus nutans (antero-posterior movements) and
ffrospamn (rotary movements).
48
7r>4
PEDIATRICS.
L K c T ij HE x: :x: -n; V 1 1 1.
CONVULSIONS.— TREMOR.
CONVULSIONS. — Attarks of niot4»r disturlnuuv nprt^ix
t'luii.ii- rijiility «»r fontraiti<»ii.s «»f uiie or inort* trnmp?? ••{* ini-.v- .
i.r :i variaMf tim*- and a<*«'<»inj»anu'<l !ir?nally l»y uiK-«»UHi«'i>:i--. * •
ii:it.«l • ••ii\ ijI-Imii^. TIh- t«nn <i»iivii1mi>ii i> applirnl t« ► a jvmj.t. :. ^
< ."ix ':l-i ti- may In- «livitLil, :l< !•> tlu-ir tyjM% int«» =1
/. '• ; :i- !•• tii'ir l«»rin, into 1) *j' n*rnl ami (2) jut 'fi*il ; a:;0.:** *.
\A iir.:;it! -n \\lii<li «a'i-»- tlitiii. into (1) *'*:ittrnJ aiKl \'2) ^Mriyl" •' .
T!,,- .•' ./'.• ri.nv'il-'i.Mi i-* an a«-tiv«' spasiiKMlh* I'uutnirti"!! '.i :. '
!i.!l..Ai.l i.y i!ii:nt<li:it«* rila\ali«»n. The omviiNioiis of i.-jiilvj»-y ir :.
'\'\v * . ■''• .-..iix '.il-i'Mi i- a nion* or !«»>< c*«»iitiii!ifd >j»a*ni •«ii' rL •
t:.- !:;■.-•!•-. Ti.i- tyjM* i- -••» n in tetanus iKTHiatomm.
T:.. •• iiv .l-JN. ni'«v«ni« nt-* may atfrct th<* ontiiv Im».1v u:-..
• ! .'liiij !•• :'■['■'•, "V i'ip y nay alUrt only cn-itaiii trroii{>> "f ni> . -■
t .• . 1'..:. !»• i ■ .lil/'tl. a- ••!' t»nf linih. Thoy luay Ix' unilat* :-.! v
I'.' - .i! ••: i:r!tat:«»n wlilrli |)nHlu<H*> the f<»iivuNi»'!» ;* vm-
T •-. "t i:i;iy I" a I'-i^n '•(' tlu" it-ntral n«TV«»u> >vsU-m mf «»i' :;:•. >'
I.' ' \ -: •:; T'.. ;-!i'i. r •:!-«• tlu- o.nviiUi. »n«i an* <jHiken •»!' ii- • *
i ••• V . •• *• ' '1 ••''•••. < "..nvn!-i«iii- art- mii».*h ni'-r- •::'
•'•• ■ ' •• !• -i.iM:: 1 an.l in ailult lift-, |.r"'-:;- ".;■ ■
: :' ■; ■•• •. * -i >: .!■ \' !'}m-i1 in tin* f«»riiii-r. N««i «•'/••»■. t^.
. • w .-:\' ;:tt;i- ix- iiiMi\- t'n-ijUfiitly tilt' voiin-« r rLf ...
i .'. • •. • : •• •'.lt..!.M.k n|.Mn tIh-m- ••«»iivul<iv.. atta-k* :> "
- • • • :' ■ • "M- r -mI.J. .-t. Tin- ivason for thi- i- t: :;' *
. * ^ ■■: ir.rhii.y an inunin«ralil«-, :ui«l. a- a n.!« . :.
- • - - . :•: ..'..I- V «!.iMriii ami in a^lults o.nviil-: •.- ..:
■ • -■••.' - ri-n- «•• ntral lt-<i.iu. (\.nvr.!-: v.-
• • ' y -''i^'' ^**"« " '"••tnjnin.^l to tlu'tl.iii v..
- . > 11- a-- ari-inir in adults. It i- a • . : '
- — '!.;..:i:!-.«l I.y hiirh tfmiH.»nuim\ muL a* :•
•: \-vy .•Mmm..nly pn*«txlcil bv a '-"rv .N:
. : • - '-»n.lition> in infancy. \\% iirx. .
y ami «-«.iiii»arativc-ly N^niim <!iara>r
. • .. rilf that they an- not fatal. Tii--
^ ' * .i'>t a-i strious ci^nditions a- th»^y u- '
- . < iip»n them a> a ^rave ^iymp^>ra unt:
_ - > ..rpmir lfsiou.s ast a cause, that woa^ :
Nvitlv *
rt'ii 1 * '^
rv-!i "i
iivif 1
It i.—
iluy -
viil^
In U -
lor i
wyw:
"iiiri* ■
li.U ^
liu- 1
tn\«"t
it i-
roll'
Nva\
f« •!•
tw
oi*
<'l.-
d.*
COXVULSION8,
755
th one of the common and mild forms of this phenomenon. We must
mejiiber that tJie convukiou does not in itself show us whether it is the
nilt of 8oriijii8 or of benign disease. The tonvulsions which occur fmra
dje organic le^it^n, such as cerebro-spinal meningitis, maydifter in no way
m\ those which arise from some simple cause, such as indigestible food,
is therefort* well U) »\yeak of convulsions apart from the diseases in which
iy occur, and which I have already described.
We are frequently called to see an infant in convulsions where the con-
laion is the tii^st and only inaiilftstation of the disease which is presented
lis. The infant after a few signs of uneasiness suddenly l*ec«jrao5 rigid
r a second or two, makt*s a srund as though choking, the eyes turn
ward and become fixed, there may be strabismus, the akin l)ec«>mc8
oaewhat cyanotic, and then the convulsive movements begin. The eye-
\b opu and shut; the face and usually the head ai'e drawn to one side;
fingers are clinched ; the arms move up and down, as do also the legs.
le batk may nt times be somewhat arch<»d and the head somewhat re-
iu*ted. The infant is apt to foam at the mouth to a greater or less extent ;
i {>erfectly unconscious, and the breathing soon becomes stertorous,
lose symptoms after lasting for tw^o or thn*e minut*^ are followed by
mplete relaxation, an appart^nt state of ajma,, and sleep. The child on
iking may be bright and well, or the convulsion may recur and continue
a much longer time, as in one of my an^^^ where an infant had fifty-
^o convulsions in twenty-four hours. There may be involuntary dist^harges
arinc and of lieo^.
I have had an infant brought to show yon to-day who illustrates very
early the fact that numerous convulsions do not necessarily lead to a fatal
me.
This infttfit (Ctae 878), eii month* old, is weU developed, heftlthy, menUlly bright,
id ha9 not bad Any convulflioaa since it wai a month old. Dunng the first two week* of
1lf«) it had LHinvulsions ftlmoet cnntlnuoualT.
Thia table (Tttblc lOu) i,'iveR the houre and Intervaltof the conYulfiions from 9 A.M. one
(jr till 9 A. K. the next day. The attacks, a« a rule, lasted oolj a few minatea.
TABLE 106.
(FOTty-one oonvuUiont in twentjr-fcmr houns,)
THme of Omvulaiontt,
0 A*M,
12 Midnight
2 42 AM.
6.22
11.85 "
12.85 AM,
8.1R »*
6.32
8.10 p.ic.
12.40 **
8.26 *^
7.10
SfiO *•
12.50 »*
8.43 ^*
7.40
4 *'
1 Noon.
4.40 »«
762
4 07 **
1.26 r.u.
6.08 »♦
8,07
428 M
2
5.20 "
an
4,40 •*
2.12 •*
6.80 ••
8.26
6.65 "
2.26 »
6.4« "
a 86
6.18 *♦
2.88 "
6.66 "
0.02
11.60 '*
pnKliH'injT the (lis4'a'^\ Tht»se cx>nvulsion8, as a nile,
ppHlui'*'*! l)y i\\v (litVuse ac*tion of the poison. In thi
prnhablt' that then' is an extremely hypersemic cone
vcss4ls of thr c<^ntral ncn-oiis system. The eonvulsio
tra(li-tiiuti«»ii to tlu* supjMwiHl ar-tive hyi^ere&mia of the 1
hi^rh tein|M'nitiin\ U» imKhu-ed by vascular stasis and a]
t4iu|KTatun'. Tills form of c*on\^ilsions may occur in tl
nr of canliac <Hs<'ibii\ Apiin, convulsions are supposed
aiurniic (Hmdition of the bliHKl-vivssels of the brain, su<
lt»ss of !)1(mk1 or fn)m (exhausting diarrhcBa. Such toxi<
S4iit«il hy (Iriip^ of various kinds, as belladonna, may pi
ciiiivnlsions. Mental disturbance, such as sudden fi
known to pHKbico a convulsive attack. In all these
(Hmvul>ions may \h^ partial and clonic instead of genera
owini: t<» the diiVusi' eharacter of the irritation, that tl
addition to th<'se i-onvulsions which arise from a diff
wht'H', a hnal lesion havinj^ occurred in the brain, fn
<«MdH)lisni, thronil)osis, henu)rrhaj];e, or any other cau?
(»f a |)ortion of the hrain has been produced. As 1
a nilr, focal in th<*ir distribution, we are apt to have 1<
a- I have ah-cady explaint'd t<) you in speaking of ooe
panilysi-, with their resulting hemiplegia.
A nunilMT of other tlisea^t^s can also, by their direc
«»f tlic t« in|K'ratnre which accompanies them, produce
mnviilsinns occur not uncommonly in the course of nep
they an' usually called unemie, also in malaria and otfc
\m — mc t'roiii tumors oi' the brain or from hydrocei
OOKVUtfilONS.
757
dLst^He whicli mmt i^mimonly gives rise to oonvulsioiia of the reflex
fi is rhatliitis. Rhaihitic children seem to be predispoaed to spasmodic
^ks of all kinds, aad a general clonic convulsion in children with rha-
corresjxjnds to the spagmodic contractions in the larynx which oci^ur in
litis, and which I have already »poken of m laryn^ospasmus.
It h probable that there is no a§[>ecial lesion in ct)iincction with the
^t^hitis which necessarily gives rise to ctinvulsions, hut that all the ti^ssuea
A^^L* di^ea^si! a!x* csjjcciully sensitive to cinisi's whicli may pn:»dnce reflex
iolonionri. The most common cause of k (hx r<invnlsioDs in in fan t** is
rojM»r food. Convulsions from thi> ruiiM arise not only where mani-
»tly indigestible articles are given to yoiiog children, but even io inianta
l^lfio are being fed from the brt*ast» In the early days and weeks of lile,
hre the breast haj^ acquired its normal fonctions connected with elabo-
rating a milk in which the solids are in pnij>er pp«iMirtion to each other and
^ the water, it is not uncomnioo fiir tlxe infant to have convulsions pnKhieed
^f a disturbance of the mammary function. In eases of this kind it la
^^ually found that the jx^rcentage of the proteid^ is high, and that the con-
ukions will cuntinue until this high |)erctnitage has been Ic^semd, if the
r jfant is allowed to continue to nurse. Whetiier the teeth of tliemMclves
uring their development are a source of sufficient irritation to produce
T" onvidsions has been questioned bv manv observers. It is, however, evident
h" hat during the diftert^nt jieriodsof dentition reflex convnlsions are more apt
a occur than when a tooth is not disturbing the infantas nen'ous system,
'n addition to the convulsions arising from impn>jjer IikmI in the stomach
luring the dental jjcritxl, foreign bxlies in the intestine, whether in the
*dhape of food or in that of intestinal parasites, may t^uae reflex convulsions,
^Foreign IxKlien in the nose autl in the ear hav^e V)een known to produce
^eonvulsions, as also has an iuflamid tonsil in tlic initial stage of a follicular
**toDsillitis. Hot baths are s«i often given to infants when they are in con-
vukions tliat they should be spiken of a:* a source of convnlsions, for
they have bt^m kno^n to pnxluc*e this result when care has not been taken
test the tem|)erature of the bath lM?fore tlie infant is put into it
* PfitXJNOiBis. — The progDoeid of infantile conv'iilsions must, as you will
readily understand, var\' much in connection with tlie es{)eeial cause. On
tvering from the attack the infant may show signs of some gerioUB
central lesion, such as paralysis, or may be left apjiarently perfectly well.
A single convulsion followwl by j)erfe«*t re<N>very is of slight tYmscfjuenee,
but where the cvinvulsive attiicks re^'ur impiently and last livnirfT than in
the attacks which I have just men tinned^ the progun-i- U* .nn-^ graver.
Even thfjugh no central legion bt» prt*sent, eontinuixl nmvulsions may
by the shock to the infantas vitality tinally vauae death from exhaui^tion,
or deatli may occur from spasm of the glottk. We must, therefore, no
matter what the cause or what the apparent result of a convulsion may
U\ always look upon it as a grave bymptom and endeavor to prevent itB
reiuirrenoe.
758
PEDIATRICS.
Trkatmknt. — When you are summoned to treat an infant wh.i
<'«)nvulsinns, yoii should first see that the bath, in which you usuaiiv-j;:
that it \ii\s Uh'ii ininuTs?ed, is not too hot, and should order the in:k-
Im* taki'U out of the Iwth iK'fore it become* conscious, or it may liesiifc^-
rnc<l as to excite a^in the reflex 8])&i(m. You should quickly eiam'^.ir
th<»rax for pulmonary and canliac lesions, and should make inquiii- i* *h
thr history oi' the i-ast', t'Sjwially as to the infant's diet. The temi^nir:
Hh«)uM Ik» takru, aud you should notice whether the fontanelle t b::::,-
or drpH'SSiHl.
llavinjr ol)taine<l this information, you can eliminate quite a number :'
i-ans<'s for the attack, such as the onset of one of the exanthemata if rr
tciii|M'ratun' is uonnal, and Keflex convulsions from food or foreign bT&i:
th«* iiosc or in the car. You can soon determme whether the corviJr-fr
arise fi-oni exhaustion, so that you can proceed at once to order stlmnki'
if nee«*ssiiry, and, if the convulsions continue, to make use of the ww-
treatinent whicli is indicat<»d for all forms of convulsions.
You should Ik' pn*|)and t*) act promptly, and for this reason yousbiiL^
ac<juin* the knowKnl^' which will enable you readily to classify the it:^^
under its projKT head and thus treat it intelligently. The parent;> a>
t<'rritie<l when a i'onvulsion attacks an infant that it is necessary for "/
physician to Ik* al>le to inform them as soon as ix>ssible whether or n«'rj
i-onvulsion is injurious. In ortler to aid you in differentiating the vario
causes of convulsioufl from each other I have prepared this table (Ttti
km;).
TABLE 106.
Infantile Chnrulsions.
roriphoral (Reflex^.
Rhachitis.
Food.
Intestinal parasites.
I>ental irritation.
Foreign bodies in the car and n-w
Hot bath».
Mental disturbance, such a* frisbtt-^
numcroiu other caustrs.
(Vmnil.
I. DixM^.'- with liiL'h ii'injM'mlure.
I Iii-olati'Ti, in<Miiiii;itis, the cxan-
llntimlM. ptiruiiiiiniM, and others.)
II. l)i~i:i«i- jirr..iiip!iiii»Ml ])y vjisciihir >tJiHis.
I r< rHi<-i>^. cartlisK' ili>«'as«», tumors,
li\«lri«c.nli:ilU' )
III. l)i-:i«.- »li:ir:t(t«riz«'tl hv ana»mm and
• •\li:iil«ti"ll.
I L- .-- ..r 1.1. mkI, «liarrha»a. )
1 \' V:.r: .11- t -xi.- laii-i-'. -u«'h !us drugs,
Ml- uiM'iiiia
! Ii'liatl-'ima. ?ii'])]iritis.)
V. ():-■..■ i. .•.i.lral i*-i(.n.^.
< '. :■ :■: il paraly-i-. <»r any other lesion
:" ill" l.laih. I
V'l. !':■ - i:..:i''i\ .'iLranif «li>turl»anee of the
l.-::iM.
iKl.i;.,.y.)
Tlic tn'Mtiiunt of iiiiiintih' convulsions should be directed tothee^p-
of tlic mnviiUinn. In ireneral, however, as oflen when the amvut*:.
■; pre-cnt it i- iiiii)(»--il)le to determine whether it is of central or of ['^rc'C-
eaiiM
eral origin, it becomes necessarv to endeavor to control the attack at once*
For this purpose in all forms of convulsions the in halation of ether in Bmall
amoont8, and the emptying of the bowek by means of enemata^ an' indi-
cated. Wliere the convulsions are of a very severe tyj^e, ci^ntiuuing with
perhaps intermissions of only a few minutes, and the infant*s life is evid€»utly
in danger frt>m the contiuuoiLs shocks which are taking pla^i^e in its nervous
sjr'stem, a rcxi-tal injection of 0J> gramme (10 grains) of biT>niide of |x>tassium
and 0.3 graiunie (5 grains) of hydrate of chloral in tiO c.c. (1 omiec) of warm
water, repeated if neoessary every hour for tliree or four dos€8, is indicated.
If the convulsions still continue and a fatal Issue h anticipated, a aubcu-
taneous injection of sulphate of morphine, beginning with 0.001 (|^ grain),
should be tried.
In most cases of infantile convulsions, of whatever form» the warm bath
at a temperature of not over 37.7^ C, (100*^ F.) can be used, lor, althnugh it
is not in any sense curative, it tends to quiet the nervous excitabilit}^ and
to lessen the mnsc*ular strain prtxluced by the continuous sptismcwJir* musfHiIar
contractions* The class of cases in which this is contra-indicati*d art* tlujse
which are caused by a loss of blood, an aoa?mic conditioD, diarrhcEa* and
canJiat^ disease, and thrjse in which venous stalls exists with a lowered
tem|>craturc. In tliese eases stimulants are indicated*
In those castas whieli are? syraptomatic of the diseases which I have
already sjx>ken of as aecompauied by high temi>enituR% the application of
cold to the hi*ad and the administration of the bnxmidi^ are indicated.
Tlic treatment of convulsions caused by the other diseases which I have
enumeratcil Ls simply symptomatic while the convulsions continue, and later
the propter can* of these dis< :t-«^^. All the rc*flex con%ndsinns fi-om various
causes are treated in like niajiiiLr symptomatically aud by tlie removal of
the espet iai cause.
I have already shown you an infant (Case 342) in chmic convnkiona,
and dcs^TilM^i ta you the characteristics of the attack, while speaking of
epik(»sy (page 727),
I have here a few aises which may be of interest in this connection for
you to see.
TliU little jc^rl (Cfuie S74) is six und nn^-bulf yean old. Bh« wba benlthy At btrth» And
hm never had any diAeii£«. For the la^t three vcaw »hc ba« from time to time hud a cf»n-
vulftiofi, clonic in typ\ When in the oonvuUionn vlie do« not bite her tAnjjrue. The lint
cc»nvuUion ocrum*d when she wa« three yean old ; the next when «he vrws four yeus old ;
the next when she waa four and one-hAlf jearv old ; And the lAft one when fhei was ilv«
yean old.
Aft a1] the^ eonvuliions hAve AppArentlj been pftiduced by the eame catiaef ft will
only tx' THH'»MiP<ftry t<i de»*crn>H th**rn in a ifrnfml wav. They have bm>n ehftrAct^iAd bgr
«omeiim«-*t p*>nlitiuin^ much lon^T thAn is iuuaI in infAntile eonvulslonji, *»n»' of them
liAring lo^tr-d fur oni* hour And a hAlf, during; whirh time tbe hAnds wem clinched, the ejAA
wcffl n*)li'<l upi Hud ihe enlin* iKidy and limb« were convuljMxl Pr**vrr»uH to eioeh uttAck ihd
child fur A number of days ha« bad indefinite tymptoroj which ihe could not deterihe
AcmimtelyT conneotod with the oMomcn and aect*mpAntrHl by o feeling of weAkneM and
Alight mtiAculAr twitcbing.
l-.i::.^.-..-.
I li:»\i- lit-if an inrant ((':i>h 375), thirtt»»'ii in«»ntb« ••M, wh-i-...- n-rv >.
•liu.iv- !•■ II ii; -• iniiali]'- a fiuilitioii thai th«' >lii;ht«.-t eaUrt.' wu* «ui}i'>:.: :
c- ',\ ul-l"::.
\\ ii- ii h.' \va- t ii^ht inMiith> «'M In* had an atUick «»f |X'rtus«ii>, and »lur uj 'i
th« .ii-:i'.- Im.' li.i'l a ninii]»-r "t* I'Miivul-i.iiis. At one tiiii*.- wiu-ii rhf j-rui-S
l.'!^;.t li>- li:..l tr .III ii!"t«»-!i i.i -i.\t<'i'ii (.■•>nvuUi<>ns within tliirty -^ix h"U>. 'i-
l.t-:;:.-- tV'M:. !r. •• !■' !«'li iiiilsUf*.
Wli-i. ill. !ir-t t««'th lM-i:aii t'lpn*** ui>»n th«» 'junis bo •n,*ca."ri«»iially hu-.l •»•
I;. MiMiii.': I" t!i«- i:«'Ii»tm1 iiiu^iular spasms h»' liad nystiigiiui^ «•!' thv r.;:'.:
til- la-! I'A' ■■:• tl.r»«' in"iitli> !»•• lia* had iu» c«.»iivuNion<. uiid the iiv?;at:i:i-:- •
n.:-..-.-:.».n..
Till- t..'\ ('a'f :>7'l'. T'lir \»-ar* •■M, ha.«f IrMiii tiiiio to time hud oaiv.r.- :.■
: i: :i- I • .1!: :i-« ■ rT:ii':. ap- -iiiiplv n.'lhx. and an* Hot cNiiin»-ct«il witli ^'}»i.-i«-'
\\ !i' :. h'- ua- -i\ ni.-!.th- "'Id h«.' had u number €»f convul-ion.- wiiiiv
;. , ,...v> \Vi., !i !..- u-.i. t\v.« vfars -ild h" had an attack **f t-pidfinic inf/^'i.-.:-..
<;-'•• •"••i .ii !\ a .' .i.v'.r.-l-'n : and th** *ann» pht»n«.>men'>n «K*C"urr»:-d when h-.' Lu
.■!' i:i!:i!!!.i; Iirv:.i:iti- -ini«- ni«»nth* lati-r.
'i -.i- !'.?;.'• 'jL\v\ 'X':i>i' :»77i. t'.-ur wais old, is. as: ytui !4»-e, a bright child. jtr.'J
■j: i i.'.ii-:.. m.. i- appar-nily r»«;..\MTini: fn»ni coiivuNive attacks whi.-l. ••
l:- it :■• ,'.• :. ;. i:. li-:* -«-..:.d and ihinl yi-ars, and whifh Wew appannilly pr^:
! j.»\. A: • •:• !'.!:.' -1." had tit';\-l*»ur o«»nvulsinn?? in toriy-eii^bl houis.
M,- i. .- 1m . :: II-.:,!. d -imply by can-tiiily n-irulating her diet and w;ib
V-
Tj. j- .:!. -:- ,:. tl.i- va-v i- n.-t v.-ry lavoralde, as she is pn>bably an epi'.-i
.;.- - : •• :: .' • : • i-- mm at any linn.-. e>peoially a- puK»rty is appn'a.-h-d
T.'..- • \' ■ :. I I (":.-• :;7Si. a ixirl. Iniir yi-ar- uld, i- a ea»»e ..f o.»n*idrn»M-
• • • _ .;•. ::.-:..:.•. .-t' -iii.' -liirht nriranlc le.fion <>ceurririsr wh^m -be ->*
:...: .- !:. :i.. mp:!:.:. d l.> a .-..nviiUinn. The «M>iivuNi..ii wa.^ -f
!>; . . • ■! : r a :' u !: i:.n:.-, and \va- aooninpanitMi by a ttin|vnttu.-'
■ 1' : ' !■."'• ■•:' 14«». (h. r.f..v.rini: fnmi the convul>i...n rhf wu- :*•
- • 1 -:: ■•:':.■ i' :t -id.-, uhit-h la-tiHl tbr only a lew hours. Sh» ih-
• : •- ':••• l:«d u nvuM,.n... but .-he ha:* never devel^pe-i -kh
• -i '■ • • '-^i'h what \v..uld In- e.\]VH-t»*d in a child of b»T a:r
• ■ ■ • • : ':> '•■•■'•• !.ir-'- a- oan-fully as thouirh >be w.-re thi^.t^ y- ur
. . ' • ' .■ "H— fair- .-a-ilv.
CONVULSIONS,
761
fttue perfectly conecioiu, and did Dot have anj other severe fljmpiomji during btr attack
meaales, nor any return of the convul«iou».
Her case h an infitance of conTubions produced by a high temperature in the initial
e of one of the exanthemata.
The next three iDfants whom I have had brought here to show you
e intt^renting examplt?;? of the neoessity of regukting the solid constituents
! the niilk wbit*h h given to young infants.
The flfVJt ca«o (Ca»e 880) is thut of a little girl, four nioDth« old. Her motht'T^ who waa
sag and well and appwrontly had pk-nty of g(x>d breaat-milk, nuriKfd her ut birth. When
k waa three months old she began tu have convulsions, which occurrtnl iiliufM^t every hour*
Ipeoting that the proportion of *olidft in the breast-milk wau tc«> high for the infant to
^t them, and that they were producing a p^^ripheral irritation which waa the cau^e of
\ reflex eonvukiuu^, I hud un MnHlys^is nf the milk made, and found that (he pmteida
iwed a percentage of fhim 4 to 5. The Inlant wa« then fed with a carefblly modified
Ik in which the percentage «»f the pn>teid6 was made 1, Within a few hour* ihu cx»ii-
liioiia ceaBed, and they have never returned, Ae you see, the infant is perfectly well and
Aving to-day.
f I liave in inntances of this kind 8o re^iilate<i the jiercentage of proteids
I tlie mother's milk by the means whieli I have described to you in a pre*
Otis lecture (Lecture VI L, paj^ 188) that an infant who before this
odification of the mother's milk had been made was having continued
nvulsions ceased entirely to have them, and w^as nursed Huct-iessi'ully for
any muutlis*
Thifl next infant (Case 881), a little gtrl, six weeka old, began to have oonvuUloni when
iWBfl four weeke old. The convulsions *>ccurred every twenty minutej* for twenty-l^jur
lin, and loraetimes as oflen u& every fifteen minutea. They luijted for only a few seconda.
M infant waa being fed on the uulk of a Jen^y oow* She wa« then fed on a earefliily
Nlifled milk with a moderate percentage of fiit and proteida, and the convuUiona did not
The thin) case (Case 882) is a boy, tix weeks old. Be waa healthy and strong at birth,
4 was nulled by hk mother for three weeks. During thi* time he gained in weight and
pested the milk perfectly. The mother, however, waa unable to continue nursing him
> the third weekt and it was decided to feed the infant on modified milk. The pn^ascrip-
fofT thia modified milk ecnt to the laboratory by a physician was as follows:
PBlSCBtPTtOlt 72.
Fat. , .
Sugar . ,
Proteida .
6.60
7.00
8.60
Soon after this milk was «^iven to th^ infnnt it b*>cran t^- hnvt? convuhiona, wbSdi
Itinued for twenty-four lioure, Ht interval of twu or thn-e hours, until th** milk waa
dtled. Another modification of the milk wa^ then 8ub«tituted for the ftrvt, and th»« infant
d to have cc^nvulaions and haA since digested the milk perfectly. The percentage in
b last prescription were as follows :
PftxacaiFTioH 78.
Sogar. .
Protddt,
8.60
fl.60
1.60
THE MYOPATHIfiB,
763
LECTURE XXXIX.
THE MYOPATHIES.
aewRKSfiiTK MrscuLAB Ateopht.— Pskudo-Hypkrtrophic Mu8€irLAJi Paraltsus.-*
Mtotonia Cokoenita (Thomsen's DI£*KAKE),
PROGRESSIVE MUSCULiAR ATROPHY, — Progmisive miisciilar
atrophy is a name used to denote certain conditions which were originally
snppoBed Uy Ix* due to a disc^a^^e of the spinal cortl. Later, however, it was
ibiind that two tbrnis of lesions produce this atrophic condition of the
inits(*le8. One of these, the neiiropatliic form, is an affection of the spinal
cord, and m designated the Aran-Duchenne or thenar type* The other form
is foiiDd to be a prlaiar\- disc^^se of the nius<-les, and is classed as one of the
mj'opathies.
NEtTHOPATHic PROGRESSIVE MiL^cuLAR ATRopir\\ — The neuropathic
atr(»phies arc so rare in infancy and early childhood that little need Ije said
concerning them. The neuropathic progresisivc muscular atrophy is cantsed
by a chronic degeneration of the ganglion-oells of the anterior comna, and
this is the form whicli I have just alluded to as tlie Anin-Dnchenne ivfe^
Id this ibrm the atrophy almost always liegins in certain muscles of tlie
hand, especially those of the ball of the thumb, and it is for this reason
called tlienar. It is rarely setni b'fon^ the twentieth year, and is not heredi-
tary. Hy|>ertrophy of tlie muscles dtx^ not <iceur.
Myopathic Prcxjressive Muscltlar Atrophy. — ^The myoimthic
atrophies shi>w a marked hereditary tendency. They have been divided by
various authors aoci^^rding to tlie difterent |>ortions of the body in wliich tljey
begin. The disease in eacli ca.se is essentially the same, and this division
mems to be unnecessary and misleading^, becaase, although the affection
may begin in any part of the body or extreniiti<^, yet, as a rule, it may be
eaid that the priniary myopathies l>egin in tlie niU8<*les of Uie shoulder, face,
or back. In all these cases the atrf>phy usually begins before tlie twentieth
year.
Where the muscles of the face and scapulo-humeral gToops arc involved
early, it is called the fado-M^iptjJo'hnuwnd type of Landonzy and Dejerine.
Where the atrrvphy l>egTns in tlie gluteal niusf»les and thoee of the tlugh,
arm, and shoulder, it is ealM the jnrnnle ti^})f of Erb.
Where the atrophy first atfects the muscles of tht* h*gs, it is called the
p€TontfU ttfjie, &tn\ the affk-tion shows itst*lf in the {peripheral nias^^le^s of the
lower extrt^miti*^. such as the extensors of t!ie girat tm*, and afterwanls in the
common extensor of the ti>e and in the pcToneal group. There is, however,
regarding lliis latter type a doubt m to whether it is a primary rayojmtJiy.
THE MYOPATHIES,
785
all tJie^e forms the muscles react to both the faradic and the galvanic^
t, and there is no ruction of degeueratioiK
DIAGNOSIS, — The dia^iii>sis of myr>pathir progressive maseiilar atnjphy
first Im? made fn»m the neuropathir form. The former Is hereditarv;
is not. In the former the atrophy usually be^tnii in the nnu^cles
le shoulder, face, and back, while in the latter it Is exoeeiUngly rare for
begin eLst* where than in the muscles of the hand. Hy|XTtn>j)hy of
in musehs and the iM^ginning of the atrophy early in life, usually
the tenth year, are charaeteristic of the rayopathie variety^ in « in tra-
ction to the late deveh>pment and tlie absence of hy|M^rtrf)phy hi the
bpatliic form.
rhe muse ulsr atrophy which accompanies cjertain cases of chronic mnlti-
peuritiB may be mistaken for a myopathic atfection, and nuist therefore
(be difleiviitiatwl. At times the rc^^emblance of the two diseases is quite
king, but it does not last for a sufficiently long time to leave the diagnosis
inch doubt. You must rememlM*r that chronic multifile neuritis is never
jitary, that the paralysis which acx?ompanies it is out «»f pri>|Mjrtion to
Cask 8S8.
cnJ type of primm> i.:
IL After the dtett^
i^iuioed.
Itrophy, and that there may alBO be dLntinet symptoniB of ataxia, all of
symptoms are unusual in the primary myopathic atrojihy*
?R<XJN08is AND TREATMENT. — The pn>gnosis is very uutavorable, and
is no known treatment which Ijenefits tlie diseai^. The |mtient s^hould
under tbe mos^t favorable surroundiugH fiir Im general health*
766
PKDIATRIGB*
Prfcautjond should ftlway» be taken to prevent the oontracnirw vhii »|
Harily oLt5tir in the laU?r stages of the di^eaae from producbg ifMl
IMiHitlouB of Xiw UkIv aiid limbs*
The /fTCTo-^<vj/*«A>-A««w*ra/ type af primaiy myopathic atropfc^ § 1 1
exceedingly rare that I am iVjrtimate in haWog a cjise here to-divfc>i
yoiK It lias been carefidly attended in my wards by my coDe^Ii
bullard.
Cask 88a.
III.
Vi
Hie lkclc>«CApttlo-huxi]ena type of pn i
iiiuc Atnyphy. r iiiiialBnnn^ll
This litUe girt (CaBe 888)» ten yeare <^M, is uf healthy parentag:^. Than m to«i^
childn?!! in the fiixnUy^ who show no sigui of disoiLsc*. This child, alihuaeli dbi^M
vant»u<$ die^AK^^ such as vancellH^ measlc^f and pertussis, b^^ on the wMe hiffiwfiMi
flirting:, and until three years ago wa» unusually wfll developed. Heiv k a r^kiai* (1-f^
705) of her inkeu at that timef just before «he wiu attacked witli the ftijciyc fnrm ~^ ^
ii now sulfering.
Tou e«« that the face ii unusually tM and plump, and mt that tlia* llien wm nn^
no iign of mn^cuhir dtaturbance.
If you will now look at the child *f ftice aft *he stands tM>for« yon fU,^ p^;p{d
compare it« emaciated old lack with the younc^* welUnoumhed look ahown ta t^ P^
(L)« you will at once undentand that ahe 10 aUbctod hy a rlitraiic of mHoib iia»il
THE MYOPATHIES.
767
L
ago ftbe had an attack of epidemic influenza. Since then she has been
it and B trench. She haa complained of pnin in the al»domenj not IcxMliied,
|iuoii« for a few houFs, and then remitting for an hour or so. This diaturb-
^ two or three days, and during this time she does not care to do anything,
•itsually on her back. Sho i>ccaiionaHy vomits ; there ii nothing character-
I vomiting, but it relieves the pain of the acute attacks. She may have at
feLgea; she seldom ha£ headache; the bowels move regularly; she has no
gbt nasal catarrh Ls usually present, as she cat<.'he9 cold very easily. She
iSf and during thi? acut'> attacks of pain she i^ apt U) have attacks of pavor
;ie is very nervuua, and cries easily.
The ftirlrv^cafnilo-humcral ryin; of jwlmju^' myof:
iit^i|ihf.
Kng tht* child in front an An* niU nn u »VkA (IIL, page 766) you ««« that the
ly well diTvclopc$df in marked contnut to the atrophy of the Ikoe^ body» and
^iration ii!i frt'e t^tid *x|«hI on both sides. The faoo and neck are enremi*ly
piiiscles uff tttrtJphiod. The muscles uf the upper extremities and che*t hto
\ but firm anil *tf fair nth*ngth, whil<» those nf th« abdomen and legs nt^ well
Irm. Thc! *kin is dry, the eyi^ ^r** bright, and Ui* reaction of th»' pupils Is
bysical examination nothing else abnormal k found, with the exciTption that
7»;8
PEDIATRICS.
ji.. .1. 'i.:! .-r th«- li«:iri i^ niUnT myul. Thtn* is slitrht siiiklo-olonu:?. un I ::■!
l!. \. - :i:' -li^li!l\ iiupa-il. Tin- iihniiN ••!' thv n«.*c'k. Hxilhi*. uriii ijr i:> ir- • • .
« • i.ir-Liil. Tin* ii»iimi" i« !.»'niial aiul run Im' |>ri»truil«.-ii j-lemiily. Thi- ♦'\i:a.- . .
uii:." -ii'Vx- It !•• I"- ii'i-iual. witli th»" f\i'«-j>tion «»f li ^liijhl irac*.' of ul't-u::!.''
Tip- • M> "ili'T la-f ••!* thir <li«-«-aM' which has to my kii«>%\U-di:'.' r-'-K t [• " .
r..il' ?!\ I- ■•!..• I>\ < »-l«r.
i>i. . \:i:uiFiiiii; ih«' thiM"- ihum-Ii-* iiioi\« c'los«-l y y«»u will ?»?o i IILitliufii -• .
ati'i'-A i- -iiu:«:««i al"i\i' iln- «lia|»hrai;iii, whil».' ibe alHlonien and !• ■•:.'• a:- r^n.:-.
T':' !!.u-. I'- atr«»i«'.i an." ih«»M« wlii.-h I h:i\H- Hlrt'ady onum^rTiilvii ir. :ii:j'-:. .
li ••■ ..!" lh.- .h— a-.'
<»;. t'.iriii!:u th" fhiM -» ii^ to l«»«.k at Iut back (IV., pac:«* TOTi ai'.! k::j^.::' .
Uj . \'ii will imiin' lip- -trikiiii; ditlVn-ncc bclWft'ii lli*.» ariii9 una upjVrT [i-r. : .
a:..l ill'- l«-i:- antl l-.WT pari.
PSEUDO-HYPERTROPmC MUSCULAR PARALYSIS.-:
ti»rin tit" |iriinarv inu>i-iilar at n»|)liy which I shall iK'Xt s|Hrak -i i- "-
iall«'«l |»MMi<li»-liy|HTtro|»lii<' mns<*ular panilysi:?. This di.'?*.'a.'i4'i* ibri:-:
l>y a iliinimit'uui nt' power in (frtaiii iiiu.scl€»js, aee«>iupaiii<^l byai:: :■
inrna-r in tlnir -<i/f aiul a diiniiintion in the size of otlier irnmj**"! :;•
Ahlionuli an a|»par«*nt iiK'ivasc in the sizi» t»t' the iniiscks tak*-? i"lii>. •'
inlarLi«inrnt i^ |inMlniiil hy an hy|KTtn>phy of the ctiiimvtiw ti-"^!' '-
nim-ii.il <lr|io-.it ol* I'ai.
Tin- <li-»:i-r allirt- nmks more fi\H|iieiitly than femalf^. It •
• Mi-nr^ lHtN\«rii tin- a.:t'- of two and cijirht, iiltlioiio^h in ex<vpti«»ua? ii-*
it- a|»|Maranr<' i- <l»layMl nntil alMiut tlie twentieth vear.
I*.\ riiHi.oi.v. -Arronlinir to Gowers, tlie patli<ilo»rv \< rtpi>-* nt ■'
|ii:i:i:n\ iiit« r-iiiial c-liann** in thi* muscles, showinir a growth"'
li-.-;.- •.!• •»{' !.ii •rlU w hifh ppwhu-cs an increase in thr --i/" oi' t. ': *
rii- i:i!i- i:l:ii' iil»i« - an- >r<-on<larily atllftcd hv tliis iiitoivtitial I »'■-
an a|.|.a:. iiil\ nanowrd hy prc-^niv. Atniphy, whidi is an i-j •.■.... "
..r ill. a!;"' . iImii. .xi-N in xhr latrr <ta«r«*^ of the dis<»a>o in thr iii> •- '
1. Li-. aii'l i- tiv.|ii.iitl\ ilir primary patliolo^rk.-il <4ianir<: in thr lui--^ "
tiijiik ami iip|Hi- lAtrnnitics. Tlic dcvelopnii^nt of fat-ti-M;** i>-'"
at:-..plii. .1 lil.rr- may prevent any diiniiHiti«»n in the a pjumiit ■*!;■•
li.ii-!.-. riii- ..:'trn. in ilie mu>eh»s of tlie ealvt^s, inav j-tni-^' tin.i '
i.ii;. ii in. -n :i-'\ in -i/r. In the np|MT cxtrc»mitit*s the dcitoid an«ltr> *
!:i..-i .•..niin':il\ inv.ilvinl. in thi' lower the ^asti-oencniii. Theinthi-;'
I'i. Iaii--ii'.i!- .|-.r-i, and the |>e<'t4»ralis major muscles an* al-'**'-'
a:.. I. J. Ti.. !. H..n i< iHiially symmetrical, affmiug Mmilar iu>^
I'"!:! -i'l'- "1 ^'.' IhmIv. hnt it may l>e unilatenil. The miK-H-!"^ •-
a!••.■l..l j.:'!tia!i\ .•!• (-..nipli'tely.
S^ Ml hiM^.—'I'l,,. (li^a-e develops slowly, and the svmpt«mi* a: '
\\!.:.-h \\..'.1.| naiaially h.- ex|>eet<d fixmi the muscular lesion^ ami a>
. i.aia.t. ri-'j.'.
'V\v lirM ~\iii|.t..in- n-nally uoticcn:! are a weakness of tho ni>
.•!'•. I a -hniili:-.. liiiM.a.ly, -wayinir jrait, with the fec*t apart andattr..^
t.. ^iiimi.l.- an«i to iii!I. The children get tired very easilv, and an:* n---
to U^
i^ AV
niiir
atr«
iie?w
i\U
aii'l
ll-U
the
thi'
utti
Irai
ulij
km
Iku
in I)
i.h,
tru
bv
tl'ii
.11-
1-
im
I'l-
III
n
tl:
of the leg, the glutei, the luml>ar mitscles, the deltoid, triceps,
ra-8piiiatiis. The muscles of the week, iaix\ utid upper arm are
r not affecTtcti, but in rare cases theiie muscles, a,s well ;i8 tho.se of
Dgue, have been involved, Exeeptiouully an hy|x»rtrophy begins in
per extremities, and in these ca^^«^ tlie deltoid muscle is usually first
B, At tiine^ only part of the muscle h involved* These children
ID walk late, and assist tlicmselve^ by leaning on tlie furniture or other
I in their path. Sometimeiji when they are kneeling on the hands and
pliere is noticed a very characteristic siuhllc-shaiM'd depre«sioa of the
irhieh is due to the wciikness of the ertH'tnr spinoB mufioles. Tins,
br, m a symptom of a late stage of the disease. When the child Is
Ion the flo4>r on its hack it has difficulty in getting up* It hai? to turn
tl its lacxi first, and then to aid the weakenwl musc*les of the legs and
py means of the hands and arms, elimbfug up, as it were, u|x»n itself
cing the hands upon the knees and then fartlicr and farther up the
L Fibrillary contractions do not *xvur. The kiiet*-jerk!! in some cases
ear as the dist^iuse advances, Sc^isatiou, as a rule, is normah There
om any di-sturbance of the bladfler or rectum.
[ the disease advantx*s, the (wseudiv-hypertropliie condition disappears
isueceeded by atrophy. In s«imc cases the atrot>hy CK^tnirs without the
iiig hypc*rtiN>phy. In the lattT stag£»8 of the disease eontnutions of
jieeles txinir, anil in this way |^rniauent distortions of the jnints may
The nmst fMunmon dcf^irmitit^ aiv talipes efpiinus and Hexion of
lees and hijis. There may be such a contraction of the biceps as to
it full extension of the arm, and in s<^irne cases the contraction of tlie
IB of tlie «dvcs is so great as to pnvt nt tlu' cliild fit>ni placing the
|K>n the griiund.
D>nling Uy Bradford and I»vctt, Literal curvature of the spine may
land at nther timt^s a |K»rnnuient flexion of the spine from weakness
770
PEDIATRICH,
gest ikiB dSBxAm. Go were also attat^hes diagnose iinpomwi^tj
existence of enlai^meiit of the infra spiimtus au*l M^aa^tiog oS tkil
cl(»Tvi ami tlie lower jiart of the iiectoralis major muacks. Wti
inniilM r that in pBcudo-hyix-rtrophic muscular paralysis, io i
to jirogi^essivo mii^iilar atrophy^ the small niu,«!cle?i of tbBlmaSt
fane are, bs a rule, not affected* that pain is usually not pmasLwii
changes in the nutrition of the skin and nails do not tfocur.
Pnudo-hypt^troptik mineolAr pamlyiis, flhowtn^ mUrvvd cmlvcK,
We differentiate true musc^iilar hypertrophy from peeudcHhtpflH"!
paralysis hy the strength which accompanies the former and by tic w* 1
ness which occurs iu the latter.
In the early t^tiis^s of the disease it is at times diffictiH t
simple l)arkwanlnt*ss in walking from e^rly t)seudo-hv}iertrophj. ^ '^^
characteristic symptoms of pseudo-hypertrophy, -which d ' "*^*
do not leave the diagnosi.'^* hm<^ in doubt. The same thiri * ^'M
diflen^ntiating psendo-hyprtrnphy from the muscular diitaftanai'^
ring iu idifxy, spastic paralysis, rhachitis, and Pott's discaae.
THE MYOPATHrES,
771
ROGNasis. — Recovery in this di^^ase k unknown, and the children
live to middle life. Death itsually <XH:»urs fn>m f^ome intetx^urrent
Tlie i'<>ur5^e of the disease L^ chnmie. The miLs<:"idar wcakue^ss, the
and the jKH-niliar gait last for neveml inontiis or a ytur. The hy|icr-
y of the muticleai then begins, and eotitinues progressively for one or
eaiN, wlion it rea<4us its maxininni and l)ec"ome,s stationan% n?niaining
r t^*veral yeiii^i ur even loii|:ren A stage of inerea.*ing feebleness and
bsion of the paralysis then bei^ins, the miiiHcles be<"onie more wasted, and
toower of miction is lost in the lei^s and arms. Snuetimes- the diseaae
f remaining stiitionary nijndly ailvances to a fatal issue.
REA TMENT. — At present we know of no way of enring the disease.
ha§ pnjved to l^e more beneficial than the use of eleetricity in thc^
Systematie muj^ndar exeivise, for the puqjose of preserving the
ttioD of the utjatTected miiseular fibr*:*s and to ward otT the |>ermaneut
pictures, is indic*at*»d. Where the mn.seleft are drawn up, tenotomy ia
^ of nmeh use, and division of the tendn Achillis mi lx>th sides may
hmi^ time restore the ]K>wer of walking. Hra<lford and Lovett
tenotomy of the Imrastrin^ tendons also, in severe cas^« Strict
ion to the liealth and hygiene of the patients, eombinefl with nuiseular
and tenotomy, will often improve the gL^neml ctinditiou for a con*
bble period of time-
Cask aSi.
[f^euda-hrpeftropkilG mueculAT [i«rml]rilA. Stiowini; pofiUoti usuioiHi Ui riting ttom the flav.
I have here a <tim which represents certain points which I have just
(sen of in deseril>ing |i!?ieudo-hvpertrophic mu^ular jmralysis, and which
enableil to show you thn^ugh the kindness of Dr. Rupert Norton,
772
P£D£ATBIOS*
LiM»ki!i^ tti ihii iwy from Wiind (Cmu 384, I,
the ciilvi*« uf the li'^ Hfu ifri ktlv tnlai^ttl.
On making tht* boy lit^ Oowti tm iht* (lij<tr nnd tJit'ti t
yini will notit^ thill ho ftfebti hinucif by jvtitting bU
highiT und hi^hiT oit lh4» thigh« until he aMumai ihe ensia p«j>itUi«u
I 8hall now ask you to look at these Ulustratifjns of fn-w ImAmi
I am enabled to show you through the kiudness of Dr. H. X. B»^<|
Baltimore.
The hUtdry of tbeM mMx [Ctam S85 *nd 386) \» mm follows. The ssDinir U i ifi|
y«ft» old, the l&rgcr ten ytsitn old. The^^ have nlwAya tiv«>d in ibe «ofiiitri% ndMS
of any e«p<»C'iiil dbe«s« h&a b««n ubtnined, but ihi^ bUtory of boUa fsmuB U ae
Cases 886 AMD 8SS.
Pteudcyhypertrophlc mtttcular pamlygte. Brothere, 8 and lo yejkrs old. 1. t^nwiiig u^m^t .r '.* • ••
enlaiKod calvea, II. Showuig ihe lunltMU.
The older boy begun to wiilk wUi^tl he was nineteen months old, but i
never walked well. When be wiv^i seven yenre old he Ixrgan to havf dimrultr inr^^'
fitttirs, and it was noticed that tli** calves of bt* le^ wer^ eri^wint? I k»^
were becoming smaller. The curve in hh l^ck wiis fix%i notiofni wli ■ >:!^^
old. When nine years old he \mi the* pt,wer of walking, atid is taki to bawgiwn*^
stupid.
try inyopatliy, wliicli i*^ usually termed Thtunsen's disease, from the
k of the physician wlio first thi>rimghly diTSfrilwHl it, is cliaraetorized by
|fail>iti(m of the vohiiitary movements. This d is t urbane*? uf movement
k to a J*titrness and tension of the muscles oecijrring at the iN^mraeiioe-
I of motion. The most important etiologieal faetor in the di.seiise is
It IP hereditar)% In uhiiost every ca*^ it bt^ins in early childhmd.
Pfie pathology of the diseaiM* has not been acx*urately estaljlished by
n of autnpHies, but an examination of sections of mnsele taken fn>m
Lgb^es^ has sliowii, ae<.ijrdirig to Erb and Jaeoby, that the morbid
Hi are the result <*f an enormous hyi>ertrophy of alt tiie miLs^-ular
L great proliferation of the nuclei, and a sliglit inei'ease of the f^eri-
mm* The dii»ease ap|K*ars to be a fxvngenital iitfk'tion of the mnseuhir
Phe symptonis of this disease are noticed only during vohiotury move-
^the wxitraetion uf the must4t^ resptnding very slowly in the will,
Hinsting for a little time at^er the individual Itas willed the muscular
iment to cease. The miiffcles of tlie arms and \e^ an» those usually
fcated* The sensation and reflexes are norniah The muselt^s ai'e
pently enlargtHl, giving at times the ai>j>eanmce of hyjiertn^phy, but the
fth of the muscle is nut iiropirtiouate to its size. Erb has deHcril)cd a
leteristic chx^rical reartion, calleil tlie myotonic rcjiction, in which tlie
actions caused by either curnmt attain their maximum slowly aiMl
: slowly, and wave-like contractions |mss from tlie catliode to tlie
B. One of the jKHndiarities of the disease is* tliat when exertion is
I, mieh as attempting to g<» up-stairs, the muscles which previously
quiesct^nt l>eciime very stiff and will scanxdy rc^]>ond to the will,
her j)eculiaritv is that long-continued rest makee the disordi*r Morse.
alsii exaggerattxl by heat, oi*ld, ami excitement,
■m^^^^uver)' of thi^ iriMitouic rc-aciiou the diagnosis of the diHejifM;
DR'JSIOX XIL
DISEASES OF THE MOUTH. NOSE, NAJ>0-PHARr;'
AM) PHARYNX. DIPHTHERIA.
I N "
lkctl: k t: >l l.
DISEASES OF THE MOUTH.
\ «f: ^-::> — M:.f. ..l :.v. — Ma :-. .:
:*!•.•• III. 'Uih y. .-.: iu::-t i:iitl* r-t:i!jl
••'!! i-'l I 'V .litter* lit a-itr;-!-* :.•• i
..: :' ;i:;"Vit'r. Sn.-h t. rii> :> - -
•.-'! :-r all:!, .-t :i:iy ni.-.rl-M -: i
*. ' .':. ''.i\z Z'.k'-y liaviL o;:-^*! t-
'.* .!" '11' •%•»>- ».•.'— ^ • •
T. Dr. Fri.
nil
Ilia;
tali
ar.i
irri
thr
irri
vcr
ku
to
th.
\« 1
1114
an
Ml
tl,
tit
.11
ir
ii
••^» ■ -k •
>.:.:.•.- a:-..i
I
m w — o ■
pry organs, and tbat sub^^tauces which are abs«jrbtil by the etomach
pe eliioinattKl by tlie aiduth and in thi:^ way Wxim(» .sourcvs of irri-
L aiid dkease m the latter. The mueous membrane of the mnuth
r almost the w*hoIe jyeriod of infancy i.s ^nhjtrt to ext4?nial soiirc^cH of
ton to whieli older ehildrt^n, as a rule, are not liable, Thu?» during
tot year the mucous membrane in .subjec^ted to more or less meeliauieal
loii through the nie<^hanisni of t^iuekiug. At this }Jeriocl, also, it is
pDOimoti for foreign organisms to be intriKlueed into the mouth by
I of the fingers either of the infant itj^*lf or «>f its attendant. It is
^ririing, tliereftjR% that we should meet with a gix^at variety t>f jmtho-
I oonditioiLs in the mouth in infancy.
be organism.*^ which rKx-nr in tlie moutli are 8o numerons that very
F them have a.s yet bet*n diffeivntiated in .such a way that they can be
b as the caiii«e of the specific disease in which they are often tound.
Blllot* therefore, at the pn*sent time deHeril)e the various diseases
p mouth under their pmper etiohigicul headings, and we are forced
Ipt provisionally the name of the pathologiml lesion which exists in
I almost ever\" dis<^n**e of the ni<mth which ix-eni-s in infants and in
\ childrt^D you will find a coexisting inflammation of the mucous
noie of the mouth. Tliis intlammatiou may a.t times be very mild
Ren difficult to detect as such, but it still presents a recognizable
bgical couditit»n. This iriflannnatt»ry ctniditiou, though not neces-
pret^ing the various diseases, yet in a large numbcT of cases either
as a basis on \\ hich the disease devi'lops, or so closely accom|iani€*ft it
he g€*neral name donmi'dU (iuflanimation of the muciuis niemhrane of
btitb) seems to be a proiK*r term to use in connection witli all tliese
pder the genenil heading stomatitis we can s|)eak of most of the
776
P£:i>IATRIC8.
TABLE 107.
J^rovisional Nomenclature of I>iseases of the Mouth.
Simplex.
Cutarrhulia
£ zanthexnatica
Traumatica J tVtlj.
Stomatitis
lloriKtica Aphthoea.
' Scorbutus.
Uloon^a
M ycelogenetica
Mineral Poisons . .
And other diseases.
Hyphomycetica . .
Pseudo-Membmnosa
Oangnenosa . . .
Sypifib.
, Nonii.
Followin^r this table, you will see that the four general namesiAi^?
all tluse (lis^'ju^^ arc stomatiHs ccUatn-IuiliSy ^amatUU herjtdica, «»cJ
rilcentsd^ and stomatitis mycefor/eneiica^ I
STOMATITIS CATABRHALIS.— The form of stomatitk^l
(^allid tlu' simph' or rrythematou^ form (stomatitis simplex) Ls cvniniT/^:
in younir infants as a hyiK^nvmic condition of the blood- vts*k ^^/-,
ditliiM' r(dn('s>^ of tho whole buccal mucous membrane. Thisomksiil
iorni is so (M.nnnon and so entirely without clinical significance tha it 1 1
Im' considcnHl as physiolotric-al and need only be referred to. l
Thr srcond form, which is called exanthernatica, is the condition.^":]
nnicous nuinhranc which owiirs secondarily to the exanthemata. Tlu?''^|
dition of tiie nnicons membrane has already been desorilwd ia c«i&^-|
Willi tlic^r diseases, and then^fore need not be spoken of again.
T\xr tliird form, wliieh is c-alled traumatica, is the one which fff*^^
tiic ehara.trri<tic sfomafitii^ catarrhalis. The causes of the traumaticJffI
of >ionKiiiii< ealarrhalis are very numerous. Thev mav bo «»«*»■•■*
fl^nnni nv rhrnncdL Among the most oommon mechanical caui^nejH
cited \\\v irritation i»ro<lnml by rubber nipples, too vigorous clcanang '^'»
moutii, injndicions rnhhing of the gums during dentition, and local ir*
lion from a tooth. TIk* thermal form of traumatism may result ii>«^|
adniini>tration of food wliich is t<.>o hot. The chemical irritation may «*
in various ways, as from lack of cleanliness in the moutii, with it? n^'
intr fermentation, and irom the elimination of irritating prodncte fi«ft*
jllands api)arently <-onnectiHl in some way with distorbanoe in the p^'
eniirie tract. It is ])rohable also that various forms of bacteria * *^
DISEASES OF THE MOUTH. 777
may cause both mecbaniail and cheniiail irritation of the buccal
&brane. Our kuowledj^ of the bat'toriohigy of the mouth is as
r, 80 limittNl that we eaii jK^nrt-ely inidortake to dt^cribe the
speeial furuis of bacteria and sjweiul leaioDs of the inu(X)t]S
JY AND Symptomatoixhiv* — As the lostous which are seen
of an iriikiit with stomatitis c^tarrhalLs during life almost
UiHipiM?ar at deatli, and as very few poet-morteiii examinations have
le oi* tht¥ie lesiouH, we can speak of the pathology and symptoms of
lee together.
lesion is essentially an inflammatory one, and occnre in difierent
On examining tlie mucous membrane in tliese cases it is seen that the
ing of the month in intensify reddenal, that tlie temperature of tlie
iuereasENj, that there is nsually a certain amount of swelling, and
Jongh the nnietfiLs membrane may lie under tvrtain circumstances,
J at first, dry, yet, a^ a rule, later there Is a hyjX'rseei'etion of
pi saliva. The IJimxI- vessels are so distendi^I and their walls are
^ so weak that the slightest traumatism may cau^e their rupture,
laliva is frec|uently mixtd with a little bliMxl. In older children
rtis membrane may \k' eonsideralily hWtillen, es|Hviiilly IxOiind the
>eth* In addition to this general condition of the mucous mem-
the montli, at times the li|>s art* found to Ik* swollen and much
i The surface uf the mucous membrane shows a number of small
bm^inenees, which are the muciparons follicles. If complete ooclu*
le ducts of tht»se follieles cn^nirs, great dilatation of the gland will
e, and a cyst may lx» formed. This, however^ is a comparatively
plication. In tTmnecticm with the disturbance of the glands in the
e lymphatic glands an: usually inviflved siMN^ndarily,
the catarrhal condition is at its height the nmrous membrane is bo
le that even slight traumatisms may cause abrasious. The most
(yraptom of stomatitis is pain* The infant i» n-stliMss, usually has
^ed tempTature, an<l refust^ to take its nourishment, Tlie saliva
its reaction, and wlien sei-retetl iu large* i|uantities fluws ont of the
pon tht* chin and nc*ck, sc»metimes causing considerable irritation.
He is dry and white at first, then lx*cT»mes of a grayish odor, and
■v»tinfi fiC ftfliivfl JnfirffiiflflB tiiP ivwtifur fif »h#> tnngiM* ik wanliiitft fill'
pnvriit it iroiii U'lii^ hamuli by a lat'k of nourishment or I
(li^tiirliancc ot* tlio gastni-eiitoric tract. If* the <:»ui?e can Ije
should 1m' n'lnovctl at once. The loc^al appli<*ation of a tmc ti
<'<)I(I Mihitinn of hicarlKiiiati' or borate of soiliiiiii ia distilLxl
vixuA. This sjihition should Ik? used very gently ovciy half-
iufant i-« awakf, by means of a dro|)|KT, and oceatiionally una
al)s<n'lMnt cotton. The infant should l^ systematically fed ai
vals, whether it n*sists or not ; and if it is not being niirsc<l o
from the nipple, a earefully nKxliHcHl milk at a teinjwratun* »
V, (1M)° F.) should Ih» aclministereil with a spoon or dropper
n<'<-<-sity i)»r trivin^ any dru^ internally in this disease.
When' the stomatitis pix)ves to be intraetahle and lasts
thre*' or four days, the mouth can lx» gently touched with ac
with II one jM'r <'<'!it. solutitm of nitrate of silver. This s
one*' a day, and the mouth washed carefully with cold sterili
the application.
Where there are any abrasions which show a tendency \
form an ulcer, they should be touched wdtli a little nitrate o:
on the end of a silver [)n»lx'. These abrasions are often so ]
tliemselve- tiny may prevent the child from tiikin^ its food,
have Imm'u trcatcil with the nitrate of silver the child wnll o
its noin'i-hmcnt readilv.
I liav.- Imp- an infant (Casf 387), 8ix months old, who is a marked
Thi^^ infant is n-portr*! to htivo always been healthy, and
i-atarrliali
ii^ inotlii I-. It (lit {!-> tii^t tootli, a iniddio lower incisor when it was
Nndiiii.:' alin.'iiiial wa- n<»tic<Ml about the infant until two weeks aeo, wt
fill. n-i!.--. lia'l a iM-iuhtrnrd t<'inj)t^rature of about 88.8® C. (102® F.) i
>i"iiall\ . Mtli-'Ui^li it .li.l n.'t crv a f^n'at deal, it frequentlv whimpenn]. j
:in.l U. |.' i...!!i-,:. i:~ tin-.T.^ to it-« mouth. A few days later it refused to
N\:i- |.'ii ! '1.. I.t':i~! it ai.tH'art'cl to In- huuifrv and \7r111l.l ♦-rti---. -u^ia ..f
DISE^VSBS OF THE MOUTH.
779
lack of fiufiicient noumhment, and if this continuea the prognosif witl toon become
e. When the mouth i« in thU conditfoii there b also a great liability to other dUeaiet
^g implanted upon it, as the mucous tuembrune is very vulnerable when a pronounced
laUriH eiiiiirrhHli* is present. The aaliva is flowing from the mouth in such quantities
ii so trrltiiting that an eezematous condition has been produced by it on the chin.
' ishild is rather Apathetic and dr^es not like to be disturbed. The treatment which I
tl unler in this case is tbut the mouth be careHillj washed with the following ^jlution
J 5scription 74) :
FBxacRiPTiojr 74,
Mpinc*
Giamma.
lodii txinitia
"Slycerini ,
Lq. destil.
fell ^«
1
7
adl2D
8
5
00
Apothtmry.
B Sodii boratls > * gr. xxz;
Glycerini , - . 3H;
Aq. d«stU tdgiv.
should be applied every hour while the child is awake. The thin should be
illy dried gently and a little vaseline applied to the eoxemaU>U8 surface. Until th»
^d Is wilting to nurse again^ tbe milk should be given by means of a dropper regularly
sry two hours. Under thi» treatment 1 ebuU expet't rupid improvement within fotir or
e days*
STOMATITIS HBRPETICA. — The name herpetica has bwn adopteci
r the next fi^rm of titoiiiatitis, because it seems to iiepresoiit most nearly
^e lesion which is s<rn on tlie tnuoous membnine, although it is not de-
nitively setdtd tlmt it is a true herpee.
The disease oontsiftts of a mtarriial stomatitis in the course of which
irtain lesions ivsembling snbc^pitlielial vesicles^ rtiirrouiKhtl by ai'eolffi occur
rregtilarly and in ditlerent part^i «jf tlic entii^ bm-cal cavity. Thb form of
0niatitLs has usually been known as stomatitis aphthosa {u^Oa^ an eruption
r ulceration,) Thin mum* wa^ given to it by Bohn a"^ tlistinctive from the
iher forms of stomatitis, but it does not represent the atlection especially
ell.
Etiolcxjy. — As a rule, when the mncons membrane of the infantas
louth Is in a normal condition it is not readily afft^tcxl by the various irri-
is which |)nxlii(*e it^ sptx-ial diseases. Wlien a catarrhal condition is
t the raucous membrane becomes more vulnerable and the various
have an f^p(>ortimity to develop. Thw apparently is illustrated in
t case of stomatitis hcrjx'tii'a, in tN>njunction with which affcctit>n a
tarrhal stomatitis is always found. No cause, either local or gt»ncml, has
i yet been dctcrmincHl ft>r this disea*^. Various micro-orgunisms have
I6e.n observwl in the mouth when it is aftt*cted by stomatitis lierjK'tim, but
to catLsal connection has been disoovered between them and the disease.
'his aflWtion may Ix^ found ass«xnatefl with a nuinl)er of other diseai^es» but
iually (x-curs alont*. It does not sc^em to lie contagious^ nor to lx» cs^XHially
onnected with ditH:*ases of the gastro-enteric tract or with dentition, although
very eoramouly fM-eurs during tlie dental period. It appears to Ix^ the
jult of certain deleterious infinencc*8 which act upon the nerve^^^entres and
jTcxiuce an heriietic etHorescence on the muoooa raembmie wlucli corrcsponda
losely Uy that which is seen in her|)es on the skin^
ilv intoi||^^Hftt]p{)o^*il to bf! a %'Ctficle. Tlic
^^n* iiujiuh npon these le!*ioffi§ ut^n^^irily pri?vetits tb'
»amf' definite ajifieiimni^ tliat tljt*y wuitld |>iic:»eiit oti tlin
of ihii di^t'aiii' my strongly ^iimukte^ tJiat of Licr|>€s ihol
Tiio )irf5fn^ral appi?araBce of the ffflorf^^eciice wliea t
of a Hul>ej>itlielial vt^k-le, 8nm€*what g1ii=lc!ninjif, of n whi
fiiirnHmdixl by a red art*i>k, Tlie lesions may be only
fic^ttcrtil irit^ularly over tlie parte of tJic* timcsaiis
alread)' dcii^ribed. At tinies, b0\iTV<*r, the €*iHore«ioeiio^ t
tinner ap[Kmriiig ua mmiiti? ^myiiib pomli^, wliti;)] iimy I
and ifjvtT the mueoiiti inembraiie so tbiekly ar« Almuei
nieiiibnuit^ lu a Htill Uter »tagi! of tlie duMimde duifd
down and form Bmall f^uperficml nlc^iB^ ^^M
An Infant or young i-*hild aifected by etotuntittif herp
eharacterigtie ap{)eanmt*€. It ]uoks dull ami npatbtilif^
quietly in l>ed* It usimlly )ias a hBigbti'Uf.Hl temper
sulTen* from pain and baat in ite mottth. Tho salivu tl
m large quantities, and oflcn trrltiit^ ihe chixt aiid nee
thiit an (^^c'^fiematouf^ condition reMiltft. Tlie chUd n^fiidei
ment, and in very fretful and ri^tlcian. Tli^ie ^ymtvtcri
or five days* or a week, and tiomt^timas exl<*nd ovi-r a p
tiia {tiM'a^le then diJMipijeariuj;; of ifcj^icjlf t in fact, it itpivmi
Uole«s the le«iona of t^toniatitiA herpetics are ean]]>ltcat
titi?; ideero8a, the ^liva ij^ never fetid,
PiKHiNOsiiS, — The progno^i^ of t^toixuittliii tieq^etk^
although infeetion frf»m other diaeases may tak** placer
ren*^ 18, however, ejEcf^erlingly rare* RclmiJa^ are
form of* stomatitis, and the h^ionB unttally b^^a) r^adilv«
TiiKATME^r.*— There h no interiml treatoieiiii
p: A-rE vin
V^«rtC«M(i
}
• til Hcf petted
SlOIDltitiS UiCBTOiA
f-uJhCu!«' w.f'f '<^^»
n.ph
ph*fi«r.i
D18E.4SE8 OF THE HOtJTH. 781
r
^^Usensc* has attacked a ptmy^ ill-aourlshetl infant, great eare and pera^
'«ttioe should be exercised to feed at regular iatervala
This boy (Cttse 888, Plate VIII. » facing page 780, Stomatitis HcrpcticA), four ye«i»
whom you sei? h«?rt^ in a darkened corner of the wmrd, U a pronounced cA&e of atomalitw
petieft. He wa* perfet'tly well until two days Hgo, when he bt*gnn to be fLn-erish, wui
le*ft at niyht, rt*l"U«ud t*» Uke his fowl, and seemed <|uite sick. On the f<»llowlnj^ duy the
irp iTiuoous inembmnL* of ihu mouth wits found to be nli'eeted with >*t<»iniitUiH cHUrrhjiIia,
i ionriewhiil Inter the heqietic form of $tomatiUit which you now §ce in diflerent parts of
mouth, i«p|H.*nred«
On dmwiM^ down the lower lip you tee on the right »idc a number of tnmll gmyiah-
Ite spots surrounded by a eomowhut deeper^ reddened mucoua membrane. At a little
(ance from them, on the left aide of the lip, close to the gum» u up^mrently a aubepitbtdial
Jcle. On the inner ^ide of the lower gum one of lhe*^e vesicle* has broken down, and a
*U superticial ulcer covered with a n^myi^b-white exudation ia Aeen. There are aUo
iofift of the *«me veificuhir character nlong the It^ft edge of the t'jngue. The t?ntir©
lOOiiB membRine of the mouth is intensely reddened, und the ca^e illu-stratefl st^imutiti^
Uurhiilb a?* well ii8 tit^imititijt lierpteUca*
The ebild absolutely refu^ci* to take fi>f>d, and, a« he is robufit, I have not advised
a great deal Hhi>uld l>e forced upon bini. In a few duys the more severe i^tage of the
will hftve pu*i^ed uwtiy iind be will take his food. In the mean time the inflamed
lotiua menibmne uan be bathed with cold sterilised witter^ and $mall quantities of an
line modified milk can be given U.t him. As you look at this ebild lyint; with his eyes
If closed, with flushed cheeks, in an apathetic condititm, occjifioniilly whimptjring as if
|iain, and with the saliva flowing continuously frt^n his mouth on the pillow, you caa
idily diu^nobtiL-nte the di«ea»e stomatitiH. Whon in iiddition you «ee these characterisUo
liona of the mucous membrane irrepularly difitributed thrtjughout the buccal cavity, and
not tlnd any evidence of a membranous exudation ^ there need be no doubt of the
lignoflis. Tnl^^rmil remedies are not needed in a case of this kind. Chlorate of (Kitaa-
kim, which i^ w eommonly used in all diseases of the mouth, is not indicated in the forma
! atomaiitiii of which I have jUHt spoken.
In oonnection with this form of stomatitis may be mentioned oertain
sions occurring in the mouths of new-born infantn whieh have been called
*ednar^s aphthtr. These lesions ef>nsist of small Biiiierficial ulo^irs usually
Hving a grayi.^h coating, and api)earing on the fH>storior part of tlie hard
alate and on the mh palate. Tliey are now aup[x>sed not to represent a
>ecifi(* disea.^e, lint to U* the result of tratmiatisni, such an may arise fn^nj a
lldly-sha|M'd rnbl>i?r nipple or from undue vic»lenee in washing the month.
They are to be treatt*d im any local irritations of the mouth should l»e,
■-nanii^y, by removing die eaiise, applying a solntion of bic-arlxmate of
Enlium, and, if necessary, tone) ting tliem with nitrate of silver.
STOMATITIS ULCEROSA. — By stomatitis ukvrf>sii we mean a jjecii-
iir patliologiad pHx-eas of the mucous membrane of tlie mouth occurring
oly where* there ai>* t**eth and affecting the gums amund the teeth.
ExioLOfjY- — Tills affection of the month may occur in the course of a
[UEiber of diseases, notably in scorbutus. It may also be produced by the
iterual !i<lrninistratiou of such minenil prisons as arsenic, lead, or mercury,
keeasioually it may occur as a hwal atJection without known «iuBe» but it ia
robably pnKliK*t*d by the irritation of some form of micro-organism not
pt determined* although the pyogenic bacteria are very a>mmonly present
^fm
Ftmijamic^
Tbe omM (\iiiimuo fciriii of utomMtitis QJoaoas pnmtiQii m or 3
poiiutiA U tltat wfaidi b Mfsci in oammMioa witii itustwM 1
Ai ill UM'Mllti-r ibrms of doiiutilis, it 10 praUihk? thsltlta
lirani* ii flrtft iirTivu<l liy a ctiiiinrtiiil proooae whidi TmAm k\
the ^^^hl iiriliitiim wliidi (tnnliiom stoniali^ olacrasL TIai {
stmniititb tntarrltAlk umy be pnidiicod cliivt^dy b>' local tmii&iii
nmutll iUrlf^ nr fimy Ix* the remit of scitnn dbtortiran! iif ir|
S3p*iiti*ni. Fur thU roatHm ^utmititt^ tilccroHa^ a^ a fule, dieiiii
priiimrily 11 lit-^ltiiy iEMliridtiiil* Thtii^, m poorly Oijoriibfd liSi «
wlitMi* mutuii ifi not (impcrly cajrtil for^ will be niore apt to htt^QsJ
(]c»v^lo|» diati otie whii t^ nrrrprtly fc«l and \vhnaf« moa^ iiAmL
l*ATHoijmiv.^ — 'llk*i |*atli**lt»gicnl cx^mlitiou in one of 1
tlieti^ in wifl^Dg as wdl a^ ilintb cif the tii^Mic&>> Tlic
iitai^tiig so the miiooiii moubnuie, miiy idctciid u» tlnr {i^ii^jiai&ai^
pnidiii» QRSivids f if tlie bone. It bvypcfi nt tlii^ it'r*^ U^rAtt <i^\
tmi €at] extend in all dErei^iotia, bttt it never pttMCs Wfuml tk 1
niemhr.ri" t tIm m ith, TIip ^•fteninit of thr* tisp^tM' ntiiod^i
it^ ctiii.-k r u i jt :u-o rindrfi it marc nioviilili-, and id lliiiVIji
at limi^ i^rofiP -u -wnliirt uoil IijcimuichI (Imt tbey may cailntd^«'*^|
Sfiiftohh.— StiimatitiH ulii^niea b tiaaally pir^eded by 1
ttttbnat mym^mBf msmh m IWcr, loes of opjic^titi^, mail fittfahtfi
{Qfiontia membraoi! of tbt? gtims at the fVcse nmrgin of ilie li^ I
nxidenad and mon begim to swell. Tlie iiurtnal i*tirve nf tlte
altiic»f*t a Htmiglit lint.^ and oovens tbe hiwi^r juan uf tbe trtjib* Tfce|*fl
tilt* >*|nu>e!i lietwc-en the teeth remnin unaltc^nod at fir»t« The m^
hmue tlipii bc^gtna to cbaii^ to oslor attd b©caiiH*7i |ittmli»h. Kil
gf^tioii and Mofteninf of tlie tisiaes allow heiunrrhii|^ to take ;Apii
tbe Hlighte»it {>roi@ure. Altlioagb the anteritir la^iirfarf! of ibe iiqb^^'^I
comnionly affected, yet io Bcvert^cmsBm tbo p<»<HtArior ^urfiwe fe »l« aal^l
Ab the pmcieHs^ develops further tbe gum Ijeemni-H mure and DfHt li^|
m it extendi over the teeth, A mtj(^»-|>tiriihMit Becretiuii ctJkra I
the gum and the tc*t*th and caiisft* a ft tit! odor. Aeftirtlifiif li* F'ctli^I
E yellowish i^w-am then a|>i>ear8 at the tup of tlw* t^woHeii aullioeof iki»l
Thifi iB due io the nioh^-ular deKtriK*tiun whii4i h&» altttvlv hfV^ ^1
fieatn in at UrBt Y^ry narrow^ btit later it nmy beoomo hnnakir noi ^^*\
idmost the whole of the gtim. In t^unniH^thm with thi^ irbawtei*^'
|M*iinintt' of the gnrns there is a gi-eat hy{M>rm5c*retiMn af fmUxK ^^1
hf.ight of the (liHi^a^e the child evidently i^ufK^rfi fnim fioiti ia ti^ -*
crit^ II [^iTut dtiii^ and ra}>idly emaciates. Tht* lymphatic ^hui- '
swollen, and n*niain ho nntil the di^^mai* haj^ eriij*?^!. Whiii r
nutteritd which conBtittites the aeani already n^lf»rred to i* itfu^A -i
atixl ^tirtW will lie found henejith, Althoiigli >tfiiniitJti^ u^orr^^^ •
nlw»nt any of tlic teeth* it8 most eoninnoi HtiirtinU'iNiint i** nnpiu-J '
iiun^>r8. A« the dijicuse improves*, the giuna i^rrailuallv l-x>»itj» l-
of the mouih in whicli the gums assume tlie purj»Hsli hue
oUen, mthy and lix»sened condition wliieh arc cliaractt'ri.stie of
ititiH uloerosa.
J^ROONasis. — The prognosis of stomatitis ulcerosa depends upon its
b and wlu'ther it L^ trcat^xl or niit. The tendency 1% however, after a
pjle jKn-itxl i*f discijinfort to the rhild, for the disease to disiippear.
If the affection is the rej^ult of one of the constitutioual diseajscs, such as
lilis or s<"orl>utus, it di>^ap[x^rs if the trt^atnient of the specific diseast> is
kfieial, otlierwlse it continues^ and may finally lead to death by exhaustion,
tREATMENT- — The local form of the disease is Ix^t treated by the
pnal administration of chlorate of jxttassium or by this dru^ in s^jhition
I as a wasix for tlie moutli. Chlorate of pitassium must, however, be
H with great precaution to infants and children, as in certain cases it
as a poison, some infants Ix-ing affected by even minute dos€s. The
ptoms which show that chlorate of potassium is pnxlucing deleterious
its in infants who are most likely tu be atlW-teil by the drug are drowsi-
i and suppression of urine, with weakness (jf the heart and sometimes
urns*. When these sympt^ims follow the administration of the drug it
ud be omitted at once and a simple wash of borate of s<Klium use<i.
(>rate of p»tiissinm when given internally has been found to be secreted
be saliva within five or ten minutes, and thus has an opixirtiniity of
lueing a direct eifect U|xin the lesions of the gums. Tlie doses of chlo-
of pjta^^ium which it has been found t^n be safely administered to
^ts awl children shonld lie rcmemlx^rt^l when prescribing the drug. I
I indiimterl in this talde (Table li\H) the minimum dose's whicli ean safely
pven in tlie twenty-four ht>urs at ditfert*nt agcs» and whicli aiv sutlicient
Irtxluec the specific effect of the dnig in treating cases of st4>matitia
C
TABLE 10ft.
\i\si <or oiilv a short time, usually disapjK'aring eutirely after ft
>ix to lorty-ci^lit hours.
I'luhT this tn'iitnient the disease is ordinarily cured in aw
(lays. The tn^atineiit should, however, be continued for a numl
at'ttT the month is ai)i)an»ntly entirely well.
When' deejHT uhvration h.as taken place, its disap{)earance
times 1k' ('xjHilite<l by the application of nitrate of silver. WTie
trum has iorm<Kl, it must l)e n'moved. Frequent washing of the i
strriliz('<l water administered by means of a dropper is also verv
es|M.Hially ai'ter th(^ taking of food. An alkaline diet is indicatrt
1 liavr Ihh' liH infant (Case 380, Plat© VIII., facing page 780, Stoma
in S('<.rl»utU'). b'n niiniths old, in wlnrse mouth you will see the charaot^^rl^
.-t.miatiti> ulcfm-a. In this cju»o the disease happens to be secondary U> scorbu
ii«»n fnr wlii.li tlw infant i< bt'ing tn*utod.
Vf.u will noti(«' that th*' infant hftj» six teoth, and that the mucous membr
only :it iIm- ju?icti<»n of tlu* i^iinis with the free surface of the teeth. The c
tln' niih'»u- nn'inl)nint' <»f tlnf mouth are rwldened, but not markedly so. Tl
thr LMnn- atr«'it«d an? >\vnlK-n, jmrplish, h»osened, and almost cover the teetl
ron-i.l'-niMi- llow of >aliva, witli a fetid odor from the mouth. An appeannc
is iliairn'»>ti(' of >l«>inatitis u1('«tosu.
1 al>o havr h« •?•«• a <'a>«' of stomatitis ulcerosa which apparently is of local
littl'- uitl i(':i-«' 'VM>} i- tliPM' and a luilf years old. She has always been he*
liM-l MO ill', a--.-^ <.f any kind. Slut was j>erfectly well until five days ago, wher
li;iv.- 1.— <.f :«it|.<tit.'. a t<'jnjM-nitun' varying from 88.3*» to 89.40 C. (101® to IC
!..■ \.ry fV. ttul. T\\vrr ilay-, lat<T the gums were noticed to be swollen and V
nd r.'l.'i-. Mii'l li'T l.p-atli lia<l a f«'tid (Klor. During the past two days 1.5
•jVMiri! .-f <lil"-rMt.- ..r p..t:i-.<iinn have l>een given to hep in divided doe^ ij
i"..ur li .in--. :.i..l. :ilili. ii-li -h'- has been nither apathetic and has wished toreini
ri...utli t -.1m\ i- in a iiiu<-h In-althier condition, and she is brighter and has a 1
Ml-p-iii.-.
In \\\-. -.v th;-. .• .lay- iii'.rc tin' disease will prr>bnbly have run it* com
r. , :•, A,:: .. iL.-i pl.M.. Th.' >alivation, which was verv marked in :
DISEASES OF THE MOUTH.
785
irbich are due to fungi are termed niyeetogenetlc metsimorpho&b, and thus
title |jaUiologi(*al txmditioiLs in the mouth which are prcKhiced by any of
iiieee forms (»f t'ungi nmv Ix* dcs^ignatixl l>y the general term myt^^^togenetica.
■pder this general liemiing of mywtogenetiea we ean inelude the various
Bms of stomatitis which are cani*ed by fungi*
f S-mMATiTis Hyphomvcetica (Thrush). — The disease whieh is aan-
imooly called thrusli is produced by a fnngiLs which tinds it5 nidun upon the
euriace of tJic muoi>us nienil)rane of the mouth, usually in young infants.
kTliis fungus wiLs tbrnjerly sup|K>sc<1 to be the oulium aihtcuiiM^ hut it is
foow known not to be this organ ism, and the pre<:*ise form of nioidd which it
represents has not yet been detcrmiui'<l* We merely kni»w that this gmw th
of thrush is one of the mould-fungi, and we can therefore at present only
classify it as stomatitis kifphmm/cdiva.
The moulds are wnuplcx in their structure, and as commonly descrilx'd
consist oi' a sorites of delicate jointed threads (myc^elium) in which spores
are ileveloiMnl. HyphomyfX^tio griiwth is ehamcterizcxl by having the spores
naki^I on e<insiiieuous tfin^ads. The fungus of thrush may be found on any
of the mucous meiiibmnes of the body. It has also been found in various
OllgatiSy as in the limiu and the lungs, antl from tlie surface of ulcers it has
on rare occasions i^enet rated the bhKxl- vessels and given rise to viscvral
ipetastasis. The usual place for it to apjvear, however, is the mucous mem-
brane of the moutlk It is a local disease, and may occur in the mouths of
healthy children as w(*ll as in tlio.se wlio ai^e diM^ju^ed, It is more likely,
however, to Ix' ingrafted uimju a <Jisciised than uixin a healthy muctiits mt^m-
braue, in acit»rdam^* with the rule which I Itave already stated. A catarrhal
condition of tlie mut^ms meml»mne, by dis|>lacing the epithelial cells and
thus interfering with ttieir prc»t4.vtioii of tlie muc^ms monibrane, affiirds the
readiest means for Uie develrtpment of the fungus of thrush. It is therefore
more likely to be fouud iu the inMUlhs of children whu are sufilbring fivun
various disease* or who an* ill eared lor. It nmy be carried to the mouth
in various ways, eitlier on dirty nipples or by the finger.
RvTiioLOQY. — The growth may take place on l^oth stjuamous and
cylindrical epithelium. AiMTirding to Forchheimer, the tii>t hnlgement of
the fungus comes betw^een the epithelial cells of the mouth, and from this
tlie gniwth works its way under the frt* surface of the mucous membiane.
When dirc»ctlv on the (n*e surface the gn* wtli is not so luxuriant and k
principally in the mycelium form. In the case of a muc^ms membrane
lined by flat or sr|Uamoiis e|>itlielium, the growth is facilitated by the rela-
tion iif the Cecils to (iue another. In a membrane lined by cylindrical epi-
thelium the growth takes jdace, but n«it so reaiUly, because there L*i btit «»ne
layer of cells. After the first develt*|uuent the gn>wth goes on very rapidly,
and after it has fi)und a nidus the ec^ls an* pushed aside and are Hurrnuu<lwl
by mycelium, the whole presenting tlic *'hanicteristic apjiearance of thrush.
The growth begins in small s|Hits, somi^tinit^ one, sometimes more, and at
times the entire surface of the mu<^ius membrane is covered with it* The
50
TSi; PEDIATRK'S.
riiiiiiu- «l«v»lo|i-. within tin* «'|»ith<'liiiin, ami it n-ijuin-^ «-«»ii-i«lr:i ' -
tn r.nmvr tin- i;n»\\tli fruii thr iniu-iMi- nii-iiiln-aiH*.
>VMrroMs. — An atta«k ai' thrush usually In-^in^ witli 1-./. • .
i»f' •Mtarrhal M«»niatiti-. At times. Imwi'vcr, ni» ^yinj»i««ni- a^ ::•-.
fiiMLiU- Uiiii; th«- lii>t alinornial c'«iinlition \vhi«'li i* notitu'.!. Ti:
aii«f i»t' th«- luML^ii- n'M'iiilih's eln<«*ly that of i-unllf*! milk. ' ..
nt't«ii iif'a rather i^rayi^h <'itl«»r. It c1<k*s not look liki* a iii»riili-.r. •
ti«Mi. Imt i- rai-r«l in --iiiall iKit<*his alxivt* tli«» h*Vfl of the ni.it»!>L-'
The iim::!!- ii-uaily ilevt-lops mi tlu» iiiiUT Vh»nl«'rs «»f the Ii|-. "■: :: .
on thi- t'MiL'ue. and ««n the hanl aiul the soft ]>alat4\ It may .x:-:. "
tnn-ii- anti |»iiaryn.\, an«l even into tlic «es4»plia<rns. Inih'-hin-r
at time- it ha- Im-*!! tl»nn<l to iriiiw so thirkly that the luru'i i-
entinly «Miln<lMl. The local <yniptnni< aro coinmimly tii'»- -!
eatarrhal -tomatiti>. The ir^neral symptoms cU*[X'n<l n\M*n i\v ♦xt'.:
local «li-ia-«- tVom \vhi<'h the infant is stittoriiitr. Iiifa!it> alilvvl :*
«li-ea-«- -M.n Iwennie atro|»hie, from a hu'k of j>ro|XT iiniirishnieuT. :-'
nf'iin MJiwillini: to take their f<MKl or c-aniiot swallow it with* nit 'i:r '
lhv«.No^i-. — The ditVerential diasrnosis i> si^hlom di:H .il: :
('nnlh"«l ma-^e- of milk on the inner stirfa<fs of the lip- a::«l • :. * .
ma\ re-« niM«' elo-i-ly tin- fnnuiw <»f thrush, l.Hit thr fornii-r :- >.:\-':
away. whil«' the latter i- tlitlienlt to flishHlir*-*. TIk* «li-eas« > -i "
det»rmiii»d l»y plaeini: -»ome of the piiwth iimha' tin.- mier--'i>.
pre-ent- eharaeteri-tie ai»jMaran<*t*s whirli I shall pn^^otitlv -li ••.•. .
l*K<M.\o<i>. — The pronrjin-i^ of tlinish varies aoMinliiiir > -_ .
«'..M«li!i««ii. tIm vitality, and the air«* of the su!>]«'<*t on \vh'«i:i i: i- .
rii. »ii-t :i-f may la-t indeiinitely if the iiiiuith is nut «7irit*ir.I\ :. .'
ii- |»;"!'Mi_i:iii«»ii may ren«l«'r the prouiiii^i-: nii»re irravt . Wi.-i- : .
i-^•r\ . \i. ii-ive. a- in the ea-e> where it has inva«l.-<l ih.e .i-;i.-'
|n«i.jii..*i> i* viiy nnt:iv.»ral»h'. In these oases tli>turl»an'v- "1 '. -
• hi. ri'- ira'i aiv apt ti» ari-e and t<» ineivase the likeliho.Ml ..f •:. '..:..
A- :! li! , li.»-v< V. r, il' tin- infant'^ health eaii Ix* luaintaiiM.ti. "■
I'.«:il II' .iiiii. lit i- earrii'd ^nt thoroutrlily. tlu» proirno^iw is fav«r:.'':
Tlt \ ^^Il:^ 1. — The tnatment shonkl l>e dirt*et*Hl to the 1.--.1 •:'
i:i'.;:Tii :i5i.l !-. -!ipp..riin- the -treiiirth hy pni]KM' nourishnienr :u.»l -^
•:.!it:! fl.. r.iiijii- ha- he.-n erailieat^tl. ( are shoiihl Iv taktn that---:
.•..•i:i. .-t.-l '.^iii. lii.- iiii'ant. .-peeially th«» nipplc»s aiul hottks fnu.!-
!.. !.. ::.l. ~! .. iM l.e a-.-j.tie, -1. that it -hall not l>e ^■'•intiniially i*^ r.'- '
i- '••' ••• • !• '.'ii'l-n. Th«' month after ea<-h foeiliiiir. and aK«»l-:--
:'"li''L:-. -:i-'.''l •••• tlinrMnuhly and s<»inewhat viir«,roiislv ruhl'": '
-•i i* •: !':•- rii.fi..!, 71. ]iaLiv 770) which I have already r»-.-'iuv-
I-.' :":.i: ;• ..' •.:' -!..:!i:iTiii- eatarrhalis.
W :;. !-. T... .li-. .1- i- in the <e<<»i»hatrns it is l^-st tn^ated hy tb ::"
11 -t a - :t :.!.:« i t li., in order that the srrowth niav tlm- U nv
ral'\ -I- :r:':. .] !!..«i) :!..• mneon- memhrane.
Ill i:::.:y ■•,-.- r'-.-. • li-a^i- i< Very Inti-actablo. No si>tvial dn:;: ii ;
ptlie tongue^ lh« ^ni», iifid the iHD^r sm^oe (>nH^^^^^HoV«fed almcNit pntiTC>1^
bite nnd gmybh-whito musses, in texture somf.'wl^^^^^(Dlitig cunll^ milkf and
ove the level of the epithelium. Between lhe«e pttcbe» the mucous inembnine is
There U a moderate flow of saliva. Tbi« morbid gmwth apparently do^ not
into the pharynx. On endeavoring to remove one of the<ie pntcbe* you ttn* that
4 be done readily^ ^ would be the case if it wer^ currlleti riillk^ but that it baa
laad between the epithelial cells down to the underlying mucous membrane,
U held Ao cWely that it requires considerable rubbing to separate it. In thid case
th 18 so extensive that it simulatea a membrane in some places, but its jK^enorally
suHace, its elevation above the level of the mucouf membrane, and the charac-
iippearance« in other parts of the mouth render ItA recognition quite ea«y.
placing s<>me particlcd of this growth in glycerin under the microscope (Fig. 96)|
a tangled mass of fine, almo«t translucent, roembered threads.
Casi 891, Fig. 98.
I^knm
of tbmsh fntenpenM*d with spona and Iwfitf dacaneimteil ceUn. {Low power £tlia Oe. %
7S.S
PEDIATRICS.
tulMnuliisis, syphilis, and disc»ascs of a like cla.ss. The formers : |
rarrly >mi in the nuKiuis niemhrane of the mouth tliat it ir u«'i >*r- ?
(h'MrilK* thtin. Thr hsions which ix'cur hi the mouth insyjiL«i-:
alnady clrs< rilHM.1 whrn siK-jikin^ of that disease (l^age 494).
C^SE 891. Fig. 99.
IV
/
Si
i:r:i ti"
r!iil. li-
lt i^
tM ih,
i:
t!.:- I
, .;' t '
.4-
iwinu' !).< : rniHiion of sport»s in the mycvtium. fZeisn Oc. 8. hom.vcc. imn-r :. ^
■•»M
• n.
a .1
«>r
a.l
11
It i".
i- a-«-
•n ill'
joiniii
1 .1 »' ■ V ,
(i vMiiLKN'twA (Noma. Canerum OnV). — Stnmiii:- :
r:in-t ami nin<t iatal furin of stomatitis wbiA .--.^
ii-u;illy iiirt with l>i>t\veeu the ages of three aud ?^ve.v-
.•liara«t,ri/(il l»y a ^aujrrenous prLK?ess which K-iriii- "-
■ innrr surtaci* ot' the cheek and spreads with gmit r::v
^ ti-Mi,>. all o\' whi<'h i^iii \x} involved and qiiicklv i\\<-
— it i- j.rnhaMc that thert* is a speeitie perm whMi ■-->*
riii- .T-aui-in has however, not yet l)eeu dcienuirwL ^'■'
ii .1m- n.t attark a healthy niueous membrane, aihl tlr-
ri .- .! -t.-iiiatitis csix't^inlly stomatitis (^tarrhali>. ^>
: .r :> nl..iM<a, prcciHli-^ it. Furthermore, stomatiti- :-•
. !::: ■ Iv- lualihy rhihln n, but usually affect^ thse wh--
■ ■! ■. j'-:!tI\ ilrl.ilitatt^l. It oceurs most oinnn^'nly"*^- '"
\. : = .'.ir.:ita. csiKH-ially measl<*s. The disfa?e t^l-^ -
i Tiat: .11 of mmniry in too large dose=.
1. lianl >iM.t in the mucous membrane, n?i:i^-;
;- ^ I 1. . in. -^ iranirronous aud extends rapidly thP'^-
t!. cluvk. pr^Klueing: perforation. It maj i^"
extf
tisr.1]
'^ri'i 1
V t:
ey*'
JH»1
TV
i-
su
In-
ri
ni'
til
SI 1
IK
li*
a I
h;
i-
a
tl
II
ii
n
it
a
8 of the face, and also invulving the Iwinej?, which beiwmr dctiudotl.
peth become lor»8e aod fall out. The txlor from the ganj^reiioiu? tissue
pessive. The How of i?aliva Ls very nmeh inereiksed. 'I*he de«:rce of
log which the ehncln?n undergo varies very much : sometimes it seems
fthey suffered no pain whatever. The tem|)ernture varies, at times
f raise<l and n^mn Ijeini^ siilmcinuaL The pulse is weak and ra|>id.
|lp|x*tito is diminished, and the ehildn;*n are likely to have diarrlitea,
iblv due to the infectious nature of tlie pivwhicts of the mouth which
(rallowcHi, Hemorrhages art^ rather rare, aiitirtlin^ to FoiThheimer, as
llood- vessels are usually filled with tlirombi» Secondary atflx'tions,
b catarrhal pneumonia from the inhalation nf si'i^tie material, are
pwmmon. The child may die from one of these st*eondary afTec*
I or it may become more and more weakened by the hwal t'ondition,
pnlt^s tlie morbid pHxt^s is arrested it will die eventually from ex-
ilA«N(>si8,— The diatrnosis of thus disease, exfxi'pt in its earlier stages,
uUflienlt* At times, however, a ItK'al ulcerative process produced by
lyed tooth may simulate (»Iosely stomatitis ^an^nenosa. In these eases
la^nosis is made mure diffit'ult by the fact that the tii^ues of the cheek
bcci>me hard and liM^k a^s though perf^iration might take place, Co-
ptly with this condition the idceration of the prum and often of the
ps membrane of the cht^ek, with the ibnl odor whi(*h emanates fi*om
ikes the similarity of the two diseases very striking* In simple uleer-
froni a tootli, however, active local treatment with solutions of myrrh
soda a>mbiiK*d witli fVr«[urnt washing of the mouth with sterilized
' is scxm followt*d l)y umrkt^l improvement, while where stomatitis
Cnosa is pivsent the morbid pnM.^»ss tiintinues to extend*
X5NC18I8. — The pn>gnosis in cas69 of stomatitis gangraiioea where
an' id is almost universallv fatal. Cases have bc<?n known,
I
~wm
790
peDJATRIOS.
may become vuliirmhle to the organL^m which produces
Qosa. In stoniaritis gaiignenoea it is very imix>rtanl fur
tz«almeot tlmt it iAmuUi be began very early in tht* *i.
diagiuii^is hns been detinitively made, it is wiser not to temfitiris i
cationis of mtrate of mUvt and other drugs, but at otKt* to pbtt ilrt
die bands of a Burgeoii and have the entire area of th«^ sniaiBii
excised* It is nlso well afler the gaitgreiiou<3 procsi^fi bas beco i
the kfiifi' til destroy an area of healthy tissue by mesm^ of tk I
tlRTrtio-t^iuttTv or by the galvano-cautery. There ahould lieflM<
o|M*nitiii^ u])OD tbe^ cases^ as great destmctiou of the tifiieoesinif ti^p
in even a few hours.
After the ojmration the tisauea should be inspected fpeqwoflv^i
whether there is any return of the gaugrenous sput/*, and, if hiad, ;
spots should \^ removed immediately. As tlie diseadc b veir tpify
plastic o)>eratio!is to obviate deformity should not be utid^sitaktii i^ ^
atler the oj^it^ratiuu.
In treating thene eases nui^ically it must be remembered thai tt*^
is in a very debilitated et>ncHtiun, and tliat if it is suffering frt>ai aaj««
di^eane treatment directed to that disease is iudiw^ated, ak«) that ^dss^l
are required to prevent the already weakened child fn>m dybg<»f'^|
tion following the operation.
Here is a liul<) girl (Ca»e 892), four ymn old, who baa been brought to tk li^M
be operated on for Btomftlitis goagrsnotA.
BlosnAtltiB gcmgni^oBa, kft cheek < before operation ^ Ktomale. I jmm «M.
Id this case the dbease was apparently pritiiHry, and began on the tb« bittiii^^
mur.ujus incnnbrHue of the mouth. It spreud rapidly, »ndf nlthtnish titeted Vrld^fP
cnlioHEt to tha mouth witb various solutiongi has now, as vou aee bin>kea tluw^^^
cheek close to the ala nasi The teeth are li>o6e in the middle of tfat U|ip<ritv,ai^
DISEASES OF Tilt: MOUTU.
791
^fi Amount of hI veolttT necrcMU. Tbere U & strong g»ngrenouF odor fiom the mmith
tiiftuei of the cht-*i'k, and a conPidenible flow of saliva. The child's jgreneml oondi-
llr, but 9bc U bt^oorninc: riiore dc^bilitat^di has lust her app«tiir*, and has a slightly
imperature. Tbt» opemtion should be performed immtxliutelj*.
Blamatltte (nrngnvnaea* li»ft ciieek {»Ster opemtioo).
jtient history.] The chiH^k was operated on the day &fter the child entered the
li by Dr. U, \V, CiJwhmc, Tbt? wuund healed readily, and this picture (11). taken
tonths afterwards^ shows Uie tear on the cheek close U* the aim nasi and a bo on the
Slomatitlf cii
' tho child At^in muirned to the hospltaU and on examination wms found
Ht the appoamncet which are av»n in thio picture (HI ), takiin at that limit
792
PEDIATRICS.
The right cheek wtA much swollen mnd tndumti^, «^n3alljii]id9ti»^:
ptfitriiWuni (>r ih«' 1ow<*r Jmw on the ri|;bl Hid*- wiLe t<>ui>d w be MSmt4,t»i:i
ppic<«^4 had unclcnuitiKl the whr»k* rb«***k u« fttr i»j* tlie i^rb\U The Mid i
Dr Bradford without »uy vxtemiil oiw^niii]^ of th«.» cli«><ik. The *oujm1 W..
child WM ditchftrgtHl fn»m thi^ h<**|>ilal, but n*turn«d ^orne numtlia l;i
i>p«»ning e*n iho rtght cheek. ThU wn» ttg^Min upptirvnilj c?ui^ hr -
ktAT the child wiw found tn havt* in ih*- lowtr J«ir a iimocMt ^ii
cunv^cl in the upper J»w, tier hoiiltli woa po<>r« #h«^ wiis |Ml4t nr ..
npptito. 8h«5 WH* opmtMl ufion Again, utid a «4H|ti«tftrt]iii w«# r»'fi
Jnw. She thon tmpn>vtHl, nnd thU ^ieUiro (iV.) wiu liUcim sums lauuii*.
WM appftrent))' in ftiir htnlUi*
*%
k
The micpoTOopic exumln^tion of the gangrenotis lisftoes ivmottd it tk flf^kj
prejiontod m»lhing Mgnittcant of any especiiil dU^iific, and a culture maatTfflii^
showed only a few gtreptcK-occi.
You will remember the case of measles (Case 2-57, page 6^7) eompbcatuAVn
gangnunoaa which I showed you at a previous lecture /'and the rwolt flC «iiA l^
report t-^ you.
As I told you at that time, the disease was prec«^ed bv pfrtuicu, ia
brfHit'ho-pneumonia. After fehe had the pneumonia for serenteen daTshcraElft^
bei^an to swell and a bad odor U* LH^me from her mouth, but nothini^f^prdalav^til
in the mut-ourt membrane of the bueoal eavity. Four days laif*r the iwelliiitl
had mmh iiK-nni^r^d, and there whs n?deniu of the lips and evelSd m tliiitthel
partly closed. The swelling wn* fern i fluctuating. The teimi^rature varied L _
39.4- C. (lOF to lOa^ F.), and the c.>u^'h had much le«*<*ned. On the Ml*^l
bluijih-black spot about 1.5 cm. (| inch) in circumference appeMn^ at the mMi
the mouth, and this rapidly increaged during the dny. Two davs InX/^ dba i
area had increased considerably in eixe and presented a cnreular oiitfitH! vilfc ft ^
murki-d line of demarcation.
The child uUo liad a profuse gn^eni^h diHrrbcua. On the followinac dar ibil
rapidly extemled, and soon Involved the wliole of the Hght cbe«k ihif tidlti^^
mouth, and the riurht no-stril. There was no external b^, ^f tU^^ TV «
extremely emaciated, and fn>m the beginning of the atUick wa^ In a hiioete «
L
DISEASES OP THE UOUTH.
793
treatment of the diMnise wta deemed ioiulvUubleu It died suddenly on the
Ca»e 257.
^tU gm .
•jiiude, 5 yean old.
5SITIS. — Glossitis U m rare a dir^^ase in childrr^n that the* p>s-
if its iKfurreut^ only ntinl Ix- mentioned. In tiiis atiwtiou there is
\ mflammatiou of the tissues of the tongue, aeomipaniod by fever,
fcent of the organ^ and eons^iderable pain. There is usrially a hypt^r-
of saliva, and at times the obstruction of resj>i ration ihnn the
I of the throat by the greatly enlarged tongue produces acmiewhat
f i^ympt*ims, thouj^jh, as a rule, not serious ones.
di,sea,se may bt^ caused by diretH injury trj the tongue from eorro-
Itancn:^, by heat, or by tlie stingy of animals, and sfimetimes pmljably
I. It rims a variable course; it is not especially serious, and tends
er after a few days. The treatment is [mn^ly sympt^miatic. The
ItK'al apiilication of iee and of it^MH^ld alkaline j^dutions to the
^d mouth is indicated,
Ijditiou of the dorsum of the ti>nj^ur is soractimr*s met with which
\ of a lx'tt*T name is called ilnf/nti tjetKjraphica^ *' nmi>[>y tongue/^ or
ring rash.'* One or more small juitches ai>|>ear on the dorsum or
pe tongue, wliirh in a fc»w fhiys may spn^ad and coalesce, txivering
large portion of the stirfaci\ They climinish in size or fade with
bidit}% to recur nt variable periods. The patehes are red and
iiid the filiform papilhe an- absc^nt. The rt^t of the tongue apj>ears
ixc^pt that the ^mpilhe on the lK*rdci*8 of the denudecj ^Kirtions are
id pnuniiient. The etiidogy of the dist^ase is unknown. It ooeui-s
kehisively in children or in young adtdts who linve U^'U subjin^t to
ShildhfMKl. It is vcr\* benijrn, and givt^s no discr^mfort to tJie child.
Upal imiHtrtance lies in the fa*t that it is 8omctim«*s mistnken tor a
fine more iserious disease. No form of treatment ka^ been
t« Mtnir n! the atit-t'tioii is ii i)n)iai>se oi tne tongue, wnicn i- •
iiiuii-lv rnlar;r<il in t'viTv dirfciion, is usually of a deep vioUt
i- rnvrnil with a thick, whitish coat. The protruded tongiie i
ami rvm nlctTattKl bv the twth, which are ofteu pushed fonvard:
rarinii^. Thr saliva flows continuously from the mouth, the
Immoiii.'^ thick and uhvratwl, and the forcing forward of the lip, 1
vrlnm palati hv the weij^ht of the tongue renders suction, majti
dr^lutitioii ditlicnlt. The nutrition of the child is thus mud
with, ami thi- interfertMiec is one of the most serious resulti^ of
Thi-i mmlitinii is not a glossitis, but a deformity which seems u
atnl with c^'i-tain other malformations of the body. In these
thr hand^ and feet are apt to be large, thick, and purplish.
Macrnirlossia ap|K»ars in two forms. One is the fibrinous, ii
<'onn('<tivr ti-sne is jmthologically increased between the mu«
Thr other i> a cavernous cvstoid degeneration of the interstitial
ti<-n<', hy which th«» n»snltin^ spaces come into connection with
vr--rU, ninstitutintr a condition closely resembling cavernous an;
whirh it rccrivi'-i its name of lymphangioma cavemosum.
riir di-casc seldom tends to recover, and the treatment is
innrh nlirl' a< |M)ssil)lc to the great discomfort which arises
<l<nn-inL^ thr mouth friHiueutly with alkaline solutions. E
-hniiM Im- dinct(Hl to the nourishment of the child. In ei
-iirjirnl intrrtrn-iicr is indicatcxl where the child's respiration
imti-itinii ;irr ntlrctcd, and in some cases great improvement is a
l»y th«' ninnval <*{' part of the t4)ngue.
DIFFICULT DENTITION.— I have already described
l>r.M<-> ni' th«' normal development of the teeth in iufanov
IuhmI, jiinl \\i\yr iin|)rcss<*d n}M)n you that this process is a i
Diir. I'll.- t« < ilj arc (I«'vrlnp(*d at birth to a certain decree, ami
. I". :i-<' ill ~i/<- iliii'iipr iiitlnirv until thcv i>i«»iw» flio rrt%9^^ ^.^.l o
ii'UNi »mii, wiiinnn hih MiiHiivniiiin' uimw im iii^^^^^^iii/ii ttnnu
f bev()n(l the general Qcrvous trritatiou which ariij^^^B the tWlmg
leeomfurt in the mouth and head. In the more extreme vui^e.^ the
I will Ijc so restless at oight that it scarcely lies still for half an lumr
time, and may spend night afler night crj^ing out oecasionally a.s
p in paiu, and knocking its head against the sides of its crib^ so that in
[cases the crib wil\ have tr> be padded. These infants also have to be
|ed sometimes from knocking their heads against the floor or wall, as
^m to beoome almost frantic from the continued irritation from which
are autfering. These symptoms occur with such regularity at a time
[ a tooth is in its final stage of development, and cease so uniformly
i the U>otli has attaintxl its growth, that the ciiusal relation between the
I and these nervous symptoms seems more than probable. This rather
jyte clinical iL^CK^ation of dentition and nerv'oas symptoms is, how-
j^rtially explained by the analogous symptoms arising from the ana-
pal relationship which exists between the roots of the teeth and the ear.
i long been noticed that in certain individuals during the cximpletion
DIAGRAM 10
Bfttbetic guiglicni ; B, wnaoil^iMitor wane*, C. ftflbreal trntiMilhetle ibm fhmi ihi»tli of B ; D.
ESfttc oelli: 2. ellbrant tjuxpnOkiUc AtaBai peooMdlnc lo tnarr/; W, uffff dllsMd ;X oanxul dM
7IM>
PEDIATRICS.
Tli<» tr«'n<*nil Vtoscnilar (llsturbaiico in the ear, represented eiiL^r t"^::
iiiirniiirnrtal»li' fiH'liiiij nf fiiliu^s OF bv jrc»neral pain, may Ik- pr^iJ^-i:
<asis(if (lillicult (Imtition l)y tliLs cloi^ conn€»ction Ixitween the H-n-'.-Li:*
iHivr^ and tin* synijiatlM'tic. Acconlinfj: to Woakes, a «.'<>nsiil».raM « - :
oi" tin* l)l«MMl-sii|>|»ly of the menihranc of tlie drum is ilirivMl rV ^ :
artrrv that havrs the iiiUTiial ean»ti(l in the carotid canal and |ir>nv>
viiy sh«)rt lonrsr dinntly to its destination. licing thus cl«>Sflv nL>-"
with a hirire arttrial tniiik, this small tymjianal branch is veniav-ni
sit'iat«Hl I'nr a spti'dy aiij^nientation of its blofKl-snpply. The Dtnivj?-:
eoiistitiitiniT the <an»ti(l plexus at this part of its trounce e«)me larvlir:
thr «itie ^aiiirlinii. (.)ii tht» other hand, the inferior dental iien^e j'lpf'j:^
the ^iinis and the t4H'th also eommmiicat<»s with thi.s gangliDn.
\Vc thus arrive at a ilinit channel of nerve coinniunicatirm betw^Dr.
snuHM' of irritation in thi* month and the vascular supply of the (Inin-i-.i:
The «':u'ach(' whicli aris<s in tlu^se cases is produced by the vo«tl? o: t.-
nu-mhrana tyinpani, \vhi<*h lMiH)me greatly distendt»d, and the ai^'Oin]<a"i'"::
stntrhini; of the t«'nst; and s<.*nsitive tissue in which tliis cxcurs atxwiDtr '
th«' |):iin.
1 hav«' rcpnsrntiKl in this diajrram (Diagram 11) the anatomical Dtrvw
eonniM'tion U'twet-n the te<'th and the meinbraiia tynipani.
DlAiJKAM II.
A. :yiri...!i:.- .n;!
I .■ i.i- f. ii;|' >r.ii !!• I v.
1'. iii-l r r.pr. >. in- i!..
L::iiiu'li..ii-. C, t<K»th ; D. iutcnial caiv»tid : E. lymrmn-il l:--:v
.'.iir i.niMi'li i.f lUiririil.Mcmptirjil niT\-c. Tin.-" ili-iul lir...--.:
■:n:il iu-rv«'.
Yon will thn-^ ><•«' tliat a <rreat many symptoms, iisuallv of sliirhtim|'":
bnt markrd fnoii^h to ^/wv innch dis<'<»mtbrt to the infant, mav ari?i' JnH'^
this |H'rind ot' drntitiun, whi-n the infant's entire nervous svsteiu stf ni-* t" >
in a yrvy s«'nsitiv<' condition.
(irM-LAN('iN(i. — The (|nesti<»n of lancinjr the gums durinjr tho i*'-'-
oi' dtiitition i< one whirh ha> <riven rise to much discussion and t'*^-:'
diverse o|)inions. In lljrnu'r tinu^ it was erroneously Ixilieveil tliai ti.>
t<cth playrd an important part in almost every disease >vhich oceum'i '■'
«arly \\\\\ It wa^ al>o -upposc<l that lancing the gum relievwl the r^p-
t« ni- of xhr^r di-ea-c- in >oMir nnr.vplained way. This extreme view ^'-a
had Ui 1m' iiiodifuMl, and of* late years many observers have oowe^^
CI
ih
in
til
11'
111
nt
<>1
<»1
h:
ot
tl
H:
tl
re
tl
t*
tl
ti
r
piiring the dental period two cla&^es of iiTitation are met with in con-
on with tlie t^dh : (1) irritatiim of the drntal nerves, with j^yriiiit<miH
ftflex aural dlstiirbaiic'e ; and (2) irritatiini of the gum over the erown
le tooth frtmi pressure, with syraptinus of local irritation. We here
[two etitirely ditfen^nt c«>nditions. If, wliere [laiii or 8vm|)toiiis in some
r part of the eeonomy ^eem to ariee from dental irritation, we find that
rum wliieh covei^s the crown of the still undeveloped tooth is 00ft and
i8 in *>ther [miti? of thp month whei'e a t4H>th i^^ not aliont to eome
dl^h, lanring the gum.'^ is manifej^tly almnrd, ns there is evidently no
pi for making a wound in the mi»nth.
The seeiind ela^s of cases, however, though exc^^'tiingly rare, must still
lized asdihtiuet in tliem^selvc^ and iitiuiring es[>ei'ial treatment. In
it is very evident tliat the gum im some ri-ason thws not give way
growth of the tooth. Where the gnm covers the erown of the tootii
kissuee are swollen, ten.se, almrjst c^artilaginons in their ftvling, and liot.
b like conditions, either in the mouth or elsewhere, when this combina-
of abnormal conditions i» found over the crown of the tooth, it can be
iyed at once by the lantx't.
t have here t^vo diagrams which represent the condition of the gums in
E» the teeth in the two elanse^ of (^ases which I have just mentioned.
•st diagram (Diagram 12) you s^'c that the rauef>us membrane over
of the tooth is flat and on a level with the rest of the gum,
DIAGRAM 12.
ttUS:!?
tk, tooth In Itaoe »oeket ; B. )aw ; C. k'tJttt, !M»n, nrit Lufliuiu»il <jr vwoUeii ; D. d«nUl lusrm
rhk is the condition of the gum in the nmioritv of cBsm of difficult
I»8
PEDIATRICS.
PRESCRIPTIOK 75.
Metric
Atr.'pm;i- -iilphal. . . .
(tl\r« rini,
A.|. .1. -lil
M
Siir. • I>r"p^ t'»r aiir.il coiigt'slinn.
Gramnia.
0 OG
&& 3 75
Apothecary.
B. Atn>pinae aulphat.
GlyciTini,
A4. d^•ftlil. . .
M.
In ailtlili'Ui t<» this, hniiiiide of potiissium should be given in :■:
d(}^r< to tlir v\W\n that is iiiiliratKl by tho I'SiKX'ial case.
Ill this ii«'.\t «liaj:raiu (Diagram l.'J) you will s?oe that t hi' mm-- m-
hrant' «(»vrrintr tho ('n)wn til' the tcnith is niarki.illy raised aUivir lij:
ol* thr ^illll.
DlACntAM
C
1;
1«M>.
A. tiMith in Imne ''•M'kct : H. jaw-bone; C, gum, tense, inflamed, swollen : I>. •ion'jil urr-^
In th('<«* <*a<<s, symptoms of local origin and often of grc-a: ^■
ari^'. Thr infant ivith'ntly hits extreme pain and tenderness in i'> -
It crn's inr(s>antly, and often n'fiiscs to take its nourishmont, on a-^'- . '
the arnt*' pain which it suffers, and also of the tenderness whirh iriTri
hy the least pressure on the gum, so that it ma\ »•
weak and exhausted. There is usually a <vi>i:"
htiirhtenin^ of the temperature, to 38.8° C. and »vrii ; -
and 10° (\ (102°, 10a°, and 104° F.). VomirL. >
nnmnunon, and there is twitching to sueh an e\:ti'
ennvnlsions seem to l>e threatening, and at tim-:- i '.
orcnr. There are also great restlessnc»ss and iii-HOuu
In thes(» eas<*s laneing the gum pro<luces imm^:di::^ :
The tem|K'rature quickly goes tlown, the pain avA :''■'
nervous symptoms disapjx^ur, and the infant ait*?r >.* ^
ipiirtly for an hour or so wakc»s up very hungn- aiil r; -
it- lood witli avidity. The treatment in this eIa^- t" '^•
when th<' diagnosis is once made, is evidently to iiin-^
i!inn. This is done in the following way. The ir.:. '
placed in the nui-se's lap, with its head in th»' li} '
phy>ician, the nurse holding its arms firnilv. Th«' pb-
at'trr havin^r first thoroughly sterilized his hand>an.lv.>
thr infant's moutli and gums with st<Tilize<l water. <:!:•
!nnkc< an incision over the swollen gum well d-'wn :
— ;; ' crown of the tooth. I have here a lancet (Fig. I'V ' -
I am in the habit of using for this purpose.
niilv thr end i)f this huic(»t is sharp, there is less danger of wniD.'. -
md month tlian when using the ordinary bistourr. Tr'^
it -honld 1m' thoroughly sterilized.
the iiitiinl'- lip-
ll-inL^ the l.MMerl
DISEASES OP THE MOUTH.
799
Although much has been said about the danger nf hemorrhage in these
i, and of mfection of tlie wound by jmthogenic orgaiiii^ms, \\?t instauois
WheitJ such results have oecunxxl ai^ so exceedingly rai'e tliat they should
not deter us fmm treating the t^sje projierly as we would tivut uii abscuss
in the mouth, toasil, or pharynx. It has al^o been said that a cicatrix may
form on the gum over the crovrn of the tooth as a rej^ult of lancing. 'J'his
is an exofHxliugly rare occurrence, and nei<I scarcely l*e tiikeu into arivmnt.
"The probaliility i.*^, where such an hiwtant'c Iuls occurred, that the ms^e was not
Bbne in which the gum should have been laiiced, and the fear of such a i"emik
Wm this should certainly not weigh in tlie balance agaiBBt the pjssible exhaui*-
tion and at^ute pain which may continue for days imlees relief is given by
cutting,
I have a numl>er of cases to show yoii which will serve to illustrate
• what I have endeavored to impress U[x>n you in s[)eaking of tltJficHlt denli^
tfoti, — namely, that the indications for lancing the gums very seldom arise*
Thia infant (Ca»e 898), tea monthfl old, hftA been Vrought to th« clinic mth the foUow-
ing hblory :
It hfti one lower incisor. At the time when tbU tiHitb whs (ilK>ut t<» nppear HlK>ve the
I mar^n of thi* ^m the infunt wus vi^ry ru8t1e&«, unci hnd comidt^mble f«ver, und putn in iti
ear. Somewhat laU^r a iiiuec^-piirulent di»cbur|i;c came frftm the ear^ but the general §jmp-
toma of PDstlestnest, pain at times ^ and the local Bymptoms of heat and irritation tn th**
mouth continued until jii*t before the tooth bad pierced the giiin. After that time, which
wa^ tliree weeka ago, the dischai^e frora the car ceased, and the infant became pi'rlWlly
well, the litcnl irritftiion alfio ha vine: disappeared.
Duriiig the la^t thrt^e or four day^, however, the same Bympiom* have returned. The
infant U evidently tiiiffiTin^ from irritation in it'< mouth. S^^motimeii the g^umn are hot and
I dry I and a^ain there i*^ a byperftet:n>tion of saliva. It c^mtinually put* it* finger to the
g^m of the lower jaw, Bametinie6 ahu4j»t locHtiog it near the platx^ where thn tlr^t Unah has
been cut. The ear has bei^n to di*char^e again, and the infant ebowf iigm of general
di^coriifort by rubbing lie Qoae and head continuously and at tinicft crying out uk^ thuui;h in
rn.
On examining the gum you see that it u not fwollcn, and that there ii no efpecially
fender pi>int On examining the ears an old perforation of the membrana tympani U found
In the right ear, which u discharging, while in the k-ft ear there i* a iimple oongastion.
Such ca^es a£ this are often tn'utcd by bmcing the gum^ yet thia procedure it not of
the slightest utte, — is, in fact, eontm-indieated, aa it will only increase the already eai»ting^
irritBtion of the mouth. The treatment h the internal adminiatrntion of bromide of potato
slum and appropriate local treatment for the ear.
The other eai^es are fv) .'Similar and are so commonly met \nth that I
need not dwell njxm them, but shall rcjnjrt one uf the rare ca^a^ in which
lancing of the gum Ls indicate«l.
An infant (Case 894), eight months old, and in good health, cut iti trti tooth when it
was seven month* old. At thi* time thore wen? no nervou« dinurbanci*, the tootli coming
tbrnUL;h tht? gum without any rvfiex or lo<*nl ivnipt/ntM whatever.
When the #ec*md tooth wa« prT^t«ding '*t\ the gum 1 wa« called t*^ relieve the ft»llowing
symptonu. The infant, who had been perfectly well, and who on exanjination showed no
dls<yi>*e (»r any organ, wa* reptirtwl to have }>een feverish, rMUeie, and cr\'ing out with |»ain
for the previoua twenty-four hours. It had t^fUsed to nttiae, hid not ulept for thirty-«it
tioOTa, had vomited a number of times, and waa found to haira a temperature of 40^ C.
S(M)
PEDIATRICS.
{ Inr F.I. It twiirht'il fnun linn* Id liiiw, mid upiiun^ntly wa* in dune«?r -fia: :
«'.•!. \ii]-i<iii.'i. On lAuiiiiniiiL; th<* iiinuth 1 found tliut itiit; of the l^wi-r luiii.-
.i.tiv.K lliP'Ut^h ilif Lrniii. Th«* ijuni next t«» tlii-* iiioi-sor wiis !jrn.a:h •-
. :iriilaL:iii"ii- ill r«i'liii:r. Imi. ami ti-iidiT, »*• thut wh»»nc*vt.*r it wa« i"U':l.-i .:
-••p-.iiii.il wiih pain. I tln-n Ihiki.hI tin- t^iiin. The **xprr-.r#i<»n of puJ:;- -L 1
III. -I ni:irk««l Mil tin- infant's tm-c. 4li>H]>|K.>anMl iiniuttliutely. uiiii w:l- m.s-.
|.r. -j..!! iif p«'rffit tran<|uillity, and it \vu> «'vid»>nt that lh».* »vvi:r»' jtiiii. L*: ■"
lI,.^^■i!:^ll i-iy. Tin- inlaiit Wfnt lo slci'p at onct?, and ^l*:'pt two h"Ur>. WI--
I!- |. iLjiiTuini'- wa- normal, it t'mk thi.* bn.*ai»t with jj^reat eagerni'??. urn] inw: ::
li:i<t 11. 1 niop' irou]»li' in it- ni'Hith. All the rfst of its teeth were cut withrjiai.'
-N niJi!"Mi-.
I have aU) to n'jH>rt to ycm uiiother instance which illu5trai*.-t :c
^natt-r rxt4'nt the iK'<*<ssity of lancing the piims in n*rtain rase*.
An infant (('a-«' X'.K'n U'lrnn t«» have irritation fn>in its teeth when it trae et-. :. •-
nlil At tiii^ till!*- it wiikf up in th«' nii;ht iscreaniinjj:, and c<jntinued t>> HivaiiTr. _
t'l.r '•■M-ral li.»ur-. diinni; wliirh tiini* its pan^nt-s hud to walk continualiy up ^ :t:_
pm.iii vviiii it. Vari-'U-. ii'initJii-.- w«-n* ad ministered, but without the j-lijihttti ^--: l.
liriMii\. ai't'T t\vi» daN-' of >iit1»Tini:. in whieh it ri»fus«Hi t^> take it*: nMuri-hnita--.t-t-.
\v.i-lii. un«l -.•.■jiH-.l MTV ill. An incM.'*ii>n was made over the hot and swollei. jn^ ■ ■
iiiiiiH-.liaii* n-lii'l'.
'rin- ^anii- ^yinpiMiii- .K-curn-d when the next tooth appeared l>eneHth thf ?u-:V- ''-
L'lim. I'lit \v«P' r.-lii'Vf.l. alt^-r wailiiii: f«»r a few hours, by laneini;. Of tb- >'^-
, i;_'l,i..ii t'«ili. 'i\ <T .iirht iravr ri.-5»' ti» •similar syniptmud, but in every i 11*^111* n---
nii'f wa* all"rii»-«l l>y tip* lancinj; «if the gum.
lull
tip •
• >n
-111'
IKII
"I I
t..
iiit
iiik
I
till
Vt ►
art
ail
In
h:i
iu
11 i
lOSE. — The nose is the normal passage for the entrunoe of air to the
L and it is priiiri|ia!ly liert.' that the air is mcHlirted lx*fort» cnteriu^
i In normal rej^piratiou the miinjUi? uiemVirane of the nasal eavitie^,
^imt of tlie i>eeiiliar nliai^e of the turbinatefi Itones, pre*;ent*« a large
to the insipin*^! air, and iri therefon^ adiniraljly adaptixl to filter it of
les of du??t and nii«To-f»rgaiiisui8. Tlie air h also warme<l and elmn|L»:<:<l
It l)efo!T» it reaehes the larynx it Is Katnrated with nir>Lstnre and h<-'at<H:l
El^ierature of 85^ C. (95° F.). This raoclifimtion of the air is espe-
Hwrtant in the ne\v-bt>rn, sincx^ the Inng has mi lately U'cn bninght
and is in such a n^mpanitively nnilt velojMxl eoudition tliat it esui*
rithstand niichangwl air, to which it adapts it^lf Ijetter later in life.
^e already desi-nlnHl to yon (|>age 3*3) the extremely narrow jia'^-^ao^e
jgh whieh the air pass*^ in going to and through the uas(Hpliar}ux in
^ infants, and how easily this passage can become oceluded. There
pt many disc^^es which oec^nr in the nose in infants and yonng ehildren,
kodc which we lind are serious chiefly by being the canst* of oechision,
k of mouth-brtiithing dne to na<al occlusion in an infant, tlie air which
pt bec*n niiiilifitHl by jmssing thnnigh the nose and naso- pharynx may
a detrimental influence* on the Inng and general cirf*ulation, thus strik-
gerions blow at the infantV vitality. In later (^hildluMnJ, aUliough the
^ioD w^hieh arises in the nares may not be sr» serious as regards the life
^ patient^ yet you will si^ the result** of such a oindition represented
tanlnl development of the t4iild imd int**rferem^ w ith the function of
K| With its resulting mental dnlness.
lie most iiommon path^dogii-al n^ndititiu which fxx'urs in the nose in
py and ehildlioiMLl i-^ some form of rhinitis. This may In* acute or
ic, catarrhal or purulent^ hyj>eitrophie or atrophic. New growths are
I Of these the mure «x>nimon is myxoma or simple mue<:>us polypus,
ling from the nose, cidUxl cpistaxis, may arise f*n>m an ordinary non-
plan*, 'flu* luitii'iit is tlK»ii tonxtl to breathe with tlic nutiitl
n-^ultinjx n»iKlitii)n of drvncss of the luiiccnis memhrane «>1* t
throat ami a choking sensation arising tnuu it follow. Tin
iUiwy of an infant or youn^ rhild is to kei'p the mouth shut
when the nos<' is «K'<-hKK*(l it brt^athos with j^n^t difficuhy wli
its fac*' U-tiiinis con^tstitl and even cyaiiotio. C)n lon-inir tl
th<' >ynij»t4nns of con^stion and cyanosis dLsa]>pear, and iht
to snoH", an<l hivathes with coniimrative iY)iufort so K>ng
remains ojH'n, nntil the dryness of the throat wakes* it np.
The pro^rnosis in thise (usi'^s of acute rhuiitis is usuall
dis<'as<* rnns its eonrse in a variable i>erjo<l of from thive d;
and, nnh'ss the ehild is snbjei*ted to tresh exjjosure, it nxi
Tlie pn»^nosis, however, as I have alreaily stated, varies in a(
ilie ixcTi^ of the individual attacked. The danger that a you
infant may die ironi exhaustion where the nares are ocoludi:
ablr. You will renienilKT the ca^ which I descril>ed to y(J
Intui-e (paL^e .M), where a pnny, ill-careil-for infant died of j
rliiiiiti--. Instaneis oi* this kind should warn lis that active
in(lirat<'<l.
riie tnatmeiit should Ik* dinxjted primarilv to relievi
ocelusioii. rhi- i- l)est ae<*omplished by atomizing the m
rii<r> thr oil atomi/er containing oleum petr«->latiim album i
all'ord irlirl'. in addition to the local treatment the adni
-tiimil.ints whrrr tlien^ is exhaustion is indicated. Vou shonl
tliMi thr inlimt i- takint^ a suttieient aniount of nourishui
(•-|MriMlly (lillifiilt to determine if it is nursing, as under these
it will ni'trii hold the nip|)le in its moutli and apitarentlv !■
In't-ntliinii i- >M iinirh distin-lKK.! by the nasal ol>?t mention tb
di-.'iw n III* 1 1 milk \'viiu\ the breast. The various druirs wh
t t\s a nilc, and the disease is ttot mnch more significant than tfie coiyza
fe adult.
^tR0LENT RiirxiTLS.^ — A rather rare form of rhinitis in at times met
lin which there have been a number of aeute attacks and the [>rm*'>is
iBoome somewhat fhnmir. In these cai&es tJie diseharge is e88eiitially
pnt, and tlie name |iurulent rhinitis? ha*i therefore been adopted.
Phia form of rhinitis i& not aceom{>aDied by any eejxxnal enlai^^meut of
Eurbinat4^*4i l)odie8, and narrowing of the na^al f]>a^^^ngt>^ h not a pmmi-
gymptom. The synipt4tms are chiefly a purulent di?^-^harge from the
pie, and nxiness and excoriation produced by the aerid character of the
phe prop^noHiB of purulent rhinitid ii* good, except in extremely debili-
1 children.
phe treatment is the same as in the catarrhal form, es|MN:.»ial attention
I |>aid t*} cleansing the n*>se with alkaline Bolutious and thns alleviating
rritiitiun |)ri>ductxl by the dirtcharge.
have a case here in the ward which illustrates the purulent form «if
bis buy (Ca*e 397) in two And one-hulf y*m> old. So far lu we can ii«c4*rtA)n« then? bt«
bo €«p(5ciHl di^)u«e Id his parents which would be significant in connection with the
it condition of h)« nose. He is wiid tt> huve been wck for four weekd. The »tta<!lc
I with fever und gt^ntfml dit^omfurl in cxrnnection with the nose. Some what later a
Ifgt? bei^iin to come from the ftntenor nares and alwj from the riirht ear. Up to the
jif this iiUiicii he had always been healthy and well developed, and is aaid to have
right itnd to have talked as well as U tieual for children of thiii age. During the latt
he has firruwn won*e* Then^ hM been an increaM^d di»charge from th<^ nare«,
ome rather dull und apathetic^ hat lott hu appetite^ and ha« stopped s|)calcing.
bild lies in bed^ or at tirnfs getf rectlen luid sits up; hia face hao a dull cxpn7««ioi];
not speak ^ and he $howii connderable hebetude. Tliore U very little dischai^
the ear, but a profuse purulent dbcharge from both uurei. The diAcharvT*^ U evi-
^ iHi the upper lip ha» become excoriated and iwoMcn, tie ba« now had
iiiakiiii: tiK' i\niiiin:itii>n.
IlYi'KKTUoriiir UiiiNiTis. — This lorin of rliiiiiti:^ i- rar--
and rliiMliMiMl, :in<I 1 shall thcit'toiv iiu*n»ly refer to it. Kliiiiiil
nf a- hv|M rtrophic when in aiMition to a chronif* iiiHainmiit
miiitiii- and suhiimnnis ti>sn(s of the nosc» theix' is an iwtiial li
i*\' \\u' iiuHiHis iiuiiil>raiH*, \vhi**h n^sults in (K*(*Iiision <it* the nar
Mtjiiiiit iiittrtinin-*' with nspinition and the ivnioval of thr i
rhari:<- fnun tlir imsi'. Oiu'oftho most c^oniiuon c-aiist^i of h
rliiiiiti-- i- t\\v iM-t-lii-ion of thi» ix>storior naix*s by adenoid lth-v
intrrfi'iT N\itli thr iionnal lutsiil seeretion.s by retaining them ii
ravltv ami allowini; them tn diH-oniix^se, A recurrent aoiite r
aUo 1m> an ititiloirieal factor in hyjK»rtropliie rliinitis.
VUr mo>t inarketl >vni|>toni in hyi)ortropliie rhinitis is the na
tinii, Nxliit'li n-^ually alternates fwm one side of the nr>se to tlio
would natnnilly Im* ex|H'<'t<'<l from the lesions, tlie synipt«mis a
irreat n-^th^-iiess, esiH-eially at nij^ht, and various reflex phoiv
n»<t4Ml with tlu* tlinKit an*l the larynx. Thus, there may be ctrntii
ami. whirr tin- Knsta«hian tiiUs are <x»ehided, deafnej^ and
lnlMtiulr. At times interfen-nei* with sjxHM'h results?. There i
na-al HM-ntion in th*s4' e:is<»s, whieh aids us in the ditfen-ntii
from th<' ntlirr li»rms of rhinitis of whieh I have just s])okeu.
The tnatmriit of thes<' easts when they are dependent iiixm
tiir na>o-pjiarviix i- the suririral n.»moval of sueh gro\vths. Mih
-jnay- -hmiM Im- hsihI, and the oleum ix'trolatum sprav whieh
irmmiiHiidrd ill eataiTlial rhinitis. As a rule, these ciises shoul
in tin- hand- nt* a s|>e<'ialist.
AritniMiic Kmimtis (Ozjena). — By atrophic rhinitis is tui';
tinn nf tlic iio-r < liarai-terize<l hy atrophy of the mucous niemhi
till' Im.ii;. in-iniin'MM-j- within the nos<*, a<XH)nipanied bv what has 1
:i ih'\ i;!! .11 ill. ;i- :i I'r^nlt ni' whieh the* }4i»i»r« kfw'kii *-*♦• ♦!.« -,.^..v *'.
The sj*mptoms of atrophic rhinitis are the iiirmatioo of cnists and the
ence of fetor.
liough the ti.ssues whieh have actually l^een destroyed by the atniphic
cannot Ik* restcjred by ti-eatment, the |)atient mn b? entirely relieved
be crii?*t formation and fet^^r by |»ei'8Lstent and patient Icn^al wa'^hintu: an*!
icatious, Tlie details of treatment differ iic^ionliiig to the extent ami
laeter of the dist^a^'. CVn.sis may bc» rc^movetl by spraying or donelnng,
B care being taken to prcvent the washing fluid fn»m entering the
Raehiafi tnlit*^!. If this is not suffiriont to n-niove thi* iTUsts, tlie nasal
ities must Ix^ illuminutiMl with a head-mirror, and the crusts carefully
■bed off with n (^^itton-sticlc. The formation of dry, hanl crusts Ls o(Wn
Rented by frei[ucnt spraying witb an oil. L«w^l a|i|»liinit!ons of <liffcrcnt
luees are i»f usi* in many cases, but tht^rte should, as a rule, lie earrietl
nder the direction of a s|>e«'ialist in the tivatment uf diseas*^ of the nose,
)U8 PtiLYl'Us, — Thin i-, a jK/dmicnlatwl fimmM-tivc- tissue growth
ing fnmi the nnif^iun mcmbnnie of the middle turbinatt* hme. It
pre in children. It d<K's not grow on a healthy munms mcmlirane, and
iways pretx^ed by st>me morbid condition of the n«)«e. It i^ often
iple.
The svinptonLs begm with a na^^al di.scharge followed by ntv^l iKfln^ion,
i diagn^wis Ls easily made by a mirror and a probe. The ti^itment is
iltjmoval of the gri>wth.
CEpistaxis {llemt»rrliag<' fnun the Nose). — During the pcTiiwl of early
klho«xl hemorrhage from the no^ i^ not uncomraon. I have m'^tiNionally
I With epistaxis in young infants, but in my exi^eriemv it is ran* in tin/
months of life. In older eltildivn recnrrc*nt epistaxi*^, es|K\*iidly if
atei^l, points to the presence of an eroi^tiou or a vari«3053e txmdition of the
in the cartilaginous 84:'ptum near the external ojM/ning of the no»se,
be individual hap[M'ns to l*e jiffretrd In biemofJiilia, epi^taxid
^
PKDJATHHSv
aij^tenllj tiii*igriificantj r^ It pUy* a %-t*ry impirtaut [Mil iutMit
thr dwmM9 If* wLielj i4}iitlrt'ji onf Imtiltv Tliir mticlitiiici ^Hi
thb- jMirti^m i»f the respiraton* tnn't ^|w*fiuUy iiuiMirtmit h tbe
HYPKirrnorMv ui* the Piiarynofai^ Ton**ii, ^ Adowiil Qr^
The ^loiifliiliu* iir lympli iiRH'iii* wliirb lincsfi tht* vntilt anil pnslal^
tlie itni<vi'[iliamix m vt*ry t^imiliir to ilmt wliieb cum)M>$c^ tljt^&ralM
tii>t iU^?HTiUxt it. Til' < irc.tiitn^taoc%« this tij^aie beoaslifjp
tnipbii^l, and ipvuft rise to thi' L-ooditinn which iip iL«umIk tl^st^i
mii'ni*id |rn>wth§, |
EnaujiiV*^ — IIj-portrc*[>hy of tJic phary]i|2:i«fil l«>u«it !iliW»i«lii»
tM?cur ill ittfantTT, is tmcommou Wfore the aefH>ii*I i*r rliinl visw, TW4«
h esBifatially tmi! i>f childhmid, as it v^ry at^hlnm ikn'i*K*|j5- tlW ^<*c
Aoute iuflamntaton^ oonditi^m^ or m^tsw ol^triK^tiin in iht* oom' on r'^^'
the ineidftg Gucii^B cif adojiti'ul grivwtlM*.
Pathuixmiy,— The pathological comlititm whk'U i£ fimoil mtlrhflr
ti-*mK*r4 of the ua^r-pharynx h^ an hyp«*rtr«>|>by wliich tn venrsflUlvftt
]iy))irtnt|Jiii* <H>iK]iiUHi of the faucial toniiits^.^ t-jcr4?pt thiil tbi* bttlitf*
a jL^nmtt'f niiioimt of i^mnectivo fibmiis ta^i^ue* The hypeitr»>pli.v mf^^
^n^atir i*r Ush oxti^nt, ^>rueftlmes nol beinf^ Kitflii^ieat tii cms^c waj^fi^
iKt'hi-^ion and at other timcH eniiipletely cKH*1ittf1iiig the pi^iterior otni-
Symfiximk — The fir»t and mosfc pmrntnont fiyitiptotii vrkiiii^^-v
tiiitl<T*tl in i'iiililfi'ti who have tlil^ dirieai«e is that ther brtnthf «tt ii
inoiith-<« ii|H'ii ut night and ,-^114 ire. Ah tjii* rian^ LK*t\vtti*» tii«>rr tjirhM i
rhiltl Ik^iii!^ t4» hniithe thnmgh it** tiiotith aLm whf-p it k avrtb. Ti
iiiterfertHicf* with tho jiropr passage of* the air to the hsTyu% woi ^
i^Hulb* In a rlminif tUrm of phatTti^itiB iitid latnnaitii^ whilr thcbWic
uf the ua^al vnd \4' the Eu^^tarhiaii tiilii*?^ mav n.*siilt io a diivtar 's&nvi
(^mditioii of the middle tmr. Any or all of thf^if! ^oiiit^iQifi 11115 w^
an individual ca^e aectmlinp^ to the aniiiunt cir |Mj^itiou of thedt^vwam
Tht^ ohildV expreasioii thanjreft, and i*H aliiRi^t eliiinictertnlir w\m^ilbif^
In fully devola|»c<L It holdi^ its mouth ojiefi, lhe hiwer jaw Vf^
drop, the HpB are apt to 1m^ thick tmil exi>rr»:-g*iotilBirf*, and mhm w*
(hilnt'tiis h atldvd t4* thf other Fym|it4)iii.s it hit*? a nttutiii lix>k W ^"
condition eontinues after th© eeveoth or eighth vi*ar» tiie Urii|^'<
mmj y apt to Ix^ pmminent and it>^ ^Ulvs t<i lfH»k pmA^d; d>e H*
may Ix- niarkt»dly anhwl, ami the upjMM- jaw narr*>w*tl tairfalk* ^•
tmnvd the twth. The faneial tonsil* may nr may not In* mliw^rd. ^^' *'
n?^ual!y .^1* This rnhirgt^niunt of the faitciiil i«»nsiL< im a^ a ruir, •♦t^^tti^
to the atfk'tion of the ijiiaryitj^c^al tuni^il, and n^it it?^ r*nii«%
DlAaNOSl^*— The diagnosUof hypertnophy of the phArrofeo) i^^
not difficult ia a rnarkod caw or if it i# po^jble tu esjuuitip t^ '^*-
naj^ pharynx. In young infaats the po^teriur rifi#ml smot* fe *•♦ s**'
thut it is almost im|M>88ihie to reach iL The dia^nsia can (iiw.^^
my other abnormal iHmditious, The examiDatiou with the miiTor in
kPOftt is Ui^ually ny difficult id young children that the direct detection
kEmos of the rtiig:»?r \^ oftpn the mo^t applicable m«*an5« to employ in
cases. The child should have a blanket pirine^l around it tightly, so
keep it fnjm mcivuig it*? arra.^. It should l>e held firmly sitting in the
rs lap. Yon can tlieu huld the chihr^^ head with one arm, pressing
bi^'k l)et\vei*u the back teeth witli the forefinger, then j>ass the forefinger
m other baud gently^ firmly, and quickly over the baae of the tongue
Wiind the 8oft paUitc until it n^achts the posterior wall of the pharynx.
^ quickly turning the fing<?r upward, you can easily feel whether the
|r of the ua^o-[iharvux h clear or wliether it k more or less filled by a
il}H)ngy uiass, the hy|R^rtr<)phi«xl ]>haryng(;itl tonsil. There is usually
|e bl<M>d m\ the finger when it is withdrawn, as the gn)Wth is friable
pleedrf easily. This exaniiuatitrn is not, as a rule, very painful to the
but produces a i*ertain amount of discomfort from a choking sensa-
When the finger is omv. in the mouth, it is not %rise U^ take it out
i until you have euniplctA^l your exaniiuation^ as the cliild can nin*ly be
^ to allow you to make a second examination. In {passing tlie finger
^le base* i}\' tlie tongue ymi must W (-arf^ful to get the finger behind the
late, and not to push it upwaixl and backwanJ, tor in tliis ease the
UBS of the }iidate may flvl like an adenoid growtli. The child can
Invented friini biting the fing<*r by sim|>Iy keeping the clieek pressed
Ben the tt^eth tis 1 have just dcscrilx^l,
Uek of development of the chest with flattentng of the front of the
DC may \y^ cause* 1, not, as was formerly supposed, by the enlai^gemeiit
le fanrial tonsils, but by the mM'lusion rrauscd by tlie hyjiertrophy of
pharyngejil tonsil. Thl-^ hy|»ertrt>|ihy witli itM resulting najsal oerJu-
Imay also 1m* the cause of pharjngitis, laryngitis, and i>erlmps of bron-
[.catarrh or *isthma, wliich mn lie cured only by the removal of the
\
808
PBMATRICSk
you hmvo once leon md Hudied n «u« of UiU kind, yau will liavr no
a dii|?iH»»ii by BimpK' innjj^wtitva. On exainiriiii^ ihi? cbiiava mouih ;»i« —
in very muCH nMied, tUnt the lonaiU arc? <?nlmr|^i, ihjil the soft —^ - -
forwarri, iind tlmt the |ihiiryux U itiirn»w«>r UiAn normiiL
(BiiUequcnt history J After removal "»f thi? ».l ui
Ooalidijc fthe fmind no dilBcaUy hi kw^piug the inou v vliiitMii
ftt ninht, und slept niucii more quietly than before. 4l»'r ^tiieh»l lk«aiUii_,
dcvclupmofit uf bcr face during' the renjainder of it.4 «cT>>wtli will iUidM»M>f b
Prognosis. — Tlie prognosis of cases of hypertrophy of the pi
tonsil varies greatly, for there are all forms and dcgrei^s uf the af ■•
8ome vn^es the swelling of the lymph-ti88ues cx^curs only at itiienijj- • •
the child has been subjected to exposure in inclement weather: itwil8<
show iL'*i'ir dimply by ofxlusioii of the nares, with the result
htstioj^: ft»r 8ome weeks, but di:5appeiiriiig eviintually as thti w*^. .
milder or if the child ia taken to a different climate. In insist mip^.^*
ever, where the atfeetion Is at all pronoiincctl it IxHxmies^ rhnmir, »^
symjitoms usually iutTca*^ in severity up to about the time of p^''^
Yuu must remember that the naso-pliarvnx has an Lm])(>rtiBt ft»-
besidcj^ Ijinng a paf*sagt^w*ay for the air. It lnbricat4«8 the ptuirnii, «*J ^
the aetitju of it8 miiH44es opens the Knstiichian tubes during ^^^ **
swallowing and yawning, thus ventilating tlje onw You will :^v, ti>'
that the prognoi^is must vary iu-eonliiig to the d^^ree in whirls aaj** '
functions art* int+^rfenil with. Whrn* the uhihlrcn liea^me dmf tli** -
gnidoally lose the power of sjK'erh, Again, from being dwil' tb«*v m' -
into a condition of hebetude which sometimes cloeelv ftimul^'- ^'
thonj^fj it i.s not true idiiKy, for tlie mental condition quicklv dmv -
the cans*:' of the disturbaiu/e has been removed. Where the'dist*?- l- -
nostii'ated in its early stagt?*?, or later, unl^ irre[iai*abK' injun h* *'^
k
DISEASES OP THE N06E, NASO-PHARVNX, AKD PHARYNX. 809
le to the ear or ike general developnient, the progin^sL? is very favorable,
|tivided tht* proper trcratment is caiTied out.
Treatment* — The best treatment of tlifst cil<4'^ is tt^ remove the
ienoid growth at ouee. The oj^niitiim in tlie handrf i»t' a skilful surge* )U
not daiigeroas mid should be uuhesitatiiigly mK isi»d. There are a num-
^Tof inethinh uhieh have been eni|jloved iu operating on tbesi* ca*^*^. The
lild shtHild Ix* thon Highly etherized. Some ojx*rat43rs pivler tn have the
lild held .sitting in tlie lap of au attt*udantj others to have it lying down
itix its head bc^nt backward. The soft palate is drawn ibrwanl by niean^
^ a palate ♦hfM>k hekl in the left hand. A j»air of jjost-uoftal fonx'ps hehl
I the right liand is intr«xluced, closed, int** the uasH-pbarvngeal cavity.
*he bhidrT* ai-c then oiK*ned^ and pieces of the ma^s are grasped one afler
|€ other and pulk^l oft' gently : under no cirtHini.stan<t^ is forc«^ to In*
fcertcd. With pn:)i)er care and assistance there is no danger to the chihl,
EkI ofteii in ten or twenty minutes a morbid condition which has existed
^r years may Ix- pnictictdly cnrc*d, Then^ are, of conrs<', many detail-^ in
lis operation W'hieh must be thoroughly uuderstcKid in order tliat it should
e sncoes«ful. Then*^ details, however, need scarcely be mentioned here, a^
le ojieration should be performed only by one whose work has es[XM.*ially
pdaptcd liim 13 ^r it.
Tbes*' gr(»\nhs when not extensive are sometimes removed even without
r with the curette or the linger-nail.
I have here a little boy who illustrates the benefit of op'nilive trtnitnicnt
r the removal of tlie pharyngt^al tonsil when hyjK*rtnjphietl.
lit' {Vaaty 399) h four yt^iirs old. You see that he ha* a very bright eipre^ion, and In*
lemki well ; he ^b«>w6 iioihint; abnormal in oormectJon with the shape of hia nos.e or ftu^*,
[e ht*tir^ \\*\]j ht' «ile4.*p8 with hii^ month shut^ and ba« ft trm p<iu«ge of atr t)in>u£^h a porAH'tly
pniinJ nost' unci nttJ*o-pharynx. When he wa« three and a half yeaw old it wa» nutictHl
kat bt!i enort^d at rii^ht, breathed with hU mouth open, nrid wai> tiuhj^cl to eontlnuul atUokA
f rhinitis and na^^o-pharYngeal ooclueion. Following: ih*9e atlacks hi* h«*arinLC l>«v.*unMi
Vecitedt and, while in hi* *ecofid year he had been bright and alwavf n*wdy to pluy with his
Ikretitit, he Ux*anie dull, and did nut eart? to play with others, but would Ait ftir ht>ui> plfty-
Ig by him^df with his toys.
A digital examination showed a masfr of considerable *i20 blockini; llie pd«*terior nah-^.
In the removal of thij^ mae»f which proved Ui be an hyfH'rtr»>phied phHrynj^*al tc»n.sil, ra|>id
pprnvcmGnt took place in hu grneral condition, tlie dulne^^ and hel»<'tude diiUlpf*l'an^d,
bd within the last month be hat returi»cd Ut the riorriial t»ndition which be repre«>ente<t in
Is iecf»nd year.
Then* are other growthn which ocxrur in the naHo-pharjnx, sncli as
InHinjatii, They are, however, tiwi rare* to need e?*poi*ial th's^^riiition.
PHARYNX. — DLsea^^e* of tlie pharynx in children are es|>ei*ially thune
■Tecting tlie ton?iils, the nvnla, the mift |mlatt% and tiie jKieterior wall of the
fcarynx,
To>3.'?n.LrTLS, — ^By tonsillitis i^ mc^ant an inflammation of ihi^ tiasuen of
le tonsil. This inflammation may be m^ute or chronic.
Acute Tonsillitis. — Acnte ton^HillitiA may he simply an inilamxnatory
-ini|>lr li»rin *)t' tonsillitis is a mion^be. The child is iLsua
-iMldrnly, with a iirijrlitoiMHl toii4K»ratiire, 38.8^ to 3l».4° C. (1
I'.), tlvrr, H'stli'ssiHss, ami S4>iiu»timc»s vomiting and lossofap}*
<liililriii do not complain of* the throat so niiioh where the toaMJ
a- do n|d(T rhildivn and adults. In fact, in many causes, unlts««
artnally insjHtttil, it wmdd s(vm as though it were not a local
till' throat, l>nt sonir p»m*ral disease affecting other ])arts **i
VtMi >hould U' (siKvially on your guard, thei-efore, not to Uav
ti«»n div('rt4tl ti-oni the throat, but under all cinnimstanees when
toni- arise in young children, even though they apparently swa
<li-<iiint'(»rt, to examine the throat before dc^oiding whether or m
di-^'a-r i- developing.
On in--|MMtion of the throat the ton.sils are seen to beeulargt^
d(gni'> an«l to U* of* a uniform bright red color.
The nnieous mend)rane of the pharynx i.s, as a rule, much r
-nl't palate may also U* nnhlened, but not ncx^essarily. The sy
tiinii' t'<»r a day or two and then diminish, and the child usuall
almut a wt-ek.
rile l«)eal applieation of a eleansing spray, and the adminb
it" (le-ind to relieve tlie discomfort, constitute all tliut is nw
tieatineiit ol' the<e <*:ises. It is lK»st not to disturb the miio^i
with a|)j>lieatioiis nu swabs or brushes.
A'-iif, /•/>///<•//////• Tnnsi//lfis. — In the acute inflammation
uhi.h i- u-iiaily called follieular tonsillitis, in addition X*\
iiifl:iiimi:iti«»n nt' the tonsils th(» erypts are especiallv afletrtetl
Mj* thi- Ini-iii nf ton-illitis is undoubtedly infection bv som
■j« rill. It i- jn-ohaMe that mon* than one fi>rm of genu i
»;iii-iii.j it. Many of tln' pathoir<'tue germs wliich infest the
•|ii<.;ii i:i;i\ !»•■ (••mi<l ill tiieepvpts in this dist»suH\ but the t*six
uvula, ami of the soft palate are usually reddened, and there is very
be de<idod rMileiiing and even swelling of the mucous menibiime aod
of the plmrvnx. As the diseai^e progresses tlies^ spots may eoale^toe
ering to the 8iu*face of tlie tousil, form a j)6eudo-membi-ane which is
impossible to distingiikh from diphtlieria without a bai'teriotogieal
ation, A'S there is a direct connection lK^tw<?en tlie tonsils and the
1 glauils, tlie latter are linl>le to Ix* involved, though any great swell*
the cervical glands in cxmnei'tit»n with acute tonsillitis is nnwmnion.
le disease is M^'If-liniite*!, and runs its eonrse in two or three days or a
at tht' end of whieli time the geueral syruptoms subside, the ap|M*tite
^, the temi>eratun> Im'c** tines Ufirnuil, and the child, although it is left
weakeuetl by the disi.'iise, s^vnis as well aa ev^er* The tonsils
i, however, do not for sume time regain their original size, and
mlation often remains in the crypt*^ and may c^use a ehmnic irritation
tendency to rt^'nrrent^.
RAOXOsis. — The ditlerential diagnotiiiB of follicular tonsillitis is to be
[ from the various forms of stomatitis, which I have already sufficiently
(bed, and from diphtheria, of which 1 sluill presently 8|>eak. It is now
Wnurally known that it is iniijossible abstdutely to ejcelude diphtheria
morbid apfjearunc^^ seen on the tonsils, In the great niaj«irity of
ss, however, where the attack is acute, where the wrvieal glands are
ially involve!, where tlu* white spots on the t4)njiil8 are clearly
iu the orifices of the crypts, and where there is no appearmnoe of a
tne on the uvula or the soft |mlate, we can make the clinical diagnoeift
icnlar tonsillitis with considerable certainty, but never surely without
eriologind exam inat ion.
NOBIS. — The prfignoisis of follicular tonsillitis h in almost every
^ftvnralilts and is renden^l mifnvunible tndy by the njinpli^-atiou of
|^Uit)set*ss. But ytiu mnst tvinemlter that iu an itdhiaa^ tonsil
1 III- III III" irin [\ :»>«■ tit'. 1 ijin* > 111., luciiis; |>ai;».' »ri. r*
yar- "M. l»a-» :iii aiiark «»f lulliculur t*in>illiti> aud illustrates wha
Sill' wa-* takt-n -i<*k two <lu\> ai;o with u hi'inht«'n»*d l»riiip»^
lin:'," K.I, l.iH» of apiH'tit**. mid ^»'iirr.il iiiului!««.*. Sh<.» diil iji.t f-i
-walliiwi'il without ilitlioiilty. Nothini; abiioriuul was l*f>und in
Imh i'li iM-|Hriin:^ tin- thn»ut the tonpiU wfiv s»M*n Im In* enlanji-d
I'lji- i»r tN\" "f tin- Mritirfs •»t* tin* «Tvpte» worv .r>oiii(>\i'hiit rai*<*«.l aV*
til*' t.iii-il. «>ii tlu' tollcwiiii; day a mixii>K-r i»f wbiu* <i^>u of di
li..tli i"n.il>. Tti-day y«iu mh* that the n-^iuess is uii>!iily CH^nlinod
til" uvula and jialati- v*-ry littU'. On tho innor !?urfaco of Nith
.m:,!.-^, ..1. -.1 that it lui«i an a|i|M'araiU'e vitv much lik«.' that of u
iioi uin .11111111*11 ill inirh'iilur t«>ii>illiti;* for thii* eoah-S'CH^noo of ihi.- 1
til'- -urfa**- ■•!' \\\r t"ii>il which |Hiints towan-U iho iniHlian liii<- ^
a|i|i« anun-f^ i»t' ihf t«u»-ils aix; chanic.'t4Ti»tio of follicular tonsillitiii
• •.Tinr.-f ilif It ft t^u-^il, oKisf U> tin* un*h of tho palato. vou wil
• •lirh-i- whiih ha*" imt tiuitc hmkt'ii down, and which ap^)*'ars as i
till- Li'MMsal -^urtaci' ol* tin* tonsils. T\w oriti(*ifs have a like app«/
I...1I1 t-'ii-iU. On tin* anterior surfaco of the left toiis-il art two
. \u.laii..i, tVoiu tho rrypis. In iht- upper part of tlic right ttin*i
i*li-\\irui' -}»oi-. and lowor d«»wn on th<; tonsil a j^rayissh-white rati
du'' 1" ill" -anil" t-aii-i'. Tln-n' an* no other lej»ionci in the thn^t. li
U..1 invoUi-d.
('iiituii"> iiiadf from this exudation did not show the prese
l-aiiilu-
ill a ia.-<' nt' ilii-i kind, with ap)K'arHnce.H such ais you see ii
tli:it ih" ili-i-a-i- i- pmhahly f(»llii'ular toiisillitin and not dipht
al— Ml ..|" liif Klfl»— Lni'lHiT hacillus has 1>oen proved.
riif . hild u-.w ha- a normal t(*mp4*niture, and is inipn.»vini»
will I iMin'l\ wll. Thr h'>i<)ns. as you see, are still present in
ii:i> -riM II- .■■•ur-i- and ha." <-«'a>«'d t»» priH-Iuce any general svnipti«i:
11 1. i:-. atiiHiri ha- 1 n -imply to fi.H.*d the child from time U
i><i| MiiiU. No li'ial Mpplii'atinii- and no dru^s have b«"*en u>cd.
Chronic Tonsillitis. — Aftor an acute tonsillitLs Y.
(.f tiiiH-, <ir win TO m clironic iorin of inflamniatioii h
IVmiii ill. 1m oiimiiiL:". :m ciiIarijtMiuMit of tlio tonsils take?
h^EASES or THE NOSE, NASCVPHARYNX, AND PHARYNX. 813
le hypertropliy, generally actxirapauietl by more or less influmran-
L If the parenchymatous or glandular tK^ues are esjxx*ially
0 find a soil, more or less ixxl and va^^ular tonsil, with large
en eimtainiijg much secretion. In the ioterstitiEl form the tonsil
tough, the cr\'pt5 less i^rominent or even very small, and the
y much diminishtHL These tyjies are* the two extrt*m<'8 ; in must
I eolargcmi'nt is csscnttally one of hypertrophy. The tonsils may
raotlerately enlarged, or their size may be so increased that they
pching ea«'li other in the mediau line. The growth i^ usually
median line. lu examining a child ibr enlargement of the
must be taken that the pharynx is not contracted by gagging at
the examination ia made. The act of gagging, which is easily
about in childn^n by a careless iise of the tongue-depressor, brings
E^ towards the mcilian line, thus giving tonsils of normal size the
of IxMUg large and obstructive.
»MS. — The symptoms of hy|M?rtrophy of the faucial tonsils vary
|g to the dcgrtM? of enlargement. Normally the tonsils can acait-ely
bn insj lection of the throat. When only mixlerately enlarged they
[Kluf^ no symptoms whatever l)cyond a fettling at times of slight
k in the throat. When in tills (*f>rjdition, however, they are more
B irritated by various external in fluencies and to be the source of
I acute affections of the tlmmt. When t^msiderably enlarged they
1 not pnxluce any marked symptoms, j>rovidiHl that thtj jKissage of
(igh the naso-pharynx is imolwtnictffd. They may, however, even
^ pharyngeal tonsil b not enlarg*"*!, cause obstruction in the naso-
l by pn^ssuiT as they enlarge up wan! and barkwanU When this
L the same interference with the breathing and dcvclo(>nacnt of the
ics place as wheji the obstructioti is primarily in the naso-pharynx.
^mptoms are the same as I have alni^ady descrilMxl in sf>eaking of
^>hy of the pharyngeal tonsil, and therefore m*ed not be detailed here.
^ionally ditliculty in swallowing and thickness of speech may arise
Uy the faucial tonsils are enlarged.
Nosis. — The jirognosis in cases of hypertrophy of the faucial
up«3n these varied anatomical conditions wliich I have just
to you* Ho long as the tonsils do not encrt>at*h on the naao-
the prognosis, so far as injury U* the child Ls ciinctrnc<J, is good*
alMH}^ i-emerabcT, however, that the enlargement of the tonsils is
onroeof irritation which may prepare the way for scricius dis4»a-sc
by the various micro-organisms. The prognosis as in their <lisji|v
is not esj>ecially gtMxl, as they seldt>m rcn^iver their normal i^ire
ive treatment when once hyprtrophied, though they genendly
slowly in si/e after puberty.
I^TMENT. — IjtK^l applieations for the redtlction of hypertrophicd
fe useless. Some suecesH has been obtained by GamjK*rt by what la
isdisNon of the tonsils. Leland has 8t2t>iigly advocated this ^ieat>
OF THE NOSEy NA80-PHARYNX, AND PHARYNX. 815
, now etherised, and Dr, Farlow has ftret^ m you tee^ excii»ed both toiuiU
» and hkn theo removed the pharyngeal torn il with the forceps,
lieu the crypt* and the interveniug contusctivc ti^ue of the exciatni
[ aUo the soft «pongy tisiue of the pharyngeal tonsil. (Fier. 101, p, 811 )
\ hihU*ry.) Within six munlh^ after the r^tiioval of the pharyngeal itnd
boy presented an entirely ditfen^nt uppeunihL^ fruru whiit he did iMrfore
Bis chest had developed^ hn had a bett«'r color and a gmid appetite, he had
muSf ulept with hb muutU cli>«4*d, and showed no tendency in the recur-
lltii from which he formerly Kufll'red continually.
EELT^AR Abscexs,- — lo s<>mt* ctm.^ ao iuflammnt^jrv pnxieaft
Suppuration fxt-iirs in tlii* ot'lliilar tissue around^ alwive, of
psil, cxjn^ti tilting: an alv^x^s Avfiich is calkxl iK'ritoii.siJlar. It
\ in early ehiltII]<KKK Tlu* dist^a^ is usually pHXY-tle*! by a
\ of fiimple tonsillitis, and when it develops the t<^nij)emture
|to 40^ or 40.0*^ C. (104^ or 105^ F-)» and the child evidently
Siain.
liiig the throat in these cases a luiilateral swelliug is s«tMi in
pod of the tousi], as a ruk% pushiug the st>rt palate forwani,
I towards the median line,
■pis is in almtist every ease favorable, exwpt those whieb
^ded ur iniproprly treated. There is sometimes exteunive
the pus, and hemorrhage, or even cedema of the larynx, may
Hent h t<j locate the afe^eess by careful pal|uition and to o|h'U
antiseptic precautions with a guar<le<l bistoury,
ms. — Au inflammatory eoudition of the i>osterior wall of the
Bier rare in iufauey, but is not unefmimon in ehildrtm. It U
lent with au iutlauiraatory wntlition of the na^>-phan*ux or
but iu a certain numljer of cases it is so much more pnjoounced
or wall than eW^where that it can b? descTilxHl as a s**i>aniti?
diseases of the posterior wall of the pharynx an' either (1) a
ftl ormdltion of the mneous mc^mbnme or (2) an inflammatory
|ch the follicks ait» t^sfK^'ially affei*t«L In athlition to these
B may form lx\hind the mneous membrane, prtHJucing a retn>-
imwM. The inflammatory lesions of the pharv*iix mav be
h.
■ i"^'
_^L1LJ
m^
THE N06Ej NA90-PHARYNX, AKD PHABVNX. 817
may arise from a relaxed condition of the moi^les of the
of the uvula, or may cjonsi^st simply of a itdnndancy of the
[sane at the tip of the uvnla. The general irritiited a>ndit5on
id the tickling sensation piYxluetxl by it^ elongated tip touch-
the tongue c^use a harassing ciiugh, which by its persistence
lild, gives rise to loiis of appetite, and ioterfcros witli it^
cations of astringents, such as alum, are at times sutticient
pvula to its normal ix^uditiou, but the dis<mse ean l>e cured
Erkiiig the end of the uvula witli bIinit-|M)iDted scnssore.
I of the entire uvula k to be avoided, as it has been Icnown to
Bcukr action of the ^>ft palate,
Ptous growth 1^ -,->rn. tins.-, tl.iind attat^lied to the tip of the
ide, which i|^t**m8 as elongation of the
l^atment is exdfeiuu, aiter whieh it does not recur.
[bynoeal Arscfss, — Retmpharyngcal abaoeas b a disease
iBually tluriug the (irnt year of life and is very rare after tliis
bsie may be secondary to injuries of the phar>Tix, to abscess
B to disea^ of the cervical vertebra?, or it may Ix? raetastatio
^oesses surh m oci-ur in diphtheria. In a wrtiiin uiimWr of
lathic so far as we know.
If. — Tlie jmthology of the diw^ase consists in the fi^rnuittoii
in the tissues of the j^jsk-riur wall of the |>harynx, and is
on one side of the pharynx than in the niCMJian line.
I — The symptoms, wheth€*r the disetise is |irimary or second-
piuch the same. The first symptom is generally diffieuhy in
\iieh. may go on to entire iuahility to swallow. The infant is
> breatlie in a peculiar way. It holds its head back and its
Tlie bn^thing may Ijc descrilx^l as smirting, and at times as
&US, ditlering marketily from the whi.stling souml which is
piiction of the larj^ux. On examining the throat the soft
Up be pushinl forward and to Ik* sonuwliat aniemic. The
K the pharynx is bulging, nsnally unihitemlly, is reddened,
and as the disease progresses is found to l>e fluctuating. In
kftlsseess burrows iiito the tissues ftf the nc^^k and apjiears
H liunor beliiud tiie ear, I have met with two t^a^en of tliis
the pus ccadd l»e reached easily by an extenial incision.
U — The diagnosis must lie made chiefly from |M?ritoriHillar
I IS, a8 a rule, not diffic'iilt unless the latter eotulition has
r that the pus by bnrniwing has invaded the walls of the
usually not difficult to determine tlie situation of the
[g the finger dirtx*tly thmusrh the moutli to the |K>sterior
ic- If then? is pus in the tissues of the pharynx a
will lie obtained. The |K»sition of the cliild in i^asea
ibso(«s is also signific^it, and is not tliat which is
62
an <'xc«'<'<lin(rly (lanfrc»n)ns (X)inpiicatioii iu diphtheria, ai
iin)M»rt in ctTvical s|)(»iidylitLS. Iu those cases of undetoi
iwv s|M)k(Mi of as ulio|)atlii(: the prognosis is verv gtxxl
nicnt is carricil out at one v. We must, however coii*
of the al»s<-<ss hurstinjr suddenly, the cliild 8uttcx?atin^
|)ns int4) iIh" larynx. This has been known to i>ccur \vh
Int'ii left nntrcatcHl.
TuKArMKNT. — In the idioi^thic erases the al>sces.s s
oner. 'Hh' nirthinl which 1 have ibiiud satisfaetorv in t
romc iindtT my ohservation is to have an assistant hoi
upriirht in the hip, with a blanket tightly pinned arounc
it tVoin niovini:: its arms. Another assistant slunild h<
moutli should then be o|K»n(Hl, a guarded bLstourv sh
inio the pharynx and the abset^s punctured. As soon
Ihmii mailc tlie bi«*tonrv should l>e removed quickly au<
^hoiiM Ih' imnu'<liat4'ly thnjwn forward and downward
Im" (li-riiarL^<'<l from its mouth and not inspired into the h
It i- n-nally lux'essary atter the oi^eratiou to introduce
pharynx and to pnss the walls of the abscess, so as to ei
may «*nntimu' to colKM-t there and also to keep the opeui
treatment, unless s<mie eomplication should arise the
i'lu'ed in al)out a \v(H*k.
Snm<- njM'ratois jm^fer having the child placed iu
ii.M'*s position, on its back with the head hanging over
II. P- i^ an infant (('«m' 402), seven months old, who has k
Willi ut .xati.ininu' tli.' throat, ycu can almost diairnosticate a
DISKA8BB OP THE X06E, NA80-PHABYNX, Ain> PHABYKX.
819
r
■| tlie left. It aIao begitn to bold its mouth open. It wu able to nune only a few seoondi at
^B a time, when il would let ^o of the nippU' and refuse to take it again. It hat been growing
J^ very we&k from lack of nourishment and from the exhaufitiun arising trom the difflcuUj
with 116 breathing.
CiAi 402.
Rf?troptiaiytig«al
Male, 7 mouthi old*
(Subsequent histoiy.) An opening in the absceM was made by Dr. Burrell» and a large
Ktoount uf pu« WU5 evacuated. An hour later the child beg&n %ct choke, and it seemed as
ibough tracheotomy would hav^ to be perfurmed^ but pressure with the linger on the walla
I of the ab^'ess from time to time, aurrounding the infant with an atmosphere containing
ateamf and free iitfmulationf proved eventually to be all that was tieoeasaiy for its recovery.
I fiball now report to you a case (Case 403) of retropharyngeal abaceas which came
I under my ol»ervation some yean ago.
An infant thirteen months oldt ^tid always strong and hwilthy, had an attack of acute
rhihitin for several days. The rhinitis apparently caused conaidenible swelling and occlu-
aion of the nares, and the infant after four or five days began to hold \u mouth (i{ien when
breatliing and to have difficulty in swallowing. This ditSculty in deglutition increosed, and
^j, il was then noticed that her head wai held back. On examining the throat a tense fluctu-
ating swelling was detected in the posterior wall of the pharynx very nearly in the meijian
I line. This swelling was incised by Dr, Hooper. A considerable amount of pus was evacu-
|ated« and the infant immediately began to breathe more easily and was able to swallow with>-
loul diffirnlty, During tbr^ next twenty-four hours the ahicesa filled with pus a number of
r times, and the pu)^ hud to be emptit'd bj pre^ure with the finger The infant made a per-
, feet recovery, and has bail nu n^turn of tht? disease.
Cases 8uch as this lead me to aay a few words ujKjn anotlier method of
drainage that I did not speok of when tolling; you aUmt oiJ4j?iiuig these
that are found in the mniith. In the nrdinan' i-a^e, wlion ttie pim
C5ome from the breaking th»wn af gkiiiduhir material in tlie }H>«terior
[^wall of the pharj^DX and already contains pyogenic bacteria, the dangers
from reinfection from a wound in tlie minUh are not serions, Hut when
be |ni9 ha8 come fn^m a tul>en'uh»uj^ fiwiis in the cervical vcrtcbrxe and
|c!ontain8 no other organisms than tlie UkUIi nf tulxrculft^is, and i}^ more-
yvvr in direct communication with an active pathologtml pnxiess in the
^ne, the risk.s of a sei-ondary fl4*ptie infection are (-onsidi'nible. It ig,
Ihereforc, the practice of many surgeons, despite the difficulties of tlie
^pemtioD, to attempt to reach the abi^^ees© by a tmreful dift^section fn>m Uie
Mit^^ide of the nc*ck, as it is far *»a^ier to keep the wound in that t^ituation
L'ptic* If there L^ any sign of the aljseertri jiointiDg extiTnally, the ont^ide
ition eihould alwayn be preferred*
820
I happeti to have hen? another case of retropbaryT^eal afannto^l
you, in which the coDclition is secondary to cservical spondvlitk
Thit child (Cm© 4(M) wm being treated <i>r cervical sp>ondyUtU by Br. Bf«lfai«
in addition to the drawing back of iu head, which you see, U bcCTii to tef» 1
diffloulty in Bwallowing and to bre«thi? with iu* momh opon.
On examining the pharynx a bulging, tenae, fluctuating abacttA gf ]
detected.
DIPHTHERIA.
821
LECTURE XLII.
DIPHTHERIA*
Diphtheria is an acute, highly infectious disease, due to the Klebs-
I Loeffler bacillus. It is primarily a lix-al aflectiou, the couijtitutioual
^nymptoms beiog due to the ab^»rptioo of toxines.
^^^ There is frecjuently a coueurrent infection with pyogeoic cooci. These
^Bqganisms produce the sectjodary iuflaiiinmtious cKX'urring in the disease^ and
^so, by their toxines, give rise to additional constitutional symptoms.
Etiology. — The Klebs-Ivoc*fflcr bacillus, first described by Klcl>s and
^Jater more fully identified by Loeffler, is a small oi'gani^m, 2.5 m to 3 m in
^length and 0.5 p. to 0.8 ;i in thickness. Its most striking features morpbologi-
-cally arc itB variation in form and tlie irregularity in its manner of staining*
■The ends of the orgauiam are freiiuently cUjblx^l, and in most cases, when it
IB stained, it &hows a series of clear Hjmces with intensely stained particles.
The form and sisse vary greatly under various cirf^unistances. I have here
a specimen (Fig. 102) fmm a blmxl-^erum culture from the throat of a child
in the diphtheria wartl^ ni* die Bost4>n City Hospital, wliich shows the
k morphologj^ of this bacillus in ita typical form.
Flo. 102,
The biiclUu* of diphtbcHii,
It grows readily on a variety of culture metlia, and most readily on the
mcxlificd blood-serum fir»t intnj<luriKj by I^>effler, it does not form spores.
Welch and Abliot have shown that in fluids it may be killed by an exjx>snre
I of ten minutes to a tcmi)craturc of 58° C. (136.4° F.). Under favonible
[ conditions it may n^niain alive tV>r wi'eks, or even months, in fragments of
1 dried membrane. The bacillus of diphtheria is best stained with Loeffler's
' alkaline mcthylen-blue solution.
The pyogenic cocci most frec^uently found in the ooncurrent infeodbnt
I are the streptococcus pyogenes, alone or associated with the staphylotsoocua
822
PEDIATRICS.
])y()gi»iR»8 aureus, the former being the more important in it? Rfck
iiuve here some tspecimens (Figs. 103, 104) of these organbm;, i-.
their morphology.
Fio. 108.
• •••••• ••• • ••
• • ••••• .^ !
£ : :
V
^•^•••^
v
StrepCoooccui pyogonieib
Fio. 104.
suithylococcns pyc^enea.
You \vill iioticx^ that they lx)th appear as dots, the streptococcic ?lK''^i'
a ttndciK y to arrange itself in chains, while the staphylococcus is irngtit'^f
biiiu'hccl.
'Ilierc is no true diphtheria where the Klebs-Loeffler bacillo? fc !:'"
pns(ut, hut its prosciKv in a healthy throat does not constitute the di^
iliphtlicria, ahhough the individual may be the source of infection ti^ih^
11i(^ contairiuni of diphtheria is contained chiefly in the secretions of i"
throat and nose, and is eoinmunicated usually by direct or indirect otitic
and, as a rule, not hy the air.
\\\ \\uWv\\v\vx wwv\x\:xvNw Q^ \Nx^xaawtK, uoae^ or throat predispoeeiDi
DIPHTHERIA.
823
pieiaaty as a lesion of the mucous membrane is neces^sarv for its entrance,
pewer-gas and ctjatint?d, impure air of any kind may at-t by weakening resist-
knoe to the baeillns, or, by producing a benign lesion in the throat, may
pfler a suitable nidus tor the invasion of the UtciUus, Altliough eliuieally
It ha^ btvn supjK)sed that animals have priuaary diphtheria, this has not Ijeeo
boncluftivi'ly pro vet! bat'terinlMgifally.
I Although diptlitlieria may occur at any age, it is rarely met with in early
Ilifa0cy* It is most commonly seen from the second or thinl to the fifth
br sixth year. It may occur more than odcc in the same individual.
pATHOLCKiY, — The most constant Icsitm in diphtheria is thi* presence of
p pscHidti- membrane in the upper air-passagt^, due to a combination of in-
pammation an<l c<»agulati(»n necrosis.
It must Iw rememlK^'rcd, however, that the same anatf»mical condition
Inay be caused by otlier bacttTia and by irritanta, and aL*i> that the prcK^ass
piay be simply a catarrhal inflammation wliicii does not go on to the forma-
jtion of a pseudLHmembrane. It Is evident, therefore, that there is no patho-
logicid (XKidition cliarat^teristic of the action of the Klelis-Loeflicr bacillus.
The adiaa?nt lymph nixies are apt to be swollen, and on rnicroscopieal
(examination they often show small ftx'i of cell-necrosis j similar smaller
liecrotic fixri may be found in other parts of the ec«:)nomy, such as the liver
knd the kidney, and are due to toxic absorption. There is also a general
lymphatic liyp<*rplasia, which is relatively greatest in the al»domcn. The
liidneys onlinarily sh<m' only parenchymatous d^eueration, but in a lew
bases of concurrent infection they may prej^nt acute lesions» Hcmorrhagi's
Into the sc^njus niembranes are often met with, and the organs in general
■how degenerative changes due to t*)Xic alisc»r|»tion. Endocanhtis is rarely
|b0O. Catarrhal lironchitis and broncho-pncuruonia f're^jueutly complicate
Diphtheria, and an* eans(^l by the inspinition of the pyogenic oooci. This
Was (hinoiistratcd by Fruddcu and North rup in a very able paper which
ftpj>eure<l in lg89.
i Incubation* — The time which elapses after exposure to the infection
pntil the first symptoms develop may W only twenty-four hours or may be
two or three days. This jk ri«Kl, however, is a very indetinite one^ since the
EtitiTval between the access uf bacteria to the muodUfl membnue and the
time when they invade the membrane with their toxic eflecta depends ttpOD
Sii'hether the ti>wues of the muttons membrane are vulnerable, TTius, it b
brobablc that the hai*illus diphtheria? may exist in the month for an indefi-
liito time without infecting the individuah
I Symii'oms. — The prodromal symptoms of diphtheria are not es{>ecially
pIiaract4Tistie. They may \k' acute in character or very mihl antl of a snb-
kcute variety. There are apt to be a sensation of chillinr--, ^. *hh heightening
pf the tem|)eriiturc, and more or less \mn in the back aad limbs. There is
nothing, however, to distinguish this stage of the diaeaae ftom many of tlie
pthcr affections of <*hildren, such a% a simple tonsillitis. The child may often
pomplatn of discomfort on swallowing, and on examining the throat the
<liil«l, as a rult\ sluiws jrnivo wmstitutional symptoms au
TUr t«ni|M'ratun' in tliphthoria is not oharactoristio, and
cially hi-h, ;5S.;i° or ;38.«" C. (101^ or 102° F.)- The
iiirn'a>«'<l in rapitlity, and is weak in pn>|x>rtion to the 8^€^
In t-axs nl' a mild ty|H* the symptoms aba to towards
\v(H'k. thr ps^MKlo-nienihnino separates, leaving a raw si
throat 1m 'ionics less swollen, and the child i'eels much
tv»T, nsnally Ktl nnieh prostrated for a niinil>er of week
mild rasrs tlu* toxie etU'ets of the disease may show thei
nt' a ncnritis, with its a<i"omi)anying paralysis, many we
tluM'ia itstir has rnn its (Nuirse. There may also even
sliirht dixharp' Inmi the nares, owing to the involvemi
nan>, and a slight alhuminnria.
I have hronj^ht you into the diphtheria >vard to-day
tlirx' mild (':isrs of <li|)htheria.
'Ilii- Im.v ('a-«- IO'jK fivr yours old, has been pick for four days.
r!i]»i»l. I'Ut nl* iTiMul -tn'ni^ili. Ilis respirations are slightly increased
ti.-n. 'rin'p* is :i -liirht ilif^-buricc ln>in the nose, and the cerTica
«iil:irL'^' (1. !!•' tjiki- lii^ imurishnu'Mt w<;ll, and is in a very fair eondit
I..i. III. r ' l.i....J->.-niMi i>f a ^brwl of membrane taken from the thrnal
till- Ki. I --!...♦ ill.r Imrillus jmd u larj|:« number of streptococci. Th
Miiiouiit of :il)>ii]iiiii.
I -li.'W V'U tlii- rjirn* as <':.jH'oialIy illustrating the typical appei
tli«- I !i !•-■:»!. :ni.l in -.nl^T tliat you may compare it with the typical a
ill I'-llii u!:ir tonsil i it i-. wliicli I .-howod y»)U in a previous lectiiK* (pi
Hti . \:iiiiiiiiMir tlii- lioyV thn»at (Plate VIII., facini; pa^e78l, '.
-i:::ili Jill. !i.- ..f Lrr:iyi-li-\vliit»' p-fudivmembrane on the upper pa
-{•V- :i'li' .' !■■ ill.- lift ari'h •»!* xhv suft paluto. The membrane has i
M.i'- .-!" f!..- u\ul;i, till' rii^lit an-h i»f the soft palate, and the side of 1
DIPHTHERCA.
825
f-^me epidemics the Klebd-Ix)effler bacillas seems to be far more
irulont than in others, and in some individuals it produces much more
ous symptoms tlian in others. The severity of the attack doe© not
Iwayn depend n|M)n the extent of the |xseudo-membrane. In general the
verity of tlie cases dependis on three fact<irs: (1) the viruleoce of th^
acteria, (2) the hx'al resistant-e, and (3) the general resistance. A numlK^r
\f what may be ealletl atypi«il eases have been observed and earel'ully
t^idietl, esjieeially by Koplik, where no pseudo^membrane was detected and
here the morbid apjieamnees in the tliniat were those of a simple eatarrh
p follicular tonsillitis. The virulent Kleb8'L»>effler baeilhis was dett^-ted
I these causes, and other children infected by them presented the typical
Deal lesions of diphtheria,
la addition to these mild cases, the Klebs-Loeffler bacillus at times pro-
noes a most malignant form of diphtheria. In these eas4^ tlie eliild either
WB a fairly mild form of the disease for a few days and then suddenly
evelops the severe form, or it may be attacked at oiiee by very severe
jrmptoraa. It becomes dull ; the temjierature Is either slightly raised or
\y rise to 39.4** or 40** G (103° or 104° F.), or higher; the jiseudo-
lembrano spreads rapidly ; there may l)e a dusky efflorescence on tlie skin,
ulating closely that which I have descrilxJ in the malignant form of
•let fever. There may also be a purpuric condition of tfje skin* The
ictiire of these septic <'asi^ is very characteristic. There is a j>ecMjIiar|
weetish mlor of the breath. There are cyant>sis and a niarked waxy
lor. There ai*© hemorrhages fmm the throat and nose, with a profuse
ucx)-purulent discharge fr«>ra the latter. The cervical gland» are often
lormously enlarged. The membrane has Iktu known Ut extend in all
irections, and sotoetimes even through tlie Eustachian tul>es to tlie external
re. All degrees of severity are met with between the mild and malignant
yjH^s of diphtheria* The nu'mhrane, instead of extending upward to the naso-
lliarynx, as cxxnirs in the malignant cases just s[H>keu of, may spn^ad down-
ard, attacking the epiglottis and the larynx, and (*ause serious obstruction,
I have alri'iidy told you that the {>si:*udn-membrane most i>iimmi»nly
ppears tirst on the t<»nsils^ thcnct* sj»rt*tuling to the soft i^alate and to the
vula. The discus* may, however, bc^in in the muci>us membrane of any
of the mouth, nose, or thrfiat.
Th0 Nose. — Diphtheria sometimes begins in the nose and sprt^s no
krther. In these cases the diH^a*^*' i.H usually of a mild ty|»e^ but it is
pifectious. These oasee are C5si>eciwlly liable to be overlooked, as die child
or imv or two days may >)\n\v m. jr l\ tli«/ symptoms of fever, malaise, loss
f ap^K'titc, and a dfeohar^"' \\n\M tin M"H', On examining the nose care-
Uy, however^ a peeudo-membrane will often be found. It is, tlieretbre,
"y im|Mirtant in cil^s of this kind to have a Imf'tcriologit^al examination
le, and to isohite the child until it i^ dctcrmimxl that the Klelis-I^x^ffler
clllus is not present. Th&«e vases are probably a prolific source of infeo-^
»n to the community at large.
nuKtuis nu'inhraiK' t)t the no:?e and pharynx may nv
ot'a |>s*'U(lo-iiu*nil)nine. The first symptom^ as a rule
rin^iiijr natiiri'. The tem|KTatiire may or may not \h
al»snr|)tioii is slijjht, cm account of the locality affec
syiiiptonis an» <'<)rns|x»nilin^ly mild. The child's s
siihin;: t'nun htrvn^'al obstruction. There is dyspi:
the iutcn-ostal and supraclavic'ular spaces, and later <
the lower <hest. This is acvomjianied by an increasin
is very i-estlcss, is lonttl to sit up in order to breai
n'nsoii, \nui\< i'nrwanl with itH liead back. In the«
nliet* is s|><-e«lily al1onle<l, tlie child soon dies of su
set of cjisis a slower form of suffocation mav result
the inenihrane tlownwanl to the hnnichi, while in
may re-^ult iVoni a complicating bnmcho- pneumonia.
A very |)rnmiiuMit sympt4)m in all forms of dipl
weakness. Ill some (us^^s the child may die sudden
stnti'd any |)revious symptoms, or death mav have be
of semi-et>llaps<.;. In other castas tliere may l>e a m'ci
Xrui jiulse thronjrliout the disease, which [persists
Tnilir these <irenmstanc<>i the child should alwavs
a <riti<'al ••oiidirion, as death, sometimes sudden, is lia
CoMi'i.KWTioNs AND Sequel.!:. — There are a mi
wli'n'li :iri-r in iliphtheria Ix^ides thosc» of la ry unreal ste
nr->. Tlir most -erions of th«s(Mirt» bnincho-pneumoi
riie form of pneumonia which complicates diphtl
nioniM, wliieli. I have ah'cady told yon, is produced, e
llri- l»:n'iMii-, Imt hy |>yo;xenic cf»cci which have beei
|)iH'nMi«»ni:i i- nmst rre(jnent and most fatal in lar>'n!
ln.ii <i|M r.'ii»il iiiM»n.
DIPHTHERIA.
827
I Among the more common ^equelte are aniemia and chrouic catarrli.
i The most common and 8erious ^iieJa of diphtheria is a jioripheral
luritis, with its aooompaiiying paralysis. This paralysis often dtnis not
j>ear until coovalesoenoe has been est^iblished, — ix-rhai^is in the tlarii or
urth week from the time of the beginning of the attack. The (laraly^is
y sometimes be raei^ely of the muscles of the sott palate^ in w^hich ease
le fluids taken by the mouth are regurgitated through the nose ; or it
,y have a general distribution, such as is seen in multiple neuritis. In
! more severe ca^es of paralysis arising i'rom this multiple neuritis, tlie
extremities are affected and the knee-jerks are absent. The electrical
ions where the limbs are involved ave the same as in jjeripheral neu-
from otlier causes.
The prognosis in these cases of post-diphtheritic paralysis is good.
DlAON'asiB, — Recognizing that the same pseudo-iuembninous condition
the throat may occasionally be produced by the pyogenic cocci, as well
p by the Klel)s-Ijoeffler bacillus, the clinical diagnosis of a typical case of
Ephtheria is not difficult A prt) visional diagnosis of dfphthcria should
t based upon the ap}>earance iu the throat of a pseudo-membrane, wliich
»oally appears first on the t<insils and has a tendency to spread to the
Ivula^ soft palate, and pharynx. When in addition to this a nasal dis-
piarge is present and the glands of the neck an* much enlai^^, yuu have
t picture which is not shown by any other disease. The most cx»mm<in dif-
Iculty met with cliuit^lly is in distiugui-^hing between cases of acute follic-
|lar tonsillitis and diphtheria.
I As I have already statetl, the local lesions produced by the Klebs-
Loeffler bajcillus may \ye merely a catarrhal inflaniniation or those of a
pllicular tonsillitis. All such conditions, therefore, should be looked upon
Htb suspicion until the absence of the Klebs-Loefller bacillus has been
lemonstratctl bactcrioloirically. Although a merabrannus laryngitis may be
Inc to otlicr causes than the Klcljs-Loe filer Ijacilhis, yet this is so rare that
Ifvery case of primary membranous laryngitis should be tx>nsideretl to be
liphtheria iiutil it has been provcxl that it is not, A decisive diagnosis of
liphthcria in any case can, therefore, be made only by determining the
iresence of the KlcljS'IxK»tHcr Ijacilhis.
pBoONasis. — Diphtheria is an extremely fatal diseade, especially in the
ptic and ol>stnictive cases. The mortality varies decidedly in different
lidemks and aceonling to the age. tliildi'eu under two yeai^ of age
iTpIy recover. The rate of mortality si'ems to have I. md in ca^es whene
lie antitoxin treatment has b<*c*n thi>rontrbly used, fhe sym|itoms which
e the pn>gnosis ii^|K'cially unfavorable are the extension of the mem<
to ttie naso-pharynx or the lar}'nx. extensive glandular enlargement,
•morrhage from the nose or intit the skin, a high grade of albuminuria^
ironcho-pneumonia, and a weak heart Moim\ in an extensive study of
lie leucocytosifi of diphtheria^ has shown that it is of no prognostic value.
the cases of neuritis invariably recover. The prognosis in all
828 PEDIATRICS.
iiiKi'rtain, and should be given with caution, as death fn>m L-ar:i:
lial»lf to otfiir at any stiige of the disease.
A rhild who hiu* had diphtheria is liable to sutfer from ih'- dr.:
etlNts lor niontlis or even years.
IMtoniVLAXis. — All ])atients with diphtheria should U- Uiiiri - }
thr Klel)s-l^K*ffler iKieilhis has disai>{x^red from the ni>st» and thnr..
tinu' whrn tliis o<'<'nrs variw fn»m a few days to a niiml>er ••!* wc^^U
In niilrr i'nrtluT to proUvt the eomimiiiity, all eases<»f s*>nMhrd>i
1m' «\M!nin<il, an<l if tlie Klelw-Loeffler bacillus is found the b i--
!-hoiiM Ik' isnlat<Hl. It is i»s|)ec'ially uecv^^sarv to carry out this pnr:i:..
srln»n|s, where the conditions are so favorable Ibr the spnwl nf tb^.i-^-
'VUv thmats and noses of all jH^rsons exj>osed tn diphthtria r .\
I'nr (liplitlnritie jKitients should Ix* n^peatedly examiue<l tl»r th- R:
LjMtllrr IntriUiis, and if this is found they should be given imoii
tlo^ts of antitoxin, the amount and frequency of the dosc*s to be ii>.r
our knowlrcliTi. increase's. If in the future it is proved that i!k- oli. -
may ppwhu-e serious etre<»ts in (*»rtain iudiv*iduals, the<e view* rr.r/
nnKliti«Hl to rnnvs|>ond to this additional knowledge. If the Klel^rL:-
harilhj^ is lIuMid in thes<' individuals, they should be ist)latrtl !?•» W:
harilhis is juv^cnt. To shorten the period of isolation. iiiiM aiiri-:
pMiilr^ «»r douches slionld Unemployed. Whether the i.s.»latiriu if iiri:
jMi-.m- who have the KleUs-Iioeffler bacillus in their thrt^at oniij^i^-
visiljle or not is Mill a mooted (piestion. Much cn>nfusion hasa^Kn
ot' ilir -o-f-alhd psen<lo-diphtheritic liatnllus. The weight nt' ev:-irii-
prrxiit. Imwrvcr, g<MS to sliow that it does not exist, and that tli? 'v
• Ir-criU-il an- intn-ly Kh'ks-Iioeffler bjieilli of diniiiiisluHl viriiKuiv. A
r;it«', I v«n it' \]u' pseiido-diphtheritie bacilhis exists, it is h.) ran- rhui.:"
Im' sifcly ex* liuh'd in clinical work. The fact tliat the KIebs-Ix>t'tSt'r -i-
I'omihI in healthy throats may not be virulent is not an anriimHi: a.-!-'-
i-olntinii. U'caiiM' it is well known that a non-virulent lorm mav Itv^'-
viruhiit wlirn transferred to a <lifferent soil. Kxaniinations of maiiy k.v':
tlin»;jt< liav«- ^liown that the Kl(»l)s-I-ioeffler l>acillus is a verv ranMubb j-'
of tlir iinrin:il tliroat, juhI that when it is present diphtheria oiten iW-':
I.itrr. 'riirnreti«ally, then'foiv, although it may be imi)osc!ihle "r '-
vi-;il»l«' prMctieally. it wonhl s<i^m wise* to consider the Kleb*-Ij«>effler -c-
III- \ iniliiit uniil it has Ikh^u ])rov(»tl to be non-virulent, and too^u^nl'- ■
j»i«-riirf n >oiirceoi' ilaniicr to the eimimunity until it is provc^l notl"l'^'
In McMition to what I have already said, I must impress ni^^n yv!:r:
iiiii"M-i;iii,v of krrpinir tlic t<vth iu go<.)d order as a prophylaotic itiKi-nr-. -
w.ll .1- keepinL^ tlie mucous membrane of the nose and throat in a a- nij-
con<lition.
I'im: vTMKNr.— The treatment of diphtheria consists (1) in attewHie'
th.' Iiy-irnic conditions : (L>) iu the administratiou of remedies. either b} tb^
skill or l.y the month, to r'ombat the toxine which produces the constitiiti- :-■
syiuptoni-; (iV) in I.)cal applieations to the nose, throat, or larynx. aftl ^^
DIPHTHERIA,
829
Lires directed to the general ccmditbn ; (4) io operative measures to
Relieve obstruction in the larj^nx.
Qoe of the most im[K>r1ant parts of the treatment of diphtheria is the
mnagenient of the room in which the patient is kept during the progress
Jf the disease. It is well known that pathogenic organisms, such as the
-Loeffler baciUiis, do not thrive where they are exposed tt> sunlight
fresh ain The nxim should be thoroughly ventilated, and fresh pure
should he allow^ed to come continuously into it. It should also be cme
L'hich hafi a sunny exjiosure.
In any tn?atment directed to the cure of diphtheria in young children
re must rememlier that the disease is so exhausting that the ti-eatment, as
rule, should be forced upon the child as little as possible. Any physical
-exhaustion produced by the treatment is to be considered serious in young
children.
It is necessary perhaps to call your attention to the fact that much
ire shnuld Ix? taken Ixith by the physician and by t!ie nurse not to betn^rae
|infe<?ted themseives by thes*x'retl*ius from the mouth and nose of the patient,
iThese secretions an? espiHi'ially dangerous if they hap{)en to get into the eyes*
tt IS proljablc that with extreme care there is not much danger of the
lprt*ad of diphtheria in a houst^liohl, as we know its tendency is not to dis-
eminate it^^lf in the surrounding atmosphere. Hence it is likely that with
proper precautious it can be limited to the room in which tlie child is sick,
ind that if it extends l)eyond this rtx>m it has been carried directly by the
bands or clothing of the nurse or the physician.
According to the knowkxlge of the present time, the most promising of
ill these fiirms of treatment is the secMncL l^his treatment is ess<*ntially
jmpriscHl under what is called serum tliera|>eutics. By serum therajjeutics
meant the treatment of disease by injecting into the patient the serum of
^mninial which has U-en n.'nden'd imnuine to the i'sjM'rial flisea'^% wliich is
Ing tn^ated^ by means of iumudatiou with the toxine of tliat disease. The
t*nim taken fn>m the animals which have been rendered immutie against
liphtheria is calhi! antitoxin serum. The serum is injected under the skin,
sually in the thigh, and the plat:*e selected shoidd always be one on which
pressure is not exerted when lying in bed. The dose should he from 5(H) to
^000 antitoxin units, or 10 to 20 e,a (J to | ounce) of the 1 to 50,000
im, aecTording to the age of the child and the severity of the disease.
The beneficial results of antitoxin are (knndeilly gr»*ater if the injwtioii
made in an early stage of the disease than if made in the later, although
'even when admiuistenHl late in the disc»ase it sometimes pnxlua^ wonder-
fully curative elfet't^ When given early, within tht* first fbrty-ciglit hours
of the di^'ase, even where the membrane Ls spreailing rapidly and inHain-
hiation of the glands with general systemic [wisoning has taken [ilace, one
pnjectton will otlen arrest the disease. Where inipn>veraent does not take
Mace within twenty-four hours, a second dos(», and^ if necessar^', a larger
moRf should be used* The sign by which we know that the antitoxin ficnim
830 PEDIATRICS.
is lM>netirial is tlu» imimivemeiit in the general condition of ti^ it: ;
Tin- vW'vrt of tin* antitoxin on the ]>seiido-niombrane L& charatfcM '.
ps<'U<lo-nuMihnnM* (I'jL^ts to spread, fre<|iieutly whiten^*, shriaU •; !
a lino i>t* (It'inan-ation, and usually within the next tlmv ..r :•.:.
iMr.iinrs (h'tarlHHl ii-oni tlic mueous membrune. The tonijvratuv >v
rix.. atur the injtM'tion, but in a lew days falls to the normal by hi--. :
tlir nion» sc'vcre cjLses a sinirlo injeetion of the serum doi> nrr -• ■
«|ui«'kly. In these itises the tem{)erature falls usually bv lyrwifr'.
Mt'iiiul Ml- thinl <los<\ The ])ulse becomes normal two or thrt-t (b- r
tin- i«!ii|M'ratiin' has fallen. The irregularities of the pulse an- !>«> :
<[innt in cliphtht'ria sincv the antitoxin treatment has been empk'VMi '
<11iMt of antitoxin on the albuminuria is still kicA JiM?/fv. hut ii ;: .
do»> not iiien-as<« the likelihmxl of its occurrence. When there i*a->"
nut InftM-tion tht* antitoxin serum is less effective, since it drK*Q-
tri'Mrt tln' t4»xir absorption due to other bacteria than the KleV>i
l):Hilliis. It is not siile to assume, however, that tliere is a coucuimtL
tioii Uiaus*' oth«T harteria are ibund in the thn.>at.
WIhmi the larynx is involved, with accompanying stenosis the aLJ. -
wniiii is tlnuul to U* very valuable, and has reduced the number oU'ji-::
<aM-.
In nunwH'tion with the antitoxin treatment no specific dnii^ «jivrV
nally hy thr month an- intlii-ated. Stimulants should alwavs l»^L'iva:-
in tliphthrria. Of I'oui-se, symptomatic treatment of anv kin«l isDi' '"
inilirntnl.
Thr ;intitn\in has Ix^'ii found to have but little effect (jn tij'- In.:
tinir iliirin.: \\lii<h thr bacteria remain in the throat after tht- dxiii*-^'
4»f tin- njciiibrMiK'.
TcM. frw rM«s have as yet Ix^n observed to estimate t lit- rekt- "
ipnncy nf tlie o.cin-renn* oi' neuritis sinc^ the trt^atiuent by anliio\ ■-
Immii inlrndnecd. Various skin and joint cx>mjdicatious, ai^-iHUjianK
frvrr, .Mvnr in a ortain pro|M>rtion of the c-asos in wJiieh antitoxii- i- >
All»iiininuri.M has U-f-n attri})nt«Hl to its use; but, as alrt^dv ^tarr'i. :.
<|ii.-ti..ii niii-^i -till lM'e(»nsi(lenHl i\SKuhjnffute, Antitoxin isak»?aiilt' -'
sn-i.-n-^ :in<l even t'atal results in some eases. How much dangv-r i^"^ -
Im- in it- ii-i' cannot a< yet iM» t»stimat«xl, but must l>e left to the tiii:r
«l.ci(|,-. ( Mn-fnl .-linieal obs<Tvatious and autopsies on Ihtal (.«c*rin^.=-
ii ha- lu«n n-<'<l ran alone enlighten us.
Hu- 1...:,! t n at nient of diphtheria consists in thortmghly cli-au^ir: ■
in. . I, til and n.»-c with warm, non-irritating solutions, sueh as norma N
-..lnti..n. nr iM.ra.-ir aei<l Ibur pr crnt. All strong and irritatiniT a|»;^"-~
tioii- t" tlir thmnt in diphtheria are harmful.
riir trrhni.jnr n\' the h>cal applications to the throat and no^i^i:^?^'*
tant. Thr in«.-t -iniple, eilicacious, and safe, and that which pnxh*^-
Na-t discnnilnrt. i- by irri<jation. The same method — ^namely, by m^"-
u luvwvvvvuv .\Yu\-v — sUvaM V^^iQmvluYed for either the throat or ihet*
DIPHTHERIA.
831
&pt that in the former a larger hard-rubber no2zle should be used than
the nose, and one which is fiufficiently long to pom over the baj^ of the
file.
Here id an illustration (Fig, 105) of the raetlirKl of irny:atifin an ein-
fed in tlie Riston City Hospital and at the \V i I laixl- Parker Hospital in
fork.
liriKatloti of note in diphtbetlA.
The ehild kIiouUI lie on its side, and the water should ho miwle to pass np
noj^tril and down the other until the t^tn:^ni ninfi elcar. In some easp.'^
child pmlerH to sit up %vhilc the irrigation is done. Oitlinarily, the
^tion should be used onee in two or three hours, jierhaps with longer
rvals at night. If the child ivsist^ this treatment, it may Ix* atlvLsjible,
irder to save it8 strength, to omit it for a time* This rule applies to all
DS of I*ieal treatment.
C4>nsideral>le suflering is at times occasioned by the enlargement of the
rical glaiifls. Sonu' patients j>refer the ap|>lication of iee jxinltiei^, others
lot flaxscMxl |K»ultiees, EitluT nuiy l>t» used if they produce the desired
0t of rtxlueing the discomfort.
Nutritive euemata made of fteptonizecl milk, with stimulant8, may, when
inoil, t)e an imj)ortant adjtmet to the trciitment, Enemata» however, are
11 not n*tained. Digitalis may be used in cases w*here heart-failure in
ieipatiMl. In ca-^ies whert* tfiere is a fauc»ial paralysis the child may often,
ii ismxx^ss, be fed through the nostril by m^'aus of ii sort-nibUT catheter
led into the o^sophagug ; this mrth<Ml may als<» W uj^ed after intutjution
*re tlu»re is unusual difficrdty in swallAwing,
Wher<» mcjL'^un's are foun<l to U* ncMt-Ksary t*i retluce ob^^truction in racial
Iteiiosts of the lar\ nx, the cliild should Ik* plaix'd in an atmogjihert* of
m, and if tliia does not relieve the i!tctta(ii» the sublimation of calomel
8:52 PEDIATRIOB.
shniihl U* <'inplnyt<l. In oithor t-ascs howevor, we must remtmivr:..
rWM >luiuM not Im' ko|)t in this atmosphere contiuuou?ly. :ir.«l •.
watrlH**! farrlnlly to s<v if it is siH»eclily relieved of th«' >Ttii->: :•
is ntit, till' ii»ntiinii)iis inhalation of ^teiini in the eonipardtivth ^ilI.
ot' l»n:ithin^ space which exists in the tout that L? u.T«*nl jl r :.> -
may ot it.-<*lf U* (h>trini<>ntal to the ehiltl\s nx'overv. from la«k: •"
nxyir^n. When tr.u'hcfitomy lias heou performed an atnll^-l■llt^? :• . I
\> ^^jM-i-ially vahial>l«'.
The tint, as ilcs<TilKil by Dr. Northnip, who has \imh\ it Njt^r ■
in tlic \Vi Hani- Parker Hospital hi New York, c»ontaiu> aK»a i~
frrt of air. To i*xti'niiM)rizi» a tent, a shw^t is thrown owr*'.ij'>r.
the rvWt an<l allowed to fall i>ver the four sidc»s of tlit* trii'. T- -.
|M»int is to have a fairly larjre and tight enelosure. The apjurair-':
iii>hinir tiie sti-ani or sublimation must Ik» free from the daui:»r»: >
ami ot' Httini: tlu* tent on tin*. For sublimation, a cUrp v.-« .'
a wa-li-lniwl, >li(»nld have an aleohol lamp phieed in it, an-l "v: ;•
till ^tii|>. Over the space when* the flame of tlie aliNihol himp t- :
iimlrr -HJe of the >trip a little, <*uiupaet pile of ealoniel, siifiiii.i.r : -
Mililimatioii, is plaiinl. Ei^ht or ten minuter are rtHpiinil T-v.-i::*.
rali'iiirl. an<l tin* tent shonld Ix^ kept closed alwiut fift<"<'n niiiiur.-. :■
ami -ati-liu'tory nietluKl is to volatilize in an ordinary crilMMU •'.: ,
i") irrain-) of i^aloinel every two hours for two days ami nijijK.V:
proloMir tlie intervals to thnv hours on the thirtl day, li)iir h-v::-
loiirtli day. ainl lat<'r tlin-e tini<»s a day, a<'€N>nlinj>: to indi(-.ui«'U- '*:
It liM- Invii l>r. Moi'm's exiMM'ieiKt^ that (>.(> irrainme (It) L:r:iii> •'
ln.iir t*.»r toiir or tive times will S(mietinu\s j>nHluee ^mhI re*:.;> ^
-iii.mII' I* <!«»-'«'< liavr faildl.
rill' mir-c may ea-^ily U^'onio salivati»d from inhalinLT tliO'-al":.'
ami -Ii.'iiM l>r «aiitiomHl in n'jrard to this. Tin* ehild shoiiKl ii«t i-
t.. :i -iMMrii «li:nii:e of tem|H'ratuiv wlu»n the sublimation i> ovit. T . '
-li'.iil.l l)r thoroiiLrhly aired ath'r opening the tent, an<l it is wtli r :■-
i1m- t liiM to aimtlier room while this is beinjr ihuie. Yonnir chiMnii':
:i~ ;i iiili". -iilTrr tnuii i»tyalism ftillowinp^ this suhliniatioii. (»Kl-r-
:i'f. r :i immlHr ot* <lay-' tn-atment, may show a mild >ti)maiiti-. :.i'. •
liiii. - •li:irrli«i:i. ( 'ln-mii'ally ]Mirt» calomel is esstnitial, a- llie iiu}'.:^ "
iiiiy ..III-.- r..niiin.tival irritati<m. If the fumioratimi ha^ ti> l-^ v.r-
l.nj. .1. .in.-iinia may he caustd. This shouhl Ih» i^omhattil }»v ir . . ■'
til. !v i- |ir.i-ti':iiiMii. M little whiskey should Ih» jriven iK-tim* tin- hi-!'.:-"
Th' -iil»liinai!Mn of ealomc«l is indicatcKl where the svuipt^'ni*"!''-. •
I.I--IIII. ii..n :iiv Mi'Lirnt. an<l may 1h» nsc»d alone or in eoniiuu'tinii wi: *••
Winn tin- antitoxin docs not relieve the symiitoms of stiU'**
\\ li. IV ihr in-Mon-^iv.' (lys|)moa is not quickly ixmtrolled bv stt-am"r •-
siiMliMMti'Hi. it i- Will m»t to delay o|K»rative interference. Tk- ••.""'
III. :iii-«»l' fvlirviiiL: -triio-is <»f the larynx is hy intulMitionor hv tni«'i»f' '
'V\v*- \\\vV\v'AUvm> \\\ v'\\\\v\ vw#A>. •Axsi.'wwi.ronlin^ to Xorthrup, a pr.ui^*-
DIPHTHERIA. 833
memitting dyspnoea, when the labored breathing b^ns to produce sen-
ile exhaustion, and when the supraclavicular and lateral thoracic retrac-
iH^ is marked. It would not be within my province to speak of the
ilftive advantages of intubation and tracheotomy. Each operation has its
lipog exponents, and so much has been said in favor of both operations
l|4 the question as to which is best must be decided by the individual
^^n in the especial case. It is probable that the antitoxin treatment
1 increase the field for intubation in operative cases.
n In the treatment of post-diphtheritic paralysis str}'chnine is the most
billable drug. Electricity, especially faradism, Ls also indicated.
i The subsequent anaemia, which I have already referred to, should be
I tfted in the usual way.
r
E
L
!i
I
I
!
58
DIVISION XIII.
DISEASES OF THE (ESOPHAGUS, STOMACH, i|
INTESTINE.
LECTUKE X:LIII.
INTRODUCTION.
Before s|>oakinp in detail of the diseases of the stomach aod oi^
a ti'w ^»neral ix'marks are necessary to explaiu how limited is our b^ii
of tluso diseases. Those diseases, however, which affect the(K<Tbr.-i
eiisily Ik' classified on a pathological basis, and are so lew in numl^:
they can Ik* inchid(Hl in these general remarks.
OSSOPHAGUS. — The diseases of the opso]>hagiis are rare io r£
and oarly ('hildh<KKl. There may be congenital malformations. ^T.di^ 3
mwinu or dilatation. The swallowing of hot or ccjrrosivo lii|iiiil^ rr^ ;-•
«»l)>trurti<»n. which is occasioned by a cicatricial strictuiv. (E-ii:.:
-tri<tnrc iiuiy also occur as a n»snlt of con^nital syphilis. P^(.^.^n^
of the o'so|»lia;rns may cause ol>strnctiou. These strictures, esjviiili—
nf cicatricial nrijrin, are aca>mpanied by a great deal of mu?tMilar -:*-
whirh at times is constant, and again relaxes. Thus, the child >rilN-
with rinnpanitivc fnx»(h)m at intervals, while at other times theoWxi^-
apixars to U' complete. In addition to the inability to swallow. SJ^-
(•onsecjiK'Mt re^rnriritation of the food, the secretion of saliva and ni=j:--
often very profuse, and causes symptoms of distress and choking.
The diaiiuosis and treatment of these cases are effected chiefly by ifi"-
of hoip^ies: l)ut, as nuich harm may ci^me from these iustrunienb, J^- ■
especial -uPLneal knowledge is re<iuircd to use them and to dtvido ^•''"^
o'sopliai::otomy should lx» performed, I shall not dwell on thU clas? •'! '^'
An inllainmatory condition of the oesophagus is said to occur in )^
infants, and is spoken of as (Vftophaffitis. It is rare. The ?vii4*»b^*
des<rilHHl hy IJillard. aR^ unwillingness to nurse, crj-ing, immediate: rtjC^
tation after he^rinnin^r to snek, and often some tenderness about theaai*
pressure. The proirnosis is bad.
It is <|nite comni(»n for children to swallow various foreign ho&f^^
DISEASES OF THE CESOPHAGUB,
835
buttcHLs and pins. These bodies may either be caiight in the \:m'k of the
fOftt or lodged in the cescjphagus, instc^l of jui8riing tiirongli to the stomaeh.
can^fiil examination of the thrc»at with the tinyiT .should iir^t Ije nia<:k\
id if the foreign IkkIv is not dt'tiK-tnl in the throat the cesophagus should
* explored ean»tiilly with a bougie, and the foreign bxly is then usually
[shed through iut4> the stomach, unW^^ it i^ thonglit wiser to remove it
th the brittle prolmng. The diet for the following twenty-four to forty-
ght hours, or imtil the body has Wen parsed tli rough the intej^tine, should
such a*^ will give sutfieieut eonsisteucy ti» tlie t\v*x'^ to protixt the lute^
le fi*oni injury while tlie body is being |>assed over iti? surtiwx*. Various"
a
CtmwtaauX AiMmtkm ta
Itaamic, 10 wcelcs cM (H namml ilaBU
Einitions of tlie tt^reaL* are useful for this purpose. If neceseary, a done
oil «*an hv given» but, a< u rule, aetive tn^itnient is ci>ntni- indicated.
I have here a specimeu of the u.w*phagUB and stomach of an infant
400) ten weeks old which shows the e<)nditioD of congenital dilatation
tbp oesophagus (Fig. 106}.
WfH' «rivc'n to it. No iinpnjvcmoiit in the sympi
incnt, :in<l although i\t timi's a small qiiaiititv of
yrt, iL< a ruU', after a few minutes the milk was r
luul no ntluT synipt4)ms, but rapidly lost in wei
rxhaiistioii.
TIk* lM»st-ni<>rt«'m oxumination was made bv D
patlH>Io«rical conditions i'ound were, as you see i
liL<t two inclii^of the <r8opluigus were dilat<xl into ;
swrllinjr, with niarkid thiiuiing of the walls and
(•oat. A <lilatation had boon formed in which e
al)oiit to |MTfordti* into the mediastinum was foui
as well as its ranliac and pyloric orifices, was mai
nitly fn >in hu*k of us(\
STOMACH AND INTBSTINE3.— Our knov
th«' >toinach and intestine is exceedingly limited a
infants and yonnjr children are concerned. The <
ca>c> on a patholojri<«al basis has been proved to t
manner a ( lassitication on the basis of symptoms i
loiri,-il invtstijrations, however, have advanced on
<'\t«'nt that wc may hoiK^ in the future to be able
on an rtioloirical basis. The terms dyspepsia,
croupous, an4l <»thci*s have become almost unincaninj
hy t< rin- uum'v clt>scly connectoil with the etioloff\- c
A«ri»rdiiii:ly, the Amorii'an Pediatric Societv
niy-rlt' t.> prepare a nomonclature which would co
niir pr«-. nt knowl(Hlire of this exceedingly dif&ci
]Mri;ill\ I.. I ni|)hasi/e the vahie of Dr. Holt's wo
>■• I mull ill my own stndics on this subject.
:i-l '['t-'l ''N tlie SM'ii'ty wjis one which es|x.vialh
DI8EA8ES OF THE STOMACH AND INTESTINE.
837
tlmii do adults, and may die before the later ainl more oharao-
ions and symptoms of the dii^ease have develoixd. Tliere are
Down imis rt'sulting fmiii tht» anatomical and phvfiioliigifal [)ociili-
igting in iniancv wliich play a sij^niticant part in all the^e diseases.
, tberetore, fii*st to explain the gtmeral prineiples whieh influentv
t«»ms and prognoc?u* of these diseases before attemptiut/ to de^erilie
s*e|)arately* In many (*a.ses we ean arrive at only a|iproximate
m^ to the actual ksion which exists and tlie prfijyfno&i8 wliieh
given. A practical clinind dia^noBis should Ik? made atx^onlinj^
ion whert^ the stres-s of the lesion exists^ rather than to the |iatho-
lt*siou8 wliich are present
I^ERAL Etiology. — In the present state of our knowledge it is not
ible to disena^ in detail the varioius s»ip|iosed caUM>s of j[^Htn»-enteric
We i-an suppo&e that these distnrhaneeti may be due to ner-
itious which may act alone or may nnder the tissues vulnerable
a. Some of thc*se dis^ai^eB are caused by spet*itit* organisms, while
due to a numlxT of oipinisms. These bai^eria act either of
Ives or through their prothiet*^.
b general way, these diseases ean be claM^Hified tm functional aiid
I. The organic elas8 may lie dividKl into inflammatory and noii-
natory dii*t»a^s, although the boundary-line bi-twcen th(jsc* two ciiu-
is at times very doubtful. A prtiminent and important peculiarity
ftdisea.'iej* as they o«x'Ur in infancy i.-<, a« would naturally lie exf»ect<'d
?early jjeriixl of development, a variety of syraptonis which are pro-
by reflex causes. By the term reflex we mean peripheral irritation
pesulting action* By functional we mean a disturbance of the fuiiKion
oi^n without a known lesion. By organic we mean a known lesion,
idditioo to these eases are others which, ns yet imj^erfectly under-
pern tfj l>e prmlucetl by certain morbid pnxhict-^ eliminated from the
y the gastro-cntcric tract, a*-, for example, urea. This etiological
in Ik* s|K>ken of under the term fiiminaHre,
s^ERAL PATHOLOfiY. — The geneinl jmthological anatomy of the
?nteric tract of infancy and early ehildh(X>d Is essentially that of the
and colon. In those cu^^ies in which the more severe lesions are
■he stress of the lesion is usually in the lower ileum and the colon,
r)- fre<|uently in the ailon only. For this reason the terms ikxH
and cYjlitis s<vm more* dt^^scrlptive than ileo-euteritis and enteritis^
eudo-membrane in ileo-c*olitis is often extensive, but sloughing and
tion are exoeedingly rare in young children. It h at present bf»Hcved
I all ulcers of the gastroenteric tract are ne<^es8arily inflammatory,
t nundier of lymph-nodules and the abundance of the lymphatic
are the princijial anatomical conditions whieh influence tlie pathol-
enteric tract in early life.
L Bacteriolocjy. — The knowledge of the different bacteria
r in the gastrr>-entcric tract, and of the ci>Diicetion which they
wlicii it is in a iiormul condition do not <'auso aiiv abi
\vli4*n the intt'stine lias bfc^omo irritated, from ineohaii
ilu' l»artrria an* able to jK^netrato it^ miioous memi
an<l pHMlnct* abnormal symptoms, often of a serious i
(iKNKirAL Symi»T()matology. — Voniitlnjr a'< a
nii>l<'adintr in rarly lite, so far as the ditferential
stoniarli aii<l thr intivitine is concerned, as it frequent
an***' in any part of tli<» ^stro-enterie tract, and slu:
JL< indii^itive of any one distusc*. Serious syniptoius
provrd at the autof)sy to have lx?en produced bv
while ^^rave hsions may be found at the autopsy wbi
toms <lurin^ life \ven» very mild.
Marke<l diarrhoea may exist during life and no I
antojjsy. Serious lesions may exist, and vet no bloi
tions. RloiMJ may ap|K»ar in the dejeetions, and yet
thr h«'morrha^' Ix'in^r only temix>rary, and coiuparal
(Jknkijal I)ia(;nosis.— The obser\-ation of th
important fJ»r the diagnosis of these diseases. As ji
IMTcitiin' of short <luration points towards functional
whilf MM <'lrvated tem|K'rature long continued points
Ir-imi-.
Int.Mlnal dix-har^rcs are often very misleading fo
IlavinL^ considcretl and ac^'epted these geueralpri
tax- of thr Lra>tro-enterie traet in infancy, the Ame]
adnptMl tlic I'ollowinfr rlassifieation (Table 109) as
their rnrniiiitt.f'. This elassitieation must be unders
vi<inrK,l, and is for t\w pnr|H)S(* of aiding those who
>iil»j»'it to \vi>r"k with uniformity.
\t thr siimr time it is lK»lievc.»cl that it i>i » .«
1
II i
III
f
I
III
I
I,
If
R f
I.
I
i!
I ? I
QattritU. GatlrUU,
&s.
SiFi
ll
Br?
^?
= •■ U
nf
I
Hr
IS
^1
If
I-
8
H
DISEASES OF THE STOMACH AND INTl-^iTtNE*
83d
de disiiturbanc'e.s which arise from animal para^itts. The dist*ases an* then
livitJeJ into thc>8ti \vhi<'h arise fmni develoiuneiital, those whieL ari^e ihnn
iDctioiial, aod those wbieh arise froai organic c^use^s. The oi^uie ditieases
siitxlividi:^! iiit<» ijori-inflammatfiry and inf1ainmatf>ry, and the fonetifmal
nd org^uiie dist^ases into acute and <*bronie.
General Treatment. — In the ti-eatment of tliese disea^^t; we should
adeavor to carry out four general rules: (I) to ctjinbat the sc^rionw eundi-
ions alivady referred to ; (2) to dislcKlge the bacteria as qnickly q& i>o68ibk\
erhaps l>v laxative?? and irrigation ; (3) oot to introdnce int*3 the gastro-
fiteric tract for a ctTtain |¥Tiod flwid whifb may prove a favorable cnlture
fronnd for the ba<ieria, siiiw it has bet^n shown that where the food is
iterile when it enters the ga^tro-enteric tract it is quite ellbctive in reducing
be number of bacteria in the inte?^ine ; (4) to intixxluce such drugs into
lie gat^tro -enteric tract as may, by their anti- fermentative and gcTmicidal
owers, diminish the action of or deg^troy the ba<*teria» This la^t lule is,
jwever, very difficult to carry out, and, with our present knowledge
jf drug** and their adrainistmtion, practically impossible. It is true
liat we kiu»w that subnitrate t>f l>isjnnth is an anti terment, and that it
eaehes the part of the enteric tract which we know to be most at!k*ted in
Snt/^ric disturbances chamcterized by fermentation. In p^o^>f of this I
dimply refer ymi to this intestine (Fig. 107, facing page 81^8) of an
ifant, given to me by Dr. Holt, to illustrate this jwiint, where bismuth had
en given, and when:* at the autopsy the bismuth was found thickly coating
Hhe mucous membrane t if the small intestine, and als<i appearing in tlie large
intestine. It is, hmvever, questionable whether in any east* the attempt to
ill tlie bacteria by the inttTual iwlmiuistratiou of dnigs has Ikco successful,
iPreparatioris, such as salol, which are known to be bnjken up into their
|carl)c»lie acid c«imp«:iuenis on rt^acliiug the intestine, i^nnot with safety lie
^ven to the infant in doses large encjugh to kill the bacteria, for in such
i<j§es tliere may be sctickjs rc^snlts fnun ijoisoning. We can, however,
eibly, by means of tht^se germicidal *lrugs, produce a ctjudition in the
Qtestiue which, though not c*3nducive to the death of the baet4?riii^ may yet
h(i so unfavorable for tlieir growth a** to aid our treatment when we are en-
-deavoring to dislodge tlieni. X^ithing detiuite has, however, as yet resulted
Ifram using drugs for this pnrpjse, and, so far as I can judge, the danger
of treating infants or ytnuig chihlren in this way is greater thau tlie good
libat may result from it.
nitrrir disturlwuKV. The only symptom which definite]
to Im' involve*!, whether from reflex, functional, or o
vomitinjr, and, tis we know that in many csjsh.^ vomitiuj
l>y tlisturlumeeol'the intestine, we reiilly have no sympi
jrastrie (lis<'jis(» alone. The diftienlty of locating di.sca*
n'lHh'reil still jrreater by the faet that serious organic
the stoina»'h without any symptoms whatever, whethc
or tenderness. We must, then^fore, be excciKlinglv «
diajrnosis of disiuses of the stomach.
r)is(>as(»s of the stomaeh may arise from derelopn
<n'f/<:nir ciinses.
DEVELOPMENTAL.— Under developmental afle
are inelndiMl niftifonnntiom and malpositions, A malfo
arh may 1m» rej>resented by a narrowing of either the c
oriliee, or by constrict ions in various }>arts of the vent
known as honr-^lass (contractions. A malposition of
met with in various j)laces, one of which is in the tho
malpositions, however, are exceedingly rare, and of patl
ol' clinical intcnst, as the diagnosis can acaroelv be ma<
FUNCTIONAL.— The functional diseases of the \
role in infants and in young children. They may be of
variety, or may be what I have S{X)ken of as eliminatii
ill wl licit certain morhid and irritating substances are s
-toniach :ts though it were an excretory organ, mav ii
many of the rather ol)?i(Mire gastric symptoms which a
at prcH'iit oiir knowhxlge concerning this class of ea
iinl<liiiitr that they need merely be alluded to. Acul
^yniptom^ may l)c produeixl by a number of causes
ar«- lo Im- imdrrstnod as arisinir from a nervnuji oionHl
DLSEA8ES OF THE BTOMACH.
841
a complete rest until the uervourt dihtiirbmice ha8 snl»^5dc«d. ^Vs a rule^
no intenml remedies are indicated in these cat^s, exix»i*t au emetic where
the vomiting arb^s from the reflex <*ause» just deftcTiljed, or, if neoeefiary,
lavage.
There is one form of Vfimiting, however, which is of such imijortance
that it must be spoken of as a disease l>y itself. There is no name which
can be given to it extrpt that of permstent mmitinf^, m no i^iingle definite
cause nor any puthologiml lesion ha*? ever been proved to prr>duee it. It has
iKit even been shown that it is a primary disturbance of the stomaeli. In
fact, in many ceases it if^ |x)*4sihle that the soure<» of irritation i* entiii'ly out-
side of the sti^mach, awl perhajM^ eonncete*! with the great sym|tatlietie
ganglia, such as the solar plexus.
Etioixkjv. — The inciting caune of the vomiting in most cases^ is olwmre,
but iai evidently very varitnl. It dms not setnn to lie produced esjiecially by
errors of diet, but, ou the contmry, occurs in child ix-n whose diet has been
moet carc*fully regulatal. Tudue exposure to aAd, fright, and excitement
all appear to me to have s^imetimes an ctiologiml influence on the ditieatie.
This fi>rm of vomiting may *K'cur at any age. I have met with oases ill
young infants and throughout the whole |)eriod of child hi>«»d, Tlie attacks
may occur not only in delicate, nervous children, but also in those who are
ijuitc vigorous.
SvMPTOMH, — The attack is very apt to eome on suddenly, the cliild
being previously in gootl health and not having shown any digestive distiirlv
ance, Tlie f^eriixl over which tfte dlsi^ase extends and the intervals of the
vomiting during the attat^'k vary i^nsiderably, but in those t^'^^s which have
come under my notiiie they are simiewlmt as follow*s. The child, witht^ut
any especial warning, l^>egins to vomit, and at first the vomitu?^ will simply
be the remains of fcxxi which still happen to Ix^ in the stomach. It will
continue to vomit quite regularly every fifteen or thirty minutes. This may
last for ten or twelve hours ; the intervals then gniw longer, and sometimes
the vomiting will (X^*^e for twelve or fifteen hours and then bc»gin again.
Ocx*asionally a little mucus appears in the vomitus, but not to any great
extent As the discast* progresst^, a slight amount of bile usually appears
in the vomit us, A very prominent symptom is thirst, the child cr\'ing emu-
tiimally for water, and vomiting it vsoon after it is taken. As a rule, the
tcmpraturt* in these cases is normal or sulniormal. The pidse varied^ bat is
very apt to hv slow% sometimes intermittent, an<l may bc<Time weak. After
the first twenty-four hrKirs tlic child emaciates rapidly, looks verj* ill, and
becomes aj)athetic.
ITnless the disease* is unwisely treattnl by endeav^oring to introduce food
or drugs into the stomach, it will usually pn»vc to lie si^U-limltcd, and will
run its coanse in two or three days. In some c$ise» the length of tlie attat*k
is much shorter, being c*jmprisiHl witliin twenty-four houn*» while in others
it may last for many days. The nx^>vcr\' is often as sudden as was the
onset of the disease. As soon as the vomiting hiiA stopped, the ap[)etite
HV2 F'EDIATRKS.
n'tiini>; then- an* iio simhIjiI symptoms of iiiditrt^'J^tion ; the ihii-iriU*:
tiNitl \v<'ll, and iho (>nia' iatioii <Iisap|K*ars rapully. Relajises ix^t: -^
take {ilacr.
l>lA<iN<)Sis. — Thf diagnosis of pen<ij<h*nf vomitiiif/ is oft.n -i"5'
iiiorr oil ac-<H»nnt of a lark of sutlicient knowledge coiirfriiinL' tLr :-..
tliaii fnmi miirh rvichMicc of the oxistonce of the dis'i^aM's wh.. -
siipjMisifl to >iinuhit<». In thfscM-cis(^ an exaniiiiatioii of the aUl>D>/ti«L
U' inadi* at onii', inchulinjr a nn-tal examination. This is nttt^^an :: • '
to (X* hull* sui'li sonnt»s of vomiting as intu8.sii.*^ri']>tion ami a]}--!!!-.
The aliM'iMi- of any markixl incnsise in the teniiK»niture and a <t*
examination ot' t lie thorax will in moi?t eases exelnde the sudilin:-"
>ome pulmonary (lisi*:isi* or of the aeiite inltH'ti«uis diseaaej*. T> ii-.-
whirh is mo>t eommonly susix^etetl in these eiises i?* tuherenlar Kriiiir
In «^omr instances, after the disease has lastixl for two or thnt- Js- '•
n'<rml)lan<v to tnU'R-nlar meningitis may be quite strikinL': Kit :* •
whole course of the atfcH'tion is taken into consideration, the dia^'UK--:
iH'com4'> rhar. In |K*rsistent vomiting the face and general apparij- :
tlu' chihl in<licate nausea rather than the apathy which would 1* |':>-
in tuherenlar m<*ningitis. The mind also, in contnidiijtinetion to what t:?
place in the latter ilisease, is clear, the child n>niaining quiet meniy ^.-a.*
it i< exhau-teil. The gn»at thirst which I have aln»ady niention»da«'»:::
pn^eiit in per>ist4'nt vonuting also aids materially in the ditfirvmia. :i^
no.-i- tVom tuln'rcular meningitis. The sudden ousi»t of the vt»miiii::: ^'
pn\ inii^ly healthy child is (juite diftcrent from the sh>w jiniirn-? ii '-'
ori-.i-innal v^iiuitinir of a eerehral type met with in tnU'reular mtr;i:.L •
After the I'nM tW4'nty-fi)ur hours, persistent vomiting is reaili'.y iii! " ■
tinted iVniii attarks of simple indigestion, as wheiv the vomiiiiu ->*
from infliire-tion the stomach is si>eeilily relieveil, and the v«tmilirL' J"*
not enntinually riiMir withtiut ap]xirent cause, as is the case wher» iitN>-
vornitiiii: i- ]»reMnt.
Ter^i-teiit v«»miting is also verj' commonly <liagm»sti<nieil a* v:*'
Lia-trii- eatanli, l)nt in the latter discuse the heighteneil tem|)eratiirf, -■'
tniiMUr. pain, and tendi-nuss in the epigiistriuni will, after the tir^t ^''••- •
tlnir li.»iir-. all.«\\ u-^ t^i ditferentiate the two diseases.
ri:«»..\o^i^. — Tin. jirognosis of jx^rsistent vomiting varies aiimiln:-
the a-, .'t' the individual aiVecte<l. In young infants, es|-»tHiaHv in '-^
\\h..-. \itality i< w.ak. it may pn)ve to l>e a verv st^ritms dista-^. ir'^^-
txhan-!:..!! wliieli invariahly arises in the first twentv-four Ik-u^. '^■'
nil. i- ihat the ynimM«»r the individual the more prostratinir un^l <i '
i- til. .li«.,:i-e. Kv.ii older childivn are at times so piiwtrated l»y tU >
tiii;i.ii- VMiiiitliiL: that grave douhts ai"e often eutertainetl a* t«' * '
'.'linittr i....v(iv. in Lxeneral, however, the prf>gnosis in tlu'!*":^"*^ '
- '• '""'. MiiipMi-h I have met with a number of them, I have ntv»;rrr.
lii. .1:-. .1- '•• -nh in death.
ji;r \ iMiA 1.— The treatment of iK^rsistent vomiting is essentially f^"
DrSEASBS OF THE STOMACH.
843
ation during tlie first twenty- four hmirrt, Tlie ohikl should be kept per-
ctly tjuiet in a darkened room. If after twenty-four hours tlie vomiting
btiU continues, or even before if tliere appears U* be tiiueh exiiaiistii)n, or if
be ehild is restless and sleepless and has an interniitleut j»uLse» liydrate of
ilorul and bromide of jK»tassium, dissolved in brandy and water, sliould
given by the reetum. These are intended to prm^ure sleep and to stimu-
Bte the nervous eentres. As a rule, however, the chilrl is quiet, and sleeps
the intervals of the vomiting, and, arf the dist^ase usually altaek.-* an
ifant or a ehild who has been |>erfectly well, cardiac weakness is not com-
lonly shown in the fii'st fijrty -eight hours. Xo ft«xl and uo drugs bIiouM
given by the niijuth. After forty -eight hours, small enemata of peptou-
milk ean iw given, and when the disea^ appears to have nin its
"course, iis it often dc»es in three or four days, small (juautitifs of a earefully
KiilifiHl alkaline rnilk ran Ix^ trinJ ciiutiously by the mouth. A mistake is
Lsuallv made in the treatment of the dist-ase in feeding by the mouth too
j^— 1 shall s|K>ak of a few illustrative cases of this disease whieh have come
under my notice, as a knowledge of them will be of great us© to you in
• your praetiee.
The llitt (Case 407) was an infant, eifj;ht monthfi old, fttrong and healtfayf whoM focNi had
Iways h**vM tlit; milk of a w**t-riun*e. Witliivul miy previoua symptoms the infant l>ogan lo
romit, and continued to vomit «ver>' fifteen minutee for twelve hours. The intLTVala then
tie longer, and the vornitinu; eeaa^Ml eniia»ly on the third day of the attik?k. During
attack the infant emaeiutod rapidly, ^o that it I* Miked as thoiis^h it wer** in th** Ijist
of »ome waiting di»eai«. It lay perfectly quiet uud slept in the inten'uli of th«
romiting. Its mind waa clear. Its tcmpi'ruture wa« ^iihnonnai, and iu pulae w«itk and
riU^nnittJng, It waa treated by rectal cuematii of brundy, peptonized milk, and bromide
Df potH»rtium.
The infant bad Myenil attacki of this bind in each of the following y<ean of Iti life
kntil it was five or six yearv uld^ when it would gometinies f^o for «ix month* or a year with-
al an attack. A» it grew older the attacks became leia leverc, and when it was i«n yean
they e<*ased entirely.
The next case {Ca«e 408) was that of a girl, twenty-two month* old, whnm I *aw in
nsiiltNtion with Dr. Jo^^ph StiHlrniin. She wa« p<*rfeelly well before the voniititig l>egau.
i«r tempi'rature was normal: tht< pul>^e was ^lit^htly acct4<*nit(<d at fli>t, and later l>oatma
llow and inUTtnitli'nt. DuHn|E; the fir^t four dayo of the uttiiok the VLnnitin^ wh^ iiliiio«t
ntintiou^, and Ahe became ai> wonk and evhauMt^nl on the fourth duy that it was (cured
! mifrhtdie suddenly. There w*.'r<-* e^rt^at rf«tk'«*ness» dihitcd pupiU, ihnmin^ of the hiwd
ekwanl, ^biw putivet and normal reApirMtiotia. The fmiiciation wim ntpid, Th«* itrtnt? tvas
aty. On the llfth duy, the vomiting hnvin^ continued, she fell into a state of roiiapfK'^
pu1»Q was hardly peroeptible^ her countenance was ghastly, and her ertr»*mitit«i w^re
old* At one tiHM^ afti*r a ^ven« nttactk i^f vomitini; t»he l)«came cyanotic^ nnd wtt« almo«t
by tc?rmdou* mucus Thiei. when vomited, appeared to invade the InrAin, mi that
it tuiuj^h ht^r life wits saved a nund^er of times by the prompt action of an
ir^'. On the niith day th«? vomiting grew leis, and on the f4*venth day
eriiMU «Shv wa« not, hi«wev(*r, ahli* to be up and about until the eleventh duy, itnd wiis
kivt rniin'ly well until tht^ thinl w«<«^k fmm the tim# that ^h*" was attacked. The treatment
this oa*e wa* the ^ame as in the previous one*
A thml raM^f a U^y (Vn*** 40!)), uin(» y«tars old, was s«ieT) by me in consultation with Dr*
0. Uarnngton. This boy was attacked suddenly with vomiUiig as described in the
S 1 I PEDIATRICS.
Hn\i«'U> rji-»-. Tin- iluRitiim of tho attuok wiis u>>«»ut two weeks. Th* rr-
•AiniiH'. :iii«l ill'* l«'y"> sln-iiirth wu.- ^upiKirttKl solely by eneniata. a» at l. :.:>..
!\v.. wiik' •■••iiKl uiiyiliiui; )>•• ntaim-d by th«* *ti»niueh.
Tln'*»' l:i-i two ru.-«- w«Ti' uiiusu.'illy pr«»tnu'ted.
AciTK (Jastimc lNi)i(iF>TioN (Acutc Dys|K*|><ia). — Byiui:-:
inraii a di-t mining' oi* tin' ^a^tric stfrtftions inU»rtoriiijr with th^ni'
iIh' >toiii;u'h tt> Mich a th'^rtr as to <-:uise inorbiil symptom.'?. Eu'
thi- ili-tnil)a!Ht* i> in infants and young chilclix?n has ni»t vk 5*'
pri»v«il. Vhv rausc of arnto indigestion in iniantsi?, and in al.'.-- "
r:LH' in y«»nn^ childn'ii, is the fixxl whioli is pivon to thr'ji. I-
i'>|K'<iallv noti<i'al)Ie in the first year. The ages at which iudi::-?:.
fni|ntntly <KH'nrs in this {KTiod are, first, in the* early days of lifi./^
e<|uilil»riuni of the hn'ast-niilk has not IxH^n etstahlishiil ; ."?«?< ul -
niidilh' of tin* tii-st y^'Jir, when the hn^u<t-niilk is so apt t<» U' n-ii
snpplenunUil l)y s<»nie other ftnA; and, thiixl, at the end of the 7^1:
tiitin'ly new artiehs of diet a«» usually given to the infant.
Symptoms. — The symptoms of acute in(ligt*stion are oxtreiL- ii
naus<a, enK'tations of gjis, a g€»neral apix'arance of discv»mfi»rt. ilurpr:
t<» the pain in<lnee<l hv the development of ga:? in the stomach. ^.:
i-e-iiiliin;; di-tention, and finally vomiting. If the diet is ox.-Iik'.-.
milk, th<* voinitns will nsnally contain large eiirds of the owiTik-'i
teids. In eonntH'tion with the gastric disturbance there is (^imm«»niy'.'
pat ion, althouirh sometimes then* may be a relaxiMl condition 4 »f tht •
'I'hr tieeal diM-harj^cs ae(*om]mnying these* attacks arc of an aluir-rn.!
n-u:il!y a niixtnn' of ^phmi, white, and yellow, an<l of si»nr «M:l.»r. 1'
\h\\r nr no ti'ver. At tinus the sym[)toms aro s«i severe tli:at ::;•
lonk- as thniiirh it were p>ing to die. In rare cases also retlex -yu.ji: :
a M rinus a-^|M'<'t may aris«\ sneh as I have already (leseribtnl wku m-^---
of a-thina ilyspeptieum (page 750).
l>iA(iN<)sis. — S>metinus the diagiiosLs is obe?cured hv the a'^''^
vniiiitinir, luit the pallor and nausea are usually of sufficient iiri>mii?n-
allnw II- t«» <l»'ci4le that the sc»at of the disturliance is the >t«»raa'.^ ■•
<nirti«-. -nrh a- one-lialf to (me tcas|KX>onful of wine of ijxxac. urui.-^
lii v«- thr -yiiiptoins promptly and makes the diagnosis cle:ir.
Tkkx'I'MKNT. — The treatment of acute indigestion is to emp- ■
>tnina<li. to i:;ive a mild laxative in order to clear awav the ut'ii*"'-
linHl. Mini tn n-iriilate tlu* diet. The laxative niav Ix* one or r*" '•"
-|MM.iiriiU nf ra-t(ir oil, an eighth to a tenth of a grain of ralomtl i-^'-
• r tlv. <loM <, nr a tea*^|MM>nfnl of li<piid magncvia. If the l'tH>*l !a- •"
iMVMM-inilk. an analysis of the milk should be made at oikv. u:i''
|.r..jMr niM(iiiiratinn of the milk, acxHirding to the rules whi«*h 1-
:iliv;nl\ i:i\rn vnu. should lx» earrietl out. If the infant is lieinL' tod "^ -
irii|.r..jMily niodilird milk, or if improper food of any kind iMbjUvn:"'-'
to it. :i n.iirr.nee of the attacks can easily be obviated hv a inoJii>^'
ot' thr rlrni. nt< ot' tlu' focxl wliich seem to have produced the Ji>Pir*-*
DfSEASEB OP THE STOMACH.
845
Ehus, in a immtx>r of cases I have fouud that whenever the infant's food
ras mrKlified so as ttj raise the j>eroeutage of the sugar alxive 5, acute indi-
KstioD tuUowed. In like maoiiiT in t'ertain ca»en tht' [xTeentage of the fat
ud to be redutxxl to 3, or ]M-*rhajxs 2.0, and the protekk evt'U a;* low as
L45y for a minilRT of weeks until the digestive function of the stomaeh
Hune norma].
H9ti older eliildren the 8ympt^>ins are similar to those which I have just
■Bscrihxxl, and the diagnosis and treatment the same as in the in Taut, for
iiere Is no way by which an attac^k of aeute indigestion van be so surely
■revented from re<Turring as by at ouee [jlaeiog the ehiJd for several days on
m exclusive diet of a n]ilk raodilied in such a way as to contain a percent-
\gc of frttm 2 to 5 of fat, 5 to 6 of sugar, 1 t*i 2 of proteids, and 10 of
time water.
I Chronic Gastric Indigestion (Chronic Dyspepeia). — If the attacks
If acute ioJigestion are allowed to i»cx?ur frequently from lack of proper
fcreatmcnt, a subacute or chronic form of the disea^ develops,
SvMiTOMs. — In intants the symptoms of chronic indigestion are much
kas severe than those of tlie acute form. The in&nt is apt to vomit ailer
■iking its ftKid, to l>e restless, fretful, and either to Ios(^ in weight or not to
Hlin. Its sleep will be very much disturljixl, ap|jarently l>y |>ain tVoin
ktns. In chronic indigestion the bowels are apt to Ije constipated, but this
m not always the ease. The fhnniic iudigt»sti(in of older children presents a
Ipmewbat ditlerent aspect. The tem|>tTature is at times Hjuiewiiat heigh t-
|Pel. The tongue is apt to be eoatecl, and the Im^ath to have an odor. These
Uiildreu do not vomit so fretpiently as do infants. They lose in weight,
become fretful, and get tiretl easily.
I Treatment. — I have stldcmi found the use of any especial dnig to be
J^f much iK^nefit iu thesc> t-ases of ehnmic indigestion* In quite a number
pf casc»s of b<jth acute and i*hrf>nic indigesti^ju, lM*fore any food is introductxl
blto the sti»niiicli it i^ often %vist^ (irst i»t wasli out the stonmch thoroughly
pavage). This prtxt'dui'e i^ es[*e<;'ially indicated if the indigestion has pro-
Bticed rontinuous vonvitiug.
The tt*« hnique of washing out the stomach is very simple. A soft rub-
ber catheter with a double eye, No. 21 French scale, aa rec«inimended by
Dr. HoU for intliuts tuider six mouths, and No. 25 for older children, is
Ittaelud by means of a piece of glass tubing 7.5 cm, (3 inches) long to
iii<»thiM" rubIxT tube which Is 50.5 cm. (20 inches) long atta<:'hwl to a funnel,
nfefllbly of haixl ruhl)er, and capable of holding ihmi UO to 120 c.c. (11 or
loimoeB). Tht* infant is seated upright in the nurs4^*s lap, with its head
Boliiied fonvard and resting on the nurse's arm. Its arms are txintrolled
my a towel pinned around them. The catheter, having lieen wet witJi wami
prater, is easily passed over the base of the tongue into the stomach. A»
Biere is often c^i^nsidtrable gas in the stomach, the titnnel should l>e raised
la high jiH {possible above the infant's head, in order tlxat the ga^ may pass
iut from the stomach. From 90 to 120 cc. (3 or 4 ounces) of dterilijsed
^4fi PEDIATRICS-
\\iti«r -li«iul«l \n' |Minntl iiitn the st«»macli liy lueanTf ui' thtf fuu^*:.
n«l is ilitii ili-|»n'*s-««'«l iK'towthe luvel of the r^touiach, and dn. iTJL-r.
will ill tlii* way U- .siphnncd mit. As the curds arv often t'^liv
iliriiii.:li tin- t-yv nl" tin* cjithetcT. a niimljer of waf^hinur^ will him: v_.
ti» linak tli«iii up. I*_v wu>hin^ out the .sUiniaeh not only ar> t. t
-iili-Uiii'T^ wliirli an* |ir(Kliu*in^ the indi^'^tinn renioveil. au«l :..- ■
liuiiiLi of ilir stoiiiarh left tree to n*oiiver itai norniul iiimlitir;.
al.^Hi |Mi--ililr tn have- a rheiiiical examination of the c*»ntonts mi!-.
rally, howt-vtr. the latter is nut neeesssarv, altliou^h it h i»i' irp-r
liliy-ioliMjiially. No IImkI should be introduced into the ?t. cii..
l«a-i two lioui> after the wa-^hin^r. The ^vai^llin^ of the >t»nna..L •
eiitinly tVii- from ilan^T. and. in addition t^.i Ix-in^ an imiN>na:::
tlir ireatiiiiMit of iiulii^t^stion. Is often of ^reat use where m»i?«:inniijr.:'
Iiav«' Imi'ii >walloweil.
This nietlio*! of treating disturl>ances of the stomach i- morevii;:
yoiin;: iiitaiit- than in older children, because the latter resist r«'v::
that tin* rt initly is oft«n of more harm than piiod. The tuK-c-JD. ir
u-iially. fveii in oMer children, be intrinluced bv aid of the <Tii:.j',.
whiih i- ii-«h1 tor intiihation. Two assistants are usiiallv ne^-i^san :: ::"•
diniiiir tin* tiilx- in ohlrr <*hil<Iren, while in infants one a-si-iani i« -d --
In -4»nu'«\'M< it i- foniul niH-issarv to introduce the tube thnMyhtir* •
Thr tnU- -li.iiild Im' |msse<l into the throat rapidly, since the jairri:-
voniiiinir o«-<Mir rhiiHy when the tnl)e touches the phaiyns. T>r ■
n-nally :m i-fajM- of j^as or jrastric c*<mtent^ as soon :is the tub.? in:--'-
^-toin.ich.
\\ Im II til.- iiitlnw ot' watrr thnmj^h the tuln* is >hown to U- 1*- ^
ilif r:Ht tli.'it til.' iiit-mt hold- its lireath t<V) lon^, or hv its crviii;:. \ ■." .
or .•.himIiIii.: .■..iitimioiir.ly, the flow should l)e stopjxHJ for a shnn timt, '-
inii-t :il-. Im- takrii n.it to introchufe the catheter too far in tr» ih- -M-
:i^ it in.iy K. nd on ii-^-lf and interfere with the flow of the retuniii.L' >
.iiid .j.iMii.- .-..iitrnts. If the jrastric c-«mtents arc* expelletl aloii!; ii>. v-
th.- tulH- iMtli.T than thnuiLdi it, the tuln? should bt- withdrawu ud; ::
viiiitin- h:i> .-.m^.m!. TIhtc mhmus to be no dan^^r c»f parsing the iv'* -
til.- l.'iiyiix. Ml' of |HTlI.ratin«r the stomach with it.
Liiv.ij.- ;«. .-..iitra-indicat^Hl wheiv there is caixliae disease ur ai.} -•
|.iiliii..ii.iiy .li^tiirl.aiKv, and when the introduction of the c-athctt-r .■.'■['.' ■
t.» . \i-\u- \..niitin- it >Iioid<l W nseil with extreme caution. Tluu-f-
til'- iniaiit i. in a f.vl.lr condition is not a contni-indiitition lotliT-^-
ni.-iii .
Ill .•Mnii.-.-iJMn with lavacre it is well to sjieak of forced fKiiiiii: -r^.v
ill th.- ii.-;itrn..|it nl" infants and yoimg ehildi-en. In cases of a.iu.-:
Hin.ni.- indJ.j.-Minn. and also where a catarrhal condition of tho ^t.:.^
i' lMv..nt. the infants at times refuse to take any fixKl whatever. T.
dn... no, cMvur iiirnly where the disturbance is in the stomach: lb'
rr.-.,iu-n(ly ni.-t uith it in severe eases of all kinds of dis«ise. h^
DIBKASE8 OP THE 8TOIfACH.
847
lumber of instances, wheie the infantB would probably have died of Bt»rva>
iou had not gavage been euipIoytJ, this mean:* of providing for their noiir-
shment has been very suecessfid. Fon^^l fec<lin^ may S4imetim€»s have to
>e employetl fi>r a numb*?r of days, and even weeks, before the child will
>f itsi'if swallr»w again.
The tec*hnir|ne of j^avage i8 similar to that nf lavage* The same aiiim-
mtud is employed, but the child should Ih' j>hice<l flat *m its back iu btxl,
md its head held by an assistant. The catheter should be passed into tiie
itomach rapitlly, the fuiuiel niiscxl up in the air for a few minute's in anh'T
hat the tra* may escu|)c*, and the amonut of fixjd adapted to the ^^^ of the
■liild should then be jKJured into the fiuiueL As the la^t of the food dis-
a{>|)ears tVom tlie funnel, the catheter is pinehnl tij^htly and ^juickly with-
drawn. Tlii.s pi-etmution is im|Kirtant, in ortler that the pharynx ^ball not
lie irritatt^d intl*er by the bIow withdrawal of the catheter or by the trickling
of tlie remains of the fluid, as vomiting may in thi.s way be excited.
One of the advantajii^es which has n:\solted from the nse of the st^imai'h-
tuhe is the kuowledgt* we have anpiircnl of the lime which the tbod remains
the 8tonia<.'h at diflerent ag«?8. Thn^, it ha^ been found that during the
early wtrks of life tlxe stnmach is nearly emjitied in an hour, while iu older
infants two hours are re*|uired for the same process. This knowledge ii^
especially valuable when we are regulating the intervals of feeding in pre-
mature infants*, and in infants during tlie tii^st six months of life. These
als I have already given in my lectures on Fnmuture Infants and on
ing.
Where other means can lye employed, they are |»referable Ut tlie stoni-
aeh-tnbe. I have found iu most instaucej* whci-e infants or children refuse
to take tlieir fixnl that the simjilest way of forcing it uj*ou them is t<j pinion
iiw arms with a t4nvel and have the nurse hold the child half inclining
in her lap. Sometimes an assistant Ls ne<*ded to hold the luad, but this is
\ often unn^tt'ssary. Simply prcs^sing thecbild^s nostrils with the thumb and
■ fingiT will f^ns*^ it to opim its mouth, and the fiiod can then be poured in
with a sp4x»n, or, as I have di»ue in a iinmher of cases, by means of a dnip|»er
with a large end. A child two and one-hall years old, who has rt^x^mly
■bei^n under my care, for several weeks would not take any food without
■being forc<Hl to do so, Althonj::h this child was very ill witlj pneumonia,
Wnvolving Iwjth lungs^ it was f*."<l every two or three honrs, night and day,
■by this metlKxh After the flrst two or three feeding?^ it did not resist, and
■the nosi^did not have to lie pinched, all that was necessary being tt> threaten
■to do so. 12(J c.c, (4 oum^es) of milk were, after a little practice, intni-
■dueed by means of the dropper into the clnUrs stomach in ^ve or six
Mninutes.
■ I have found ttiat the m*-^ Ts run* of chrcmic indigestion is to give
■the child a carefully nvMlit^ ine milk. In some eases it will lie
■necessary to reduce the fat or sugar, in others the proteids, but in every
Base, as soon bb it is d<!t«rtiiiiM9d which of tlicse elements in fiitl stt^ngth
the niiiii^'sU'<I f<M)<l which passes into the diiodenuni i?f
intostinai disturlKinco. This, by adding to the dii^oor
w«*ak('ns it, and tends to prolong the gastric iudigt^tion.
ORGANIC. — The organic affections of the stoniac
into non-inflannnatorv and inflammatory'. They an*,
very ran' in c()m|>aris(.m with the functional disea^sos
d^'scrilHKl.
Non-inflammatory. — The non-inflammatorv eoudi
<H)nipris<' a diminution in the size of the organ, uiechauic
and new growths.
Contraction of the Stomach. — In certain ca$es 1
of the stomach is drndwlly diminished. This diminut
rule, cle|K'nds ujxm a lack of use, such as occurs in infant
eieiit f<HMl to fill the st4>mac*h is not taken, and in this
not c-*ille<l u|)on to jHTforni its normal work. In cases,
eoutiuuoiis voniitin^, this same lack of use may prtxluce
size of the stoniaeh. These cases are of pathological rat
interest, as they ean si'ldom be diagnosticated, and their
tially that of the siH^eial disease to which tliey are seoonc
Dilatation of the Stomach. — Dilatation of the stor
<'oi union in infancy than in older children. It may ran
nialfnrnintioii, such x^ a stenasis of tlie pylorus, but ii
result ot' errors in fe«ling. It is more apt to occur who
inir-r.l. ^nIe^s especial care is taken to give the infant tl
which i< mlaj)te<l to its ajre and gastric capacity. When 1
the l>n;i-t se<nis to provide the amount of food which is si
from «rror> in fe<-<lintr may Ix' caused by the fact that the :
eithrr in <jiiality or in jpiantity, to the age of the individi
tlh' ijimlifv i- at fault, the nutrition of the tissius^ or t^^,
DISEASES OF THE STOMACH. 849
e size of the stomach at different ages, and the amount of food which it
^rmally holds. I shall, therefore, not repeat what I explained to you
fuUy at that time, but shall merely impress upon you the great impor-
Doe of carefully regulating the amount of food which is given at each
eding during the first year of life.
Pathology. — The pathological condition which exists in cases of
istric dilatation is well represented m this stomach (Fig. 108).
Fio. 106.
Dilated stomach. Bhschltic infant, 7 months old. (Natoral sise.)
It was taken from an artificially fed rhachitic infant (Case 410), seven months old,
lo died under my care at the Boston City Hospital. The gastric capacity in this case
IB 800 c.c. (10 ounces), which corresponds to the gastric capacity of an infant twelve
^nths old. You will notice the shape of the stomach, which is very significant of the
mptoms I shall presently describe.
Tou see that the lesser curvature is not much altered, while the greater curvature is
ly much increased. The pathological condition of the tissues is such as would be expected
64
850 PEDIATRICS.
fruM ijonrml nialnulrition. In such diseases as rhacbiUs there is a stpetchiiig it^-jy^
fil.n>, us wfll lie an atrophied condition of the entire gastric walls.
Symi»t()Ms. — The symptoms of dilatation of the stomaoha!VHS£:i
th<»s<' of rhnmic indij^estion. Vomiting is quite frequent, and-^Ur
until the stomach has \m.'U entirely emptied, when a periijd of peli: >
to last until fn^sh irritation arises from another supply of fond. Aicci
paiiu tlatulcnt'O, and general discomfort are prominent syminom?. hj
iition and rai)id loss in weight also occur. In some cases, in youii^-i^
^•onvnNions may arise, api>arently due to the reflex dlsturban-v A-i :
juckIih**-*!. There are usually considerable thirst and lo» oi' ai^i^i?
When the dilatation is of a high grade, the vomiting may iK.iur nnl. Ji
eonsidcrahh* intervals, — twenty-four to forty-eight hours,— durioj si
time the finnl dcK's not jMiss out through the pyloric orifice to aay t-r
but <*olli'<'ts in the stomaeh.
If yon will l(M)k at this dilated stomach (Fig. 108), you will ^-^
nndrrstand tin* mechanism of these symptoms. Under normal oti •
the stomach, as I have alnnidy shown you (page 85), is s«3mowhat ni-u
in sIkijm' and ohliqnc in iK)sition. The food thus easily j)as^e^lh^d.:
f-anliac to the i>yloric orifiei\ In dilatation of the stomach, on thr o-.ii:r
the tinatcr <'nrvatnre is so nmeh increased and depressed Wow the k-l
tlie pyh.ric oritice that a i)oueh is formcnl. The food, wlleitini' ii '.-
|M>nrh a< though it were at the bottom of a well, has to he praiTri;
pninpcd, hy the contraction of the muscular walls, up to and thnuii:^-
pylori<' orifice. The already weakened stomaeh thus has to |wr1inL '^
t(»r whicli it is not titt<Kl, and finally is relieved bv spa-^mf^li'' v-rui".
When only the small amonnt of fiKxl adapted to their uonual r--'
(•M|»:i.ity i- Liivc-n t«> yountr infants whose stomachs an» dilat4xl, a br:^ -■:
of (inj)ty <toniach is lelt alnn'o the level of the liquid which ha•itrr^
the -tuniarh. TJiis creates a feeling of emptiness and general di^n-TJ*
so that the infant apjH^ars to be hungry when, in fact, it k only ?.if'r.-:
from the i'eelin^ of inc(»niplete filling of the stomach.
I)ia(;n<)sis. — On insi)ection the abdomen is seen to be di^teftWi-
tense, and on percnssion to Ik.» highly tympanitic in its upper port. Sa»''-
>inn i- not an especially valnahle diagnostic sign in dilatation of the rt»aa
Sncen^^Ion is s«) freqnently fimnd in many cc:mditions, and is s^) liWy '• '*
<'nnt'nnn<le(l with that which (Krurs in the colon, that it cannot bereli^'i'?^
Th.- nntliiie< «.f a normal stomach when somewhat distended vary fo Lf:.
in inl'aney that the resnlts of jx^rcussion are often very misleading, ^t:-^
ho\ve\ei\ the tynij)anitic n^sonance is found to extend' below the line yt' -•
nnil.ilieii>, wt- may snsix'i-t that we are dealing with gastric dilatati"n. I:
inlaney the eanlia<* end of the stomach is so slightly developed that *='
ureiit inere:i-e in the area of gastric percussion to the left is an imp-rtc-
aid in inakin^- tlio dia«rnosis.
Tlie ditl'erential diairnosis is to be made chiefly fit)m dilatation nr'i
eolnn. In many cases when the colon is dilated it is impossible to i:^
DIBEA8ES OF THE STOMACH.
861
le whether the stomach h also dilated, smoe under th^e cireumstanoes the
m can almost completaly cover a krgely dilated stomach. In older
dren, in (ust*.s where the dii^pio8i\s is uiiet*rtaiii I have found a valuable
Uis of detenu iuing the prt^i^encre of dilatation to bi^ artifieial distention*
B can be done without harm <»r discHHnfort to the child by givinjj^ it first
half of a s«?it:llitz ptvwder imd then tlie other half, so as to allow the
tnical eombinaiioii to take place in the stomach, Except tn certain cases
ere it Is very ut^eessary to deterinkie whether the stomach is reallv dilatedi
i is not a pnx'ediire which I am in the habit of adopting. In most ca^iee
infants unci children clinically satisfactory result*? can be obtained by
eui?»iou.
Prognosis. — If the dilatation is due to congenital stenosis of the
orus the pn^guosis is very unfavomble. In other (*a,se4 the prognogis
■endj^ uyyon whether the coiidit!t>u arises from improjKT amountft of food
krom some dis^'a^e, such as rhachitis. In tlie Ibrmer class the prognosis
pod, and the st*nuarh under a pro|*er reguiati<in of the diet stxiu resnmea
natural size. In the second class it is not so g^xxl, and, as a rule, the
Inaeh will remain more or less distended until the disease which causes
dilatation ha^s been cured.
Treatment. — If the t-ast* is an obstinate one, lavage is an inipirtmit
t of the tn^atraent. In many cases, however, good results are obudniKl
tply by regulating tlie quality and quantity of the food. In b<jth intknts
children carefully nuMlified milk is tlie ftxxl from which the Ix^st rt'sult^
obtained. Whtn the fcMwl is first given ui tlie proptT amount it will, as
kave just told you, not fill the stomach nor satisfy tlie demands of the
int. Under these cireiimstantX's tht^ infant will W very n\st]css, and will
|n cry almost continuously from the time of i)ne feeding until the next.
ti must impress upm the nurse that tht^st* signs of dise^jnifort are liable
ast for a numlwT of days, until the stomach ha*^ more nearly resumwl its
tnal size, and that an additixMial supply of IovhI must mit bt^ given to it
I ihull riiport to you ihe cafle of an infant (Case 411), four months old* which illustimtca
Ulion of the stomach at it i>ccurs in the first year of lifo, Thi« infiint, a male, vunt well
itroni^ Ht birth. It was not nurswlt but wa* fed on a niixtun* c>f milk, cr»^4iin, aiid wattr
ftis an iinu!*milly vigoroiw infant, and i* rrportod to have never bL»6n ^utiifled with the
II quiii»titi*'« ut foiHl suitnhU> to \v^ nfze. \Vh**n it waA thr^ wc^k^ old it wa« i^ivcn 150
^ cc. (6 or 6 aun(?6«) at i^ach tncul. Somewhat lat^r^ in its M^ymd and third moniKi, it
iually developed syroptofns of indit;;ei»tiiin, and when I wa* failed Ui *w it wa» in a vci^'
wndition. It had b<H?n havini; frw^uent and pndoriKi^t convuUioTia. At limca wb«*n
|u In the convulsions it would fall into a state of eollap«e» the pallor of iti fare would
Itxtreme^ and U wnuld look iu* thoui^h it weri:« dyini;. On examination, nothtni; iibnor-
was found in the thorax The entire toMomrn wa^ ftnind l** Iw di>»lendoii, L^^^NV^ially
|l« uppfrr part, wh'<rp the gn^tric tympany wait pn>nounc^ and «*a«tly marked out by
Ion. TUv p«>n*uik9ion showed the it^tniach to be dilated, and to tuctend below the Une
ie umbilicus and far to the left of the median line.
The infant waa given amftl] Ainountfe of f(^>d at fa^quent intervmli* For th« flret two or
d*y» it eried and »cn*iimed for mor« ftxid, but the convubions c!««aed, Its |(«naml c«)n-
i improTvd, and by the end of the w(!6k th« distaotioii of this ttoiuach had lub^lded
852
PEDIATRICS.
vrry mmrk«dly and the ia&tit bad become irmnquU From tbU Haw tbatvii^i
reiic<» of ib<» fymplotrifc,
I Imvc here iu the w&itb to «bow jou « colorml bcij (Case 412)^ six ^«iiv 41
Cask 4IS
This child b tnnrlcedly rbachitic. Ho b re^K^rt^ to hav« been in frtr
delie»u% until one month iit^o^ whea he began tL» have pemiatmi vvutitliac
i^rcatly in weighty haa biM:;n very restless at rughtt and haiS bad ODotiniial
Phydciil examinntion shows niurked Abdominal onliir ,- Qn
trip tympany is found to ext<jnd duwnwurd a* far as the u . 7 j^ ^-^fi <1
right of the mfidian lino and t0*4 cm. (4 Incbt's) to the letV : Qm
lint^ which rt^presents the greater curvature of the stomach, u tip?
of the colon b uUo exaggerated in thUcai^T and ai» its diflbreniititlori fiticn thataf ikt
1st snmrwhiit difliculti becauae it evidently overlaps the Itiwer boitler •*€ lb# *h^^^
endt^avor to eliminate thiB oh<^tacle to diagnosis by nic^ohanical mriMW V
child readily takeii half of this geidlitz powder which ha.^ been dieaolvct) m
other half, which ha& also been dissolved in wat«fr* is next ^uraltowvd^ A» tJir
of the two §alts takes place in the stomach you can ejLHilv hear with Ih^
chciiiical Hction which is reaiilting. Tht* child shows no si^dj^ ^tf dUcomfoftv
hediicji not ftnl any pain or any niorf tenderness in the epit^Hstrtunt than bdi»t^
were taken. The ouilin<* of the upper part of the stomach can oow lie fklftrwlt*
on percussion the tine of the greater curvatUPB i» fi>und U> he %Q cm. (1 Jt^) ^
#«^
DISEASES OP THE STOMACH.
888
^fne of the umbiliciifl, lh« oolon lioving beeo puahed out of the wny by tho diatended
pxnjich I huvf? indicated the line of jjrpeaUT curviiiure by a brotd white line, And in thU
VAy wo detemiira' tlmt Ihv aUmiAch is r»5«lly dilHted,
(8ul«equont hiritor)'.) In thb cuiw? »t wa* not found necowiafy to wash out the itoroach
noTG than <mcc or twice, for a^ ^oon at ftuizdl aiuountii of food wen? fjivcn at frequent inter-
ila Uj<? vomiting ceaaed and th« itomach gmduully resumed iu nominl siawj. At thu end
Df two months the child left the ht>&pital free from any abnormal g^astrie symptoms.
Ulcere. — Ukvr^of the stomanh in infancy ami early rliiltlluMKl aiv very
are, but cartes have been rej.>urted. They may bc^ m>rwij»rtauiinati»ry or
aflaniniator}', tlie distinction between the two often being very difiiciilt to
ake.
Thn:)Ugh the kindness of Dr. Northrnp I am enabled U* rejioit to you
Buch a ca;^, iieenrring in a female one year old who was under Ids care, I
have here the stomat*h (Fig* 109) to show you.
Fid. 10S».
FnUii'ttbir uln r
mach. Kemale, I year old.
f Thi? ififimt (Caw 41H) wa« under treatment for one month. It had Tomitin^ find dfar-
^ rh'i'H. Ihjrini^ tht* flrst ww*k that it was in th** hospital it* l«mpemtur<? varii^l ^
to 39.4** C. (lOS* to in»« P.), after that \mn}* normal or fuhnormaK The p ;
led fW>m 40 to 60, luid tbe pulii* fmm 120 ki 140. In the aecood week tt bipgaa to r^ftiie
irrimi HI.
Inflammatory. — The inflammatory lesions of th
c'itluT a<*nio or clironu', and are termed g:astritis.
Acute Gastritis. — Acute gastritis may be dividet
catarrluilis, (2) pistritis (xirrosiva, and (3) ga.stritis j>t5eud
WvWiW doseril)ing thest* forms I must state that, in
ciisi s in whifh a csitarrhal rt)ndition of the stoiiiai*h can
arr V4*rv liinittHl in ^'omjiarison with those in which the 1
which I havi' aln'a<ly di^scrilKHl are pn»sent. I believe tl
lx*r ol* ras<s which are s|M)ken of as gastritis catarrhalis no
is pnscnt, and that thov would be much better cla.ssified
of indigestion. I am hnl to Mieve this fixjni the nume
a diagnosis <»t* gjistritis has Ix'en made durinjr life, an
autopsy, no definite lesion has been found. When, h
present, as a rule the acute form is more cNuumou in
ehrouie form is niort* fnHjuent in children towanls the a^
(fi/fifrifi.s (nfarrhaliH Acuta (Acute Gastric Catarr
aeute gastric eatarrli is somewhat obscure, but it is ii
arise from an exaggeratiH.! form of indigestion, or from t
tant-; of various kinds, among which t<X) hot food has be
Pa rn()Lo(;v. — The pathological lesions which ehara<
<nt;irrli are hypeneinia of the gastric mucous menibninc
niiicu-. -mall j)unetate hemorrhages, and slight thicken
e«»:it.
SjM-eial work ou this suhje<^ has been done by Kiiste:
l)y jjooker in tliis eountry. According to Booker, whc
(litioii «►!' the gastrie mucous membrane is present tlie i
l(»niirr in tiie >toniach than under normal oonr1ifi^r»a »-^
DISEASES OF THE STOMACH.
856
I
1*
I
I
I
I
high. The first class, or afebrile form, is by far the more oommoo^ and is
what is usually spoken of as gastritis* catarrhalis. It h subacute rather
thau acute. Aoortrding to my experience, it is difficult and almost im|M>s-
fiible t<> state definitely the symptoms of the afebrile forni of acute ga.stric
catarrh. They so nearly appnmch those which occur in cases of indiges-
tion, where we believe no gross pathological eoudition exists, tliat we should
always be guanh^ in our use of the word catarrh. Pain is so eoinraou a
symptom in all gastric disturbances, the existence of tenderness is so diffi-
cult to determine in infautj? and young children, and a hyiKTscrretioii c>f
mucus is so often known ti occur without the presence of an inflammatory
condition, that there does not seem to be any one symptom upon which we
can rely. The general picture of tlie disease which is supjKJsed to represent
acute gastric catarrh is that of fever, nausea, vomiting of ftiod mixed with
mucus and at times of mucus aloue, and a sense of tenderness, uneasint^ss,
and discomfort in the epigaiitrium. There may be frontal headache, a
rather swollen, coated tongue of somewhat glassy appearance, and often a
slight follicular (pharyngitis. There is loss of appetite, with, at times* hic»
cough and eructations of gas. The bowels are usually constipated at first,
but afltT three or four days diarrhcea may result.
Where the infant or child secniH iirostratitl for a few days, and sick
beyond what would natupally be expectt'd in an acute attack of indigestion,
and where, in eomlnuation with a somewhat heightenefl temperature, fre-
quent viimitiug of mucus occnirs, we are justified in .sup|>osing tlrnt we are
dealing with a catarrhal condition.
Treatmext. — The treatment of cases of this kind Is the same m that
which I have described in speaking of indigestion. Food should be with-
held from tlie stomach for many hours, for^ as I have just told you in
si>eaktng of the pathological c^mditirms w^bich cKicnr in gastritis catarrhal is,
the fi>od Remains so long in the stuuiach that a frcssh supply at short inter-
vals will act as au additional souri-c* of irritation. In tho«ie cases which do
not respond rt*adily to long intervals nf rt*st and to feeding with small
quantities of a nuxlified alkaline milk, lava^^^ will prov^e of value. Much
judguient should be ustn] as to the time ^vheu the food isi U} be increased in
strength, for unless great precautions are taken relajises will frequently occur,
and as a result the disease may finally lietNime chronic. After oonvaleseonce
has been t^^blisbed the child will Ix-gin to gain in weight Some simple
tonic, such as nux vomica, is usually indicated for a week or ten days until
the child has recovered its strength. During the beginning of the attack,
when fixxl Ls being withheld, if the child is made very restless by extreme
thirst, teas|XM>nfid doses of ice<i mda water can be given, but with taution
and as seldom as possible. The second or febrile form of acute gastric
catarrh is rare, but Is of much more serious import than that of which I
have just sj^K>ken, It is chanu^terixed by high fever, 39.4"^, 40°, 40.5° C.
(103^, 104°, 105° F.). The invasion is very acute. It may last for two
or three weeks and show severe and alarming symptoms. There may be
iiviui nr lilt* iiinra.x. i iiu oust'i ui piitnuiiuiiia lu sMiiiii.* cais
c'.\|Mrirint' rari'ly, siimilaU»s this dlsi^ase. The pulse is
TIhh' is usually constiiuitiou at first, lollowtni by diarrlue:)
Tlu' i)n)irnosis is pMxl, excvpt in very debilitated childi
The <*hil(I should Ih' plat'tKl in a darkened room, sooti
ap}>li('(I to tlu' aUlomoii, and small quantities of iocd s
Tlif \\uh\ should Ik' ^iwn as I have just described in t
pi-triti- ratarrhalis ; that is, in very limited quantity and
If iUvvv is nuich exhaustion, stimulants are indicated.
(fU^sfrifis Corrosint Arnia. — C-()rn)sive lesions of the n
of th<' stoinarli an* at tinus imKluced by swallowinjjc i
arsiiiir, farl>olir ari«l, and csiustie fluids. In these cassc
usually IouikI on the summits of the rugae.
TIh" tnatiurut is l>y washing out the stomach \^'ith la
wat« i\ adiuinistcrin*: the i)rojHT antidote, and feeding the
diit -«» rnoditiiHl as to U* as little irritating as {K>S8ible to th
iiK'iuiM'anc.
(fftsfrifis IWudn-wrmhrantmi, — The membranous for
extninciy rare in inlancy and ehildluxKl. Cases have l)een
th«'-r nf Wnll^tcin. lu tliesi' casi^ the anigestion of th
!uarl<r«l, and alonir the trn»at(T curvature extendcnl over an
ot' inclM-.. Tiicrc was a thirk jrrayish-greeu membrane, \vi
The 2a-trir walN wcrr nuich thiekencd.
The .^i/fiijffniiis of i»;astri<' disturlmnce in these cases
rntiiN'ly al)-«'nt, l>nt then* may Ih» vomiting, ])ain, and 1
(•jn'.::i"-tii<' P'L:n»n. and insitiahle thiiNt. A pathognomonic
Im- tin- vninitini: of shreds of membrane, with or ^vithout j
DISEASES OF THE STOMACH,
857
Pathology. — The )>aihoLtgieal c!f>iidition which i.*i found in chronic
Agastric catarrh is tlie result of long-continued hypcncmia. There h aft»?n a
slaty dirtc<^)lonition nf the mitcfmi§ raembraue, with cellular infiltration of the
^ submueosa. In addition to this there is usually found a considerable c|aan-
wtitf of tough muciLs.
" Symptoms. — The symptoms are not so clearly defines! a.^ in tlie acute
L form ol* the disease, but are variable and of a rather sUi^^ish tyi>e. The
H tongue is apt to be much coatit^d and the breath to have a disagreeable iKlt>r*
' There is considembie alxlominal distention after mealfl) 80 that the children
» complain tliat their clothes feel umx>mibrtable*
Frontal headache is apt to «.>cc»ur. The children gradually gn>w thin and
aiuemic. Tliey vomit at irregular intervals, and are usually cunstipattHl
There is oib >n a slight cough ♦ and the symptoms, so far as the stomach is
a>ncerued, may form mi small a part of the general picture of the disease
■ that the child Is not infre(|uently brr*ught to tlie physician on account of its
oough and kt^iuse it is supi>ased to have some ijulmunary affection.
^ Pr<k;no8Is. — Although tlie disease is ofku somewhat intnif-tjiblc, die
■ prognosis under proper tn^tment is good. It may last for tixree or four
^months; but in many cas<^ which are uisually considen^l (*bmnic gaBtric
■ ttitiirrh it has schjiubI to mv there is no organic lesion, but that the disease is
functitmal iu its character, and the prognosis conse^picntly very gocjd.
ft Treatment. ^ — It is ot\en nece^ary in these (^s:s to precetle the treat-
* ment by carefully washing out the stomach. We must remcml*er, however,
that a cfinsiilerable quantity of mucus may be in the stomacli wliich cannot
■ be removed by washing, so that if the symptoms c«intiuue atler one or two
washings, even though no mucus is retnrnc»d by the tulx;, we should re[»eat
this treatment from time to time. The diet should l»^ an alkaline mollified
I milk, witli a low percentage of proteids, if necesaary peptonized, and a
mmlcnite jxTwutage of fat and sugar. The jiercentagt^ f»f tlie ililferent
elcmunt-i should Iw increasttl as improvement in the gastric symptoms takes
place, and later brotlis and milk t*an be trieti 8y mptomatically in certain
cases pe|)sin, dilute hvdnK'hlorif acid, and bismuth areiK^casionally indicted*
A valuable tonic in tlie after-treatment t>f thes^* case« is nux vomica.
fiu V J^xjv^x ^jbLjL;jx^ X n 1 1»-
ini*»stine cMH'iir as a rt'sult of abnormal development.
an* of that class which 1 have described in a previous
in^ of M(H-kers diverticuhim and of imperforate red
MaliM»>itions arc met with in infants where there is
alKloininal or^ms.
DIARRHCEA. — As vomiting is the most significai
disturhaiKX', so diarrhcca resulting from increased intes
most charact^'ristic symptom of intestinal disturbance.
a symptom, never a dis(»ast\ There seems to be a pred
in the fii-st two years of life, which decidedly lessen
tilder. The m«»st fre<iuent time for the occurrence c
the siimmtM" months.
PROPHYLAXIS.— Much can be done at all s<
])revent the (M-currence of diarrhoea, but prophylaxis
|>ortnnee in warm weather. The children should be
cloth injr from extremes of heat and cold, and from dan
if |M>ssil)le, Im' taken away fn>m crowded or unclean k
towiw (lurintr the Iiot weather, and have the advant^
or Hji air and «^(K)d hygienic surroundings. Both
<|iiantity of the fo<Kl should be carefully regulated.
wMtcr should he pure and sterile, and in very hot wea
()f water should Im» allowed and the solid fcxxl som
anuMiiit. rn(ook(Kl fruits and food are contra-in<
weather. KsjM'eial attention should be paid to any
\\ hirli may arise in hot weather, as it may render th<
al»le t(» ilie various causes of diarrhoea.
INTESTINAL CONTENTS.— Before speaking in
(li-ca-c- of the intestine, I shall des<Til)c to you s<.>me oi
mI.
ri.;..i»
l-kK^i* It'lfl-k
DISEASES OF THE INTESTINE.
859
'This specimen, which in Dumbercd 16 (Plate III,, faciug page 112), is
what Is usually spoken of as clay-cx>lored. This clay color may be due to
a diminution in the araouut of bile which enters the intestine, or to un-
digested fat. This a>lor is abnormal, and is uijually met with in intes^tinal
diseases of a subacute or a chronic type. It does not necessarily indicate a
lous c<mdition^ however, as even a g^mall plug of mucus may iuterfcix^
with tlie flow of bile into the duodenum.
This sjjccimen, which is numbered 17, is the light green color, which
be simply a change that has taken place after the fieces have been
, and which often is not significant of any esijecial |»athologicaI condi-
iQ. It may, however, show that the changes which have tiikeu place in
Ithe food during it^i passage through the intestine have not been entirely
normal. It is the least impfjrtant of the changes which take place in the
c^>lor of the iutcstiuul cijutenti?. Tlie colors in these next twr» s]>t>cimen8,
numbered 18 and 19, are what may be seen in a more serious disturbance of
the enteric tract. These colors may ap|iear in any of the iutfstinal <lis-
which are atx^-ompaniiKl by diarrhcea, but are significant of no aH|>ecia!
They are merely to be considered pathological in contradistimlion
" the normal coloi's in these r»ther ^^pecimens, -3, 4, 6, 7, 8, 9, and the
beginning abnormal condition rei)rescoted in 17.
Besides tJiese shades oi* green there are a great many varieties of c«*lor
produced hy the mixture of green^ yellow, white, and brown. Thesi:* mx*
valuable merely as instructing us %vhether we are dealing with a uornial or
an abnormal tMjnditii»n of the intestinal contents^ and, a-s I have already
told you in my general remarks on diagnosis, are not signifitiint of any one
I, either functional or oi^nic. Much variety in the nil or also arises
ftom the admixture of bloinl, mucus, and shreds of membrane. In this
connection it Ls well to remember that the yellowish-white lnm|)s seen in
ujidigest*'*! fieees are often mad*/ up of fat as well as of jirotrid material.
The ct^lor of the intestinal cHmtents may also be changtnl by tlie admin-
istj*ation of various drugs, such as iron, which causes a more or less black
color. Bismuth gives the colors which yon see in thes** three specimens
numliered 12, 13, and 14. Numljer 12 Is tlie color which wa*^ prcHlnee<l by
giving to an infant 0.18 gramme (3 grains) of bismuth every two hours
for six doses; nnml^er 13, where 0.24 gramme (4 graias) of bismuth was
jpven every two hours for six doses; and number 14, where the hitter
dose had been omitted for twenty-four hours. The size of the dose antl the
inter\"iUs between its administration will of course produce different shmles
of color.
Where the solids of tlie intestinal (ontents are much re«iuced in profi4j»r-
)|ion to the serum, as in cases of acute ami frtM^juent diarrhopa, the discharges
h€*come mom* and more fluid, and sivmctimcs almost entirely lose their color
and hx)k like water.
CJoNSiSTENCY, — In the first year of life, or while the infant is having
©idy milk for its food, the consistency of the fa?cal dischargee is inter-
very hu-p'ly incii'as^Hl, hut it cannot lx» considered to I
tt-ristir nt' an inflaniniatory condition, as the secretion o
may Ik* wry much incrcjisod in purely functional c*>ndil
art' very numerous an<l of many varieties, but in most &
any isiMK'ial flirm of these* organisms does not aid ns in
(^jHN'ial (lisrasc. Notahle cx(vptions to this statement j
tin- tyj)hoi<l l)arilhis, tlic comma l>ju*illus, and the amceb
Odok. — While in th<' normal iivc^l dis<^hargesi of inl
milU tlir <Hlor is <-om|uirativcly slight, it becomes niiiol
artirlrs of lond, cither of a starchy or of a proteid nati
WIktc :u) ahnormal condition €»xists, various clian^*s ti
llrinciitaiinu, where tlie oilor is sour, and in albumii
wlun- tin- nilnr is very ioul. Although these condition:
In- cnn^iderc<l of ^reat <liagnostic im]X)rtance, they are i
to iiiai<c u>c of them in the diagnosis and treatment of
'riiu>^. w here aeid fermentaliou is supposed to Ix? preseni
|MrccntnL!<' of the suirar, and ]KTha]>s of the fat, is ind
alhmiiinon^ dccinn|M»sition is susiKvttHl a nxluction of
IJmhI i«- (•allc<l for.
Amoini. — In estimating tlic amount of the frecal
<on-idcr the total amount in twenty-four hours, and not
.iMiniiiit whicli iiiMv occur at on(» movement. The total
Unii- h.uirs i> of nnich importance in both the acute and
of th<- iiitc-tiiic. In the acute diseases, the more tVequei
\\u' l:irL^«'r the amoimt the greater is the exhaustion ar
l»r«».jn<)-i<. In -nine rhronic dis<»ases the total amount <
IIIMV ln' v.Tv lariic In these easc« the larger the total j
I't .11 ih'- .•il»-nr|)tion and the worse is the prognosis, for
:'i<Ii' ;:!i..ii th:it tlic ehild is iM-inir starved from m ln#.L-
DISEASES OF THE INTESTTKE.
861
I
I
Nervous. — To certain infants and children whose nervous ivstem is
easily affected exaggerated peristalsis cauning diarrhtea may arise from a
numbc^r of causes without any kmiwn IcBioni*, fever, or gastric disea^.
Among the^ ctmtiesi may be eitetl heat, cold, and fright. In !ike manner in
these individimla foreign bodies, food or otherwise, may by simple n^flex
irritation cause s»uch a nervous disturbance as to produce diarrh«pa. In ihcsN?
cases either the small or the lar-ge intestine, or Uith, may lie afiected, and, mo
fiir aa we know, the mufou8 mei«l>niiie is either normal or nimply liy|H^ne(uk\
There ih more or less stToua exudation. These cases are rare in ccmipari^>n
with the other forms of diarrhtea, such as those which are cause<l by bacteria,
and in them intestinal dt<*omiKjsition and intestinal ioHaiumation arc not
present priraai'ily.
SvMPmMs.^ — The symptoms of simple diarrhrea are ver}- ai>t to apjx*ar
suddenly. There is usually alxlominal pain, not, as a rule, of jjreat in*
tensity. At first there are two or three rather liquid yellowLsh-bro\ni dis-
chaises occurring at intcr\^als of perhaps one-half or one hour, and often
accompanied by considerable flatus. There is a etTtain amount of restk-ss-
neas, pallor, and exhaustion. Vomiting is rare. The temperatun?, as a
nile, is not raistnl, or is raised very slightly. The pulse is rather weak and
somewiiat quickeueil. The nuralxT of the discharges may Ix^ eight, ten, or
twelve in the twenty-four hours, and thcst^ s<w>n Ix-come watery an<l of a
lighter color, but are seldom green. The odor h somewhat incrt^ased, but
not cxfx'ssively. Th^ic* symptoms, unless they are exa|L^*ratecl by im|>rt>|>er
focxi or by bad treatment, usually disap^Kiir in a few days.
Tbeatment. — If there is a known cause, such as some intestinal irri-
tant, a dfjee of castor oil or calornel may be given, but, as a rule, tliis is [ir»t
necessary. The cldld should be kept in bed. F(mx1 should be withlield
for gome hours. A few drops of tiuctura opii camphorata and hot appli-
cations to the alxltimen are indieatcd ihr jiain. If there is a tendency
for the diarrhiea to continue, the sulniitrate of bismuth may be given,
and in some cases where tliere art* signs of exhaustion a stimulant may
be n<-*t*dcd» For several days the diet sh*»uld be simply milk heattil for
twenty minutes at 75^ C. (167^ F.) and confining ten jxt cent, of lime
water.
I must impress upon you that these simple diarrhoeas, especially in hot
weather, shtHild never Ix* allowed to continue, as they n^nder the intestine
vulnerable to the more serious <liseast*s, which may at any moment gain an
entrance in this way.
Tubular, — In addiliim to these more common intes^tinal affections of
nervous origin is one that is callc^d tiihnlar. This di5<»ase is so nirt»
before the age of pnl)erty that it need r»nly be alluded to. It is a condition
of the muixuis membrane of any part of tlic intestine in which an exudation
of mucus takes place in such a way tluit masH-s closely simulating a mem-
brane may form on the surfaet\ When clischarged through the rectum
tbey are 6<^»metimes found to have formed a cast of the intestine. These
8f>2 PEDIATRICS.
inasK»s SLTV mostly niaile up of mucus, and may occur in shred;? of graser ■
less cxtout as \\iA\ a^ in the tubular form.
The <lisc»a*»i' is supiKis^ii to be of nervous origin. The ^vmp^^c^i'•■
pain, toiuloriK»sri, and tonc^smus. The tcmjXM-ature is usually normal.
Thi» pr(H/nfM<i^f as a rule, is gofxi, although in s<nne ca-sos the dL^A^iL:-
Im* niucli pn»l<»ii^tl.
The frcftfmvnf is to be directed essentially to impniviu*: th- ^arri
health an<l the nervous eouditiou, the local treatment being nit- rely ^j::;.
tninati<>.
Indierestion. — Disturbances arising from intestinal indigestion in D^'
<'as4s may Ih' I(K*at<Hl in the duodenum. It has yet to l>e proved thi-z
patht)l()^i<iil h*sion is prt»sent in these cases, and for the pres^^nt tbeymi-:''
lnnk<Ml xiyHtn it< tiUK'tional.
'rhesc» easi's vary in their symptoms with the individual and aii-^fc
to the pai-t of the dutMlenum which is most involved. In one^t-tof -jr;
thr <listurl>aiie<' of di^'stion is shown simply by the increa?«i jKTttiiv.
siirh as 1 have just d(»seribed in the nervous erases, but here the t\'i:e'u.^
points to an undi^st^Hl condition of improper articles of ftud wliiolb:;
Ihh'h ^ivrn and \vhi<'h ap|M>ar in the discharges.
The treatment of tliis elass of cases is very simple, and con-iat?bt.v
^ivin;: a laxative and then regulating the diet according to the age i';>
individual.
What is usually s|>oken of as a "bilious attack" represents another i>
ot' ra>e<. This rondition is very rare in infancy, and usuidlv (ni^u>:
niid«ll<* anil later ehildh<K»d. In thost* ciLst^, in addition to the iixTfv
jMri-tMl-i- nn<l cvidi'nit' oi' undigt^ttd ll>od, there arc frcfpientlv irtini-i
v.-niitiiiL; nf l)ih'. in a<l(lition to th(»so symptoms then^ mav In* li.->t
ami r\c->iv(' nausea. The i<'tenis is usually slight in degnt*, but uti^n •
ni:iilx<'<l ;nnl is notic<'al»h' in the conjunctiva? and in the urine. Her*i-:
>jHriinrn (Plate III., liu'ing page 112, No. 11) which I have niimW:
I I, .Mxl wiiich shows the staining of bile on the napkin of an infant dd".:
an arnte aitaek of indip'stion involving the duodenum and accomiuni^'l ''■
irt.rii-. The tenijMTatnre in tlu^sc cases is usually slightlv rai-Jtil :ir:
feu <l:i\- nixl then U'eonies subnormal. In a certain numljcr «»f 'a-^i^i ■
t;er:il di-eJiMri^e^ U'couie elay-C(dorcd. Tliis color Ls often pnxluced mH:u>
i«':illy, a-^ I have already explained.
Altlmu-h tiie -yinptonis in these acute attacks may often appear ./li:''
>eri.Mi^, tlie |»roMiin<is is always g(MKl. In some individuals thev art- lia'i
tn ivciir rM'u wlieu the diet an<l the general health are well attends! i-.
Ill th«' tnatment of this class of duodenal disturl^ancos we mu*t '^>
.-i«l<r that tiie I'ats in the food arc* in all probabilitv esiiecially lidMr t
proinn- the <li>ea>e hy not being projKjrly digested so long as the foiiili-«
of the (liicMlriniin is involvnl. We should, therefore, in treating these «=<^-
h-seii the amount of tat <riven in the finxl. I have found that the treatment
\\\\\e\\ u\u>x sy^hAWx A\v^TVA\^ V\\^. ^WskKk VK C^LVtotal restriction fiom fo^
DISEASES OP THE INTE8TIKE.
8G3
jfor twelve hours, with the admiuktration of small quantities of oold^ steril-
water if the thirst is exce^ive, and (2) the adaHiilstration of small
juantitie!* of milk modified as in this prescription (Prescription 77) :
PaicBcmiPTioK 77.
Fat. .
Sugar
Pr«4eidrt
Lime watt'r
0J«
6.00
3.00
10.00
The mixture to lye heated tu 75° C. (167^ F.) for twenty minuUi^ ; from
12C) to IHQ c,c, (fnjm 4 to 6 oniiLt-3), aecording to the a^e, to l)e given every
fthree hours*
I'^ufler this treatment the ictenis usually passes away in a few days, and
[the cliikl mm then schjo be given its onlinarv food-
Chronic.^ — The rhronie funetional diseases of the intestine may be the
[result of acute nervoUxS disturbances, or they may arise from a number of
'prolonged attacks of acute indigestion. Inctnitinenee of faeces and consti-
pation arc aJHO forms of chronic fimctional intestinal disturbances. Under
I Ibis same heading we can cla*^ infantile atrophy.
Nervous. — In the chroni*' form of ner\'ous functional intes^itinal di^turl)-
anoe eitJier the small or tlie large inteetine may be affccteil, and, as I have
^readv stateil in desc^ribing the acute fcirm, the cnuidition of the mucous
mcnibnuie, sti far as we know, is cither noruial or hy|ienemie. The muses
ar^' the same as in the acute tbrm. This class of cases is not csfRH'ially
"^ common, n» they are merely a prolongation of the symptoms whieb I have
ILfilrt^dy sufficiently desiTil>etl in speaking of the acute cases. The treat-
ff m€*nt of these* cases Is *^sentiaHy with stimulants and care of the general
^ health.
IndigeBtion. — The ehronie form of functiutial intestinal indigt^stion plays
an important |*art in intestiuul dij^aisc*s, e>|M<»ially when it is Icx-ateil in the
dumlcnum. Chronic indigestiou of tlie dn^Mlcnum constitutes a disease of
itst>lf, and is one of the most difficult to cum which we meet with. It has
usually l:>een sjKiken of under the names of chmnic gastn:>-ihiodcnal catarrh
and mucous disease. We at prestnit, however, have no proof that cither
a catarrhal or any other pathological h'sion of the mucous membrane Is
present in these cases, and the weight of evidejioe is in favor of the \new
that the disease is pundy fimctional.
ynoiXJOY. — The etiology of chn»nic diHKlerml indigt^ticm is in many
obscure* but in a lai^e numlx»r of ceases it is pnnbic^HJ by the con-
administration of f*x>d which is not aiiaptetl to the age or digestive
ilities of the cliild* It is at times met with as a sequela of some
, ^A>.».jsting discasi^ sueh as typhoid fever, pneumonia, or one of the arute
exanthemata. It very rarely occurs in early infancy, being usually met
With during the midtlle and later periods of childhcKxi.
Symptoms. — The symptoms are at tirat somewhat varied. The di
I
j
864
PKmATRICS.
may In? pn^ot^iai by a iiumV)er of attacks of ^astro-eiiteric indi^ieta^
a sulwirntr <*luinwt*»r. A tendency U> naii?*ea and v^omiting extendini fnp|j
nnnilHr of numtli:* may .stmetimfs precede the full deVf^lopioat U ^1
disea^v Tlie gastric disturbance, however, is not marked, and fe pn4it
a reflex tHuidition de|>eiiding upon the functional distiirbantt* of tl^ ^
deniitn. At first tlie tkn^al discharji^e:? sh*)w merely the varitnis 6sz^
which (MTiir in ordinary indigetjtion, g^i^metimes manifestiniir a tfoir^'^
diarrhdii and sometimes to txinstipation. The csolor of the disdb*:
thi-H early |>eriod in not f^ignifieant of anythinjar beyond ordinary iml,--
anil is ustitdly a mixture of yellow, white, and g^reen, A^ (it -^
pni^resses, certain characteristic symptoms arise and definitrly mrl i
jm^^i'nee. Miieus hetrins to ap^iear in the fiecal discharges. a»l -» <
corner quite lai^e in amount.
I have hire a ^^jecinien (Fig. 110) of tJie shreds an
which ap|>ear in the di^nehargesi, and which, in combination sMth i
*^ym|itomrf which I am about to df^eribc, are so j^igmficaut of th' -
thiU it will be well for you to examine them closely*
Mactu troni ftecal dlKhaqsvi In ft case n€ chvual^i dtxydeaml 1
With this hyj^>erseeTetioo of mucus, which I shall again im]'
you is not uet^^s.'^arily an indit^tion of an int1animat«ir>* * ^ '
l>e^ins to he fretful, to be wakt'ful at night, t<j grind its U
weiglit. The skin becomes drj% and there is usually a ooexisdafr fiilli'i*
pliaryu^dtis which causes a short, dry cou^h. The child gfis tind adr,
and nnnplaius of pain in tlie epigastrium at\er eating. The abdomn'i^if^
ti) l>e distended and tympanitic. There are frequeailv frontal faatUti
coated tongue, and a disagreeable odor to the breath. The fwtal mcrtrw*
now l>egin to bet^jmc clay-colored, and the skin to assume a biiUiowM»^
at times a slight amoimt of icterus. Sometimes an exsixxAmAm d i^
symptoms takt-^ place, resulting in an acute attack of indigetfioa ^
8ympt4>ras, varying iu intensity, and sometimes ceasiuj^ to be pfonuMtf ^
days or wtH?ks, usually continue for months, aiul in inttuctaUe a» ■?
last fivr years. The tem|X'rature iu tliis disease ia usually omoal, *^
tiuu?s subnormal, but may of course, where an exacserfaatioo oocaat'
I^F~
DI8EABES OP THE INTEBTINE, 8S5
srvroowliat raided. The pulse is ti^tially mtxlerately slow. Sometimes a
Bubacute form of brr>nehial mtarrli a(*eompaiiies the diseajse, but it does not
a|i|H"ar to Im? a jmrt of it. There is often a craving for large quantities of
*- II Liar.
DiAONORis. — When all the symptoms are present, tlio diagnosis of
«'im>nic duodenal indigestion in not difficult. The appearant^ of the rhild
ii* eliaraeteri.Htir. It** eyes are dull and ht^avy ; it^? skin h dry and harsh and
SfimetiDies slightly icterie, while tlie loss of flesh, the distended and tym-
[ttiiutie alxloiuen, and the ermtc^d t4>ngue are more marked than in any other
di-4*jis*\ Wliei*e, in addition to this picture, an examinati^jn of the fieeal
disi'fjarges shows them to be clay-eolored and to contain a hirge amount of
mueus^ tlie diagnosis is quite evident. The disea.^ which is most com-
monly mistaken for chronic dmxlcnal indigestion is pulmonary tiibenndasis.
The shi^rt, dry cough, the eniaciatiou, and in some c^as^j'S the Immchial
catarrh, often make parents and physician fear that tliis serious disease is
pre^nt. If, however, the entire history- of the ease is studied carefully,
pulmonary tul)erculosis can six»n l>e eliminated.
pRCKiNOSis. — The prognosis of chronic duodenal indigestion is in
most cases goixl. Even in those cases which last for a jieriod of years
the licalth is asually entirely restored* Where, however, the disease has
lasted for a long time, and the child is in a very delnlitiitwl wmdition, the
irognosis l>ei*<»nies more serious.
Treatment. — The tn*atmcnt of this disease* is i*sscntially by diet, and
lot by drugs. Such articles of food should be given as will l)e chiefly
ligestt^ by the stomacli and will not tax the duodenal digestion* This of
urst^ iuflie^ti's a proteid diet, and o>ntra-indi<'ates the administration of
tart*hcs, sugars, and fats. In onlcr not in tax the distnrlx-il duinhnum by
verlontling it in its weak r*ondition, small amounts of RkkI at shorter
ntervals than usual are fcmnd to unKluec a Iw'ttcr i'«:^suh than the regular
linx* or four daily nu^als. The diet wliich 1 have found most valuable in
iting these erases id a milk so modified as to have a low |)ercentage of
lUgar and fat, a high jjen-entagt; of pntteids, mi<l ten or fifteen [>er cent of
me water. 8<»ups of various kinds, and meat, can also be given, and the
srust of French bread in limited quantity. A valuable adjuvant to this
treatment, as a mild astringent and stimulant, is a small amount of claret^
pre(end)ty given in seltzer water. The meals should be five in the twenty-
four hours. It is exceedingly difficult in most eases to keep the child
tills diet, but if it is rigorously enforced tlie duration of tlie disease
11 \w deeidedly ahortened. As the epigastric pain and the amount of
ueus in the dif^^harges grow lc*ss, the diet may be somewhat varied by
iving tish and e^gs, and the |iereEaitage of liine water in the railk may be
n^ductxl to five. As relai>ses occur very easily, however, it is generally
fest to iHintinue with this rigid diet until the fje<5al d^charges liave bcn^me
omial in color and have not shown the presence of mucus for a numlier
f weeks. In mild ciases where thei*e is ninch oonsti[»ation, small dos4» of
,S(>«J PEDIATRICS.
caloiiK'l, or any mild laxative, are indicated. Podophyllin can ai- ►
af< in this jm-s<Tiption (Prescription 78) :
Prkscription 78.
Mitrie. Apoihecajy.
Urammse.
B INilophyllin 0.06 B Podophyllin
Alr..h.»l 8 1 76 Alcohol
M M.
Siix. — Kp •111 :i to '» iln»iv«, according lu the ape of the child, in the morii!u' a..
k's'-«MiiiiL: th<- (!•>..(• it' it ouiiM*{i more than two discharges daily.
Wlu'iv tluMX' is a tendency to diarrhcea, ^inall doses of biimutt i«r : -
Xn Ik- valual)lr.
'I'incturc of nux vomica ireely diluted in water and given in i
a (v\\ drops at't(T each meal seems in some cases to be of valiio.
The n'niaind<'r of the treatment is essentially symptomatio. aal ::
I'hlMnn arc wrak and amemic tartrate of iron and potassium can l^*' ^^
Duriii;: ihr wlioU' course of this disease cod-liver oil is contra-biir-
hut whtrc the dis<asc li:is l)een cured and the child is left weak an It;-
atinl it may in sonic cas^s l)e l)eneficial. Its administration, howevi'r.?L:
always l)c can'iully sui)orvised, as it may cause a relapse.
I li:iv<- li»'n' u child (C'aso 413fl), thn-e years old, who has an attack of ch? nic ;:• :i
irulii:«'.-«tii»ri. ami who n'pn-suiits very well the general picture of this dis*a-:v I - •-
t<. riMtic.' ♦■-p.riHlly in tlii" i-ase the distended abdomen, the dry. harsh .-kir. ^- :
hli-liily iit-rii'. ainl th»* ••videiit 1«>'*.* of flwh. She has been atfected by tht i:---- "
p:i«t t\S" :ii"ritli-. Tlif pniiiiiiK'nt syiiiptoms have l>een epi^rastric pair; :ir;ii ./-•■
Ill- -v 'Id. :it' with :i liN prrM'('n'ti<»n of iiitt'Stinul niuous.
Tlii- littl.- trirl t('a>o 414), Aj. years old, repreifents also a case of cbrcti. ■■-
il:'li-<-ti..M.
Sli.' \s:i- li»:iltliy lit hirth, and was nursed until she was thirteen month? 'li I'-" ■
ii« r tir-t \<:ir Aw liad an attack of ])n>nchiti8, and since then she has been iunj-^!'. ■.
rr.'\i.)U-< t'» thi- :itia»'k >1h' lias novor hud any intestinal disturbance. Her aUi-'-r:-- ■ ■
t" liuv.' Immmi alway- rath«T pn»riiincnt. From her earliest infancy she h^"; h-.-". a : ' •
cliiM. Ii:i- M'.t -li.pt w.jl, lias talk^ni much in her sleep, and has <»cca5ionally wa!*-: :.
-.!♦•' p. Si\ rii.-iitli- airo -In* h.-ijaii to lose in weight, and two months a^.i hert ujii^--
.jiiiif ..v.-n-. Sli.' ili.-n hail an attack characterized by vomitint; for twenty-fuur : ^^ " ■
l.-w-l |.\ aii-n-xia, f.-vr, laiii^uor, and apathy; the bowels became c^nstij^w. '.t •
i. f'lir. til.- iiriii.' .lMrk-('ol..n'd, and the faecal movements light-colored. She h*: ^^ '■'■ '
. r.i\ i::- i-r Hi-.ir. an.l at.' all that she could lay her hands on, so that she bad w^-:^-' '■
V. : V •■■■-•ly t.. pivv.iit her r^atisfyins: this morbid appetite. Her appetite: f«>r "«tLe: u-: ■
..t r.w„l ^s:i. |,..,.r. V..II will notice that the al>d<>inen is distended and tynipaniti . i' ■ j^
til'- t'Ti-u.- i« .-..at'-il. Th.' ])n'ath has a disairreeable o<lor, and there i.« 1*.>S5 of t'-^i T:-"
i- M i'..!ii.ii!:,:- pharyriiriti^. which is evidently tho cause of the cough, as nolliini: * ■"-
(■:i!i !■'■ .1. t.-.r. -l ii. tin- luni: nr tht* nose.
.Si]l.«. .|.i. .It hit ry. I Th.- child was placed nn the following diet, Herfir»tx^>''
'iii'.k -. m.-.liii.-.l a- t" cTitain fat 2, sutjar 3, proteids 4, lime water 10. With thi«E-a ■>
u;i- :.:i-\s -.i t.. hav." a -iiiall amount of the crust of French bread. The sec^^Ki ="'*■■
>i>--.i ..f l.p.tli M!i.l til- rni^t ..f French bread, and one ounce of claret in half ato"^*
-. ;t;/.r w.t.T. TIm- tliir.i Mi-al con>istod of meat, the crust of French bwad, cU^»- *' ■
- it/.r w.ij. r-; tip- fMurili, -.f -mij). the crust of French bread, claret and *eltxer«w^
DIBEASBB OF THE IKTE8TIXE. 867
ii of the modified milk and ibe crust of French breiid. After each meal three drops of
iure of imx vomica were adminbiered.
This diel was carried out rigorously for one week. At the end of that time the child
ted much better^ the urine was clear, the fiecal movement* began to resume a more imt-
or, the muciia in the discharges was very much lessened, and the ttbdomeii was not
Chfonle diMMleoal lo^tlipeiUoQ. Fvjstale, 0 yean oldt
aucb distended. The tongue was less coated, and the couich had almost diaappeared.
ras also found that the cmviog for sugar had much decreased. The diet was then
btlj increased in variety. At the end of a month the child had recovered entiri*lyi
\ weeks later an ordinary diet at the usual times was given to her.
Incontinence of Feecee. — Inefintinenco of fieces is a condition in wbirh
re IS a Ickss of fx>wer of the sphincter to control the movements. It may
iue to or^nic or to fimctional cuuses. The or^nie causes are very mre
ihildhood, and will liest Ix* spokeo of in connection with the diseaftea b
ich they occur. Functional incontinence may arise from nerv^otw infltt-
es, such as excessive mental fatiguei or from stretching of the rectum
!n habitual constipation.
il!u-!r:itt' till' «''Mnlitit»n nf iiit'niitiiicnoo ln»iii habitual dnisti
\\:i- t'..uinl t.« iIi-ihihI i.u .-intc'hiiiir nf the ret-luin l»y iinpuctod
Till- nrtum vvH- «'iii{itii-(i by u do>u of ojiPt<ir fiil and an t.'}v
it :i \M • k lie- )»>y had r«':iM-(l to liuvo involuntary thecal iii«ivei
tiiiu* <l wi'U.
Constipation. — Hy constipation is meant a c
Fn«»v«'mrut- of the lM)\vrls do not take place as oft
in«livi«liial.:iiicl in wliicli tin* consisteney is abnormal
tinii i- M symptom, and not a dist»a:se. It is a relati
lie iinrnial in onr individnal may l)e abnormal in an^
yrar ut" liti- t\\<» <n' thn"** daily disrliarp^'s may be eo
x'.inid yrar two discharo:t*s ; and in the third and fbi
i- th.' ii-nal lunnlHT. 'rhocaust^s of const ijmt ion ;
ra-r- rather ohsinrc. Mechanical ol>struction ma;
Thii-. a- the sigmoid ilcxuiv is pro|H>rtionately l«j
ina\ •Mriir. with rcsnltin^ ol)Strnction. The usiia
h«»u«\rr. i- <){' a Innrtional clianictor, and may be ^j
SiHtsnintfit'. — The spasnimlic cjt'^tis are rare, but s
tlii\ In- inrntly cause nuieh disturlwnce of tlie eliil
th.-. ra-r-s tlh' i'aM-al niovenicnts are usually much in
-1-1. n.\ . IMii- rondition pnMlmx»s so nineh |>ain and
thai th«- «'hIM eiidravnrs not to liave a movement.
,\f.,„/r. — riir atnnie is tlie most common fi>r:
-imply iT|n-c^rnt^ a >hiiri:i>^h con<liti(»n of the intes
ii-'.iIIn «"iii-.d hy foinl which is not ada])te<l to the
«1 ■■<l Thii-, in ><»nie ca^-s een'als, sneli as oatmesi
t ■■::'liii"ii. althniiLili in a hir«re ninnlHT of causes tliev
\- :i v\i\r, c.»n>tipatinn can I)0 easily ciiretl, b
'\ i:"-.'. i:iM.- :unl la-t tl»r a nnnilwr «»f*
\-ciO«>.,
DISEASES OF THE IKTESTTISJ^
869
an. Many drugs have been employed in the treatment of consti()ation,
as a rule, we should endeavor not to use them, m they are very apt
be only tem|X)rary in their action. In e«jnne<^tion with the diet, I plac^e
reliaucx^ upon enemata and laxative suppiisitories, such as those made
yf glyeerin or of gluten. Massage of the abdomen is useful in some etu^s.
In£antile Atrophy (Marasmus, Athropsiii). — Infiiiitile atropliy is easen-
illy a disease of infancy and early ehiklhood. It i.^ a condition in whieh
rtreme atrophy of all the nniscolar tissues take» place witliout demon-
ale disea'Ae of any of the orn^ans. It is ap|)arently due to a vice of
[jrption, although this haj^ by no means Ijeen eleurlv pruvt'*!.
The primary cause? of inftmtile atropliy is unknown. In a numlier of
tlie disease seems to l»e see«»n(lary to grave intestinal disturbances,
whether of toxic or of organic origin*
Pathoix>gy. — The pathological conditions which are found in cases of
linfantile atrophy are exa^^dingly unsatisfactory, and have not given us
[much inturmation concern uig th*' disea^. Thci-e is an atrophic condition
lof all the muscles. Nothing abnormal is found in the various organs
fwhic^h can be especially attributed to this disease. It is supimsed by some
[pathologists tlmt the lymph-glands are enlarged ; but this enlargement doe^
[not SLvm to U* a prominent feature. No |]>athological condition of the
[mesenteri*' lymph-glands has been found, and the atroj>hy of tlie mesentery
[around them is so great tliat their inrix*ai*e in size may l)e seeming ratlttT
f than real. In the intestine, although in some casi»s there is considerable
atn>phy i>f the mucous membrane and the submuoins tissne, no chamcU*r*
listic lesion has been proved to be presf*nt.
Symi^ttjms, — The symptoms of infantile atropliy are those of starva-
I tioo. The infant Ix'gius to emaciate, and cxtivme loss of weight is the
[prominent ftature of the disease^ The f<x»d is apparently digested wellj
and the ffecal movements are often of a nornud chamcter ; in many eases
.the total amount in tlic twenty-four houi*s is almi»nnally large. The appe-
Itite is, as a nde, leaseneti, the temperature is normal or subnormal, the pulse
(is weak, and the respirations art* generally norraab Csnally the infimt
seems not to suffer fmm pain, btMUg s*>nictimes tjuite apatlietic^ but in s<jme
[cases extreme fretfulness ami restlessness occur. Vomiting, apparently of
a reflex nature, is at times a pniminent symptom. The weight CMintinues
to dimiuisli, and iii^thout any other symptom the infant may die fn>m
. exhaustion.
DiAHNOSIS. — The diagnosis of infantile atrophy is chiefly to be made
from ortlinarv starvation and from general tul*ercuh>sis, Frc^m the former
it is scM>n diflcnuitiated liy its lack of n^sfxtns** to goixl fo<xl* In the
ortlinary cases of starvation which result either from imprni>er food or from
lack c»f fcMxl, a dit't canfully ado{»te«l to the age of the infant or child is
soon followetl by ra[>id improvement. The differential diagmiisis fmm
I genenil tulKTcuhjwis is at times exoet^Iingly dittirult. I have had under
I my care in the hospital in adjoining UkIs an infant with infantile atrophy
oil int'-rnally aihl l)y iiiiinrtlniis.
TiMiArMKNT. — Tin- tn»atin<'nt of infantile atroj
^\\r]\ a motlilicatitiii of tin* coii^titiK'nts of tlii* milk a>
al»-MFj>tinii, an<l without (lni«rs. Althouuli, as I hav
hot I ntinly proviil that the inorl>iil (Htnclition is thai
ti«»ii. y.'t my cliniral n'sult'^ aiv nn>st favombK' when
tnatiil on thi*» i>rin<i})l('. Aft<T exjMTimentino^ in a 1
liy nio«lityiii;r thr (liiK»ivnt ooiLstituents of tho milk
havf arrive*! at tho iollowiiijr a»n(.*lu.sion : a niixti
which ri.ntaiii- a h>\\ |H'r<'enta.tr«* of fat, a high |x»rcvi
iieMhiMt*' jMreentaire of |»roteitls. Thc» low jx^ri-entaj
the -iipjHi^itioii that the infant will inorea.st> in weight t
prMjHirtiMii of* fat, |)n»vi(hHl it is al)sorlx»<.l. I havo foi
I>»n«iitaL:vs of tlit are ^/ivvn th(» infant continues to
aJmiiii-tration of nxl-liver oil is not incli(*atcHl in 1
only l)y a pn'ri^' a<ljn-tnient of the junventagc of the
iiMli\ i«liial |»o\v(M- of al>sori»titni that goinl n^nlts ui
>-iii:ar of luMh iMrerntaLfe antl the prnteids iif n«>rnial i
«liL:«-iril an<l al^orUil |)rovicle(l they aiv eonihiiunl wit
fit. -inc.- I»y thi< <*onil)ination th(» nutritive proix^rties
tlir piMtiiiU arc injulc ns<' of The prescription whii
tin- l». LiiMninir ai' the treatment of these ctisi^, where t
vMi"! iji;., i^ ilu- fnllowinir (PresiTiption 79):
Prkscription 79.
I's'
!'■
DIBEASKB OF THE INTESTIKE.
871
Fftt
8uj;ur . .
1 14me w»iGr
PKCSCRimON 80,
. 8.00
.......... 7.00
2.00
The 8amG treatmeDt can be carried out when the disease occurs in chil-
n in their 8ec*<md and third years, hut in these cases it is asually jMjssible
i increa.sc the iKTceutages of the different elements more rapidly, and after
RTo or three weeks to bt»gin with other articles of diet, such as Ix^^f juice,
roths of various kinds, and finally* with caution, cereals.
These sjie<:dal raoditi cations of tl»e milk do not, of e^iurse^ suit every
kdividual infant or cliild, and \vl»en tfie treatment with them is not success-
|], eaeh of the elementfi of the milk must be carefully changed and different
mliinaticins of these elements trie<l until the individual idiosyncrasy of
qitiou in the sj^tx'ial cjl^ lia^? been discovered.
I have here a cast? of infantile atrophy of high grade to show yotu
TbU infant (Ciue 417) U tdne months old.
nfL 417
Infiantile Atfopby. temiut*. y uumtris mn*
She has bwn fed en food* of variou* kind*, all of whiob havo contained a consideniblo
ftrcvritiigtj of mUirch. She is ftaid to have been healthy and ptump at birth and during
i« early motitha of life while »he was nur»ed. After the wa« weanod and placed on tbece
rchy foods she began to lose progreti«iyeIy in weight, and she is now^ aa you see, in an '
Etremely emadaied oonditioii. Physical examination shows nothing abnormal, Sho has
Air teeth. Her temperature is slightly subnormal, her pulse is regular but wt^k, h»?r rm-
irationa are normal. On first enteriiti: tho bii^pitol tbit boweU wore c«int»U|Mil4>d urn] the
I movement* were brown and I*H>ktxl p»Mjrly dijij^wited. Since Mug ptacMxl on a diet of
l«>difiod milk the movements have become well dige«tt?d iind of normal color, but the total
tiount in twenty-four houi« is greater than normal. She has been vety fretfVil, and at times
»mits« but since her diet has been regulated she is less fretful and is somewhat a^iathetic,
It entA'ring the boepital she weighed 29ft0 grammes ((^| pounds), She has been in the hoa-
tal two weekf* and has gained in thut time 1000 crnimme». The fn<id which has bMn
Itnd to suit ber powers of ab^rption eimtain» fat 1, jiugnr 5, proteida 1, lime water &, and
to 120 c.c. (2 to 4 ounces) have been given evtrry two houri).
Thi'^ is a case in which it is uncertain whether recovery will orentually take plaoa,
the emaciation Is so extreme^ but the pM>gnosis If mndored somewhat favorable by the
Ct that *be has already gained 1000 gmmmes,
(Subsequent history.) The inlknt did not increate prugreeslvely in weighty but soid»>
872
PEtUATRICB,
tiiiMt Imt otmmid^mhiy, and nt one t)mc it i»io«»tii<«<l us tUougb ftbe oovU M^atr »|
Ail«r tiwi food had be©n nnMlitl<Hi in vitnau* wiiye. she fiiuiUy ^m^K^a •« top^ii
fche WM Able todi^Qsl and uli^rb 150 c c. (5 MUtiee«» of milk 90 modyfli»te«vi|
M, vug»r 6.5, and pDU^da 1.5, she improved mpidly, mnd dnallr mctnmUiamt hf
ttmpmlum, willi fbw fxoeptJoiiA, wa* nonunl ur subaontiAl thuDOglk ti» «iiii»<
Infantile atrc»phy i^ so exci*ec1iii^ly intraictable a disease, «id » ^
taxei the iiatienoe and skill of the physician^ that it nmy beof iflt-
encoiiragement t« you in treating these caaes to see tim ebild wi
had brought to the hospital to show you.
Thii boy (CMe 418) in thrve y«an old. He
wnd wo 11 diiring the <Mi.rly months of hb life. He
ilthy at birth, mi
then fed an a ri
Cask 418,
tihy of m^h gm
Iboda, and - _^tr» ta l*>se pixjEfressively in weight. Hew^, ,., .i, ,,.,._. "
tjjonths, iind was a typical case of a very high grade of infantile stx^phv fuch * 3 i**- .*
shuwn you. It seemed at one time as though he could scmrcely live ttomdtijU>^^ ^
fljiaily the proportions of the food were so adjusted that he begmn to alMarh a *i»fl »*^
of nutriment He then began to pain in weight, and r«^ov«*red etilif^^W Tfl^iTf*
third year, he is, aa you see. « reninrkiibly Mrtmg:, well-developed^ and r*>Wl cHi'd, i«l. •
fur ft8 I cnn detect, is in a perfectly TKirma! condition.
This next infant (Case il9) is also a ca&e of infaiitile atrophv of hi^ gtida
DISEASES OF THE INTESTINE. 873
niii infant entered the hospital one week ago, with a hUioiy of having been fed on
111 foods containing fitarch from the earliest months of its life. It is said to have beea
by at birth and of average weight. On i^nteHng the htii^pitul it weighed 259S graminei
ouodB). It b, as TOti »eei extremely emaciated, and illustrates the more advanoed 9tage
luitile atrophy. It is unable to nii«e iU bead ; it i^ apathetic ; \U skin b cool and dry ;
lpration£ are shallow ; its puUe is weak, and its temperature U slightly subnormal. It
liutautilc iitrui^liy. KcnuLle, 10 mouths < M
as though ft could not live many days. A physical examination shows nothing
inal in any of the organs. The fiscal movements are rather large in amount, and^
its food h&B bec'n carefully regulated, are fuirly well digested. On entering the
tal they were still larger in amount and were of a brownish color. It weighf to-day
grammes (about 6J pjundii)^ which is slightly less than its weight on entering the
kal. This is a case in which the prognosis it very grave, and unless we can soon
t the fiMHl to the digestive tract so as to have it absorbed the infant will die in a short
It is being fed on a modlied milk in which the percentage of fat is 2, sugar 6, pro-
iy lime water 10> Although the skin h cool, it is not so cold as in this next child (Case
ivhom I am about to show you,
Subsequent hist<:}ry.) In another week the infant began to gain in weight and evidently
torb its food. Although it had a number of relapses, in which it lost cun^idenibly in
It, it finally b^an to gain steadily. At the end of three months it had recovered
y, md, as is teen in thit picture (Case 419, II.), was quite plump.
Ca81 419.
TI.
Itpcovvry aftvr Uiitbv moothi,
^Un^if9 the percentage of the fnt wan finally raised U^ i, and that of the sugar to 7,
ie proteidii hud U> be kept at 1 : the lime water was n-duced ti> 5,
liit infant (Gate 420, page 874)| a f(!fniil«| one anil a half yean old, entered the hot-
874
pKixiAnacB.
pJut two irdeks a^o, 6he then weigbed 4281 jErmmBiiPs (14 pooiida). She ifliiiii
winE:bt*d but 900 gimnitnef (2 pounds) »l lilrth. Bb^ wm« ouned If I
ftppaiTinUj had plenty of good brcAsUmitk. and mhi* hwl twt» oifaeri
Cask 420
I.
lanmUle am^plij. F^eizi«lc« IK rc<M» old.
nur>oii ttiaL were heikltby and tlrong. As the infant did Doi gsin, iA« vs^ t
a ibort Ume, and was then fed on variouf artifictal ft>od&. She begiui I0 loie'B v^^l
thU Iocs baft continued ever since^ §0 that now^ a^ yau see. Ii«r enoariatioii if «
On pbyucal exarninatfon I find that the anterior fonCaiieJJe w wideiy optfi. TW<i|
Infimtlle atrophy, Ehawing extreme emaciatloa of anna, tACk« and kk|a
enlar^t-ment of the epiphyses of the ankle* or wrists, l,ut th^re It ft sUghl Aidtei*^ !
Nothing abnormal can bc^ detected in any of the organs. She hmi toar ttp|Plf^^J
lower inci«ore, 8he is very apathetic, and aeema hungry, bat wlieo r.»d l« ^t«%»Vt<
BI8EA8BB OF THE fNTBBTINB.
876
iniU* Since entering the hoBpitul the haa loei 519 gmmnies (1^ pounds). Her skin is dry,
fnhf and »t tiine« quite cold. It baA teemed to me ever since she entered the hospital that
was no hope of aaving h*ir lift?, and^ as she ia lo»iDg in weight and doe* not rwp<^md to
various oiiKliflcationA of the food which hav<» been given to her, th« probability \s that
ft will aoon die. The fttH.*al movi^ments in tbit caae are very targe in tiiuount, but since
Bering the boc^pital have been fairly digcssted. When she ia lifted and placed so that
can M^ her buck (II') you will appreciate the atrophic condition of her musclefi^ the
ieemingly being covered only by «kin. The cervical and inc^uinal glands are
lilly «^tiIur);iHJ, ami she has a slight eough.
(Buh^quent history.) The infant lost steadily in weight during the following week,
>«»n it «lii^<K
The po«t-mortem examination, made by Dr. Councilman, ebowed the following oon-
lo&i:
There was extreme atrophy of all the muscles. There were no changes in the meien-
ic glands, and they were not enlai^ged, although the extreme atmphy of the mesentery
Mttid them made them look so- The liver was normal, and itfi tissues showed little evi-
of airttphy. The «pleen was normal. Sections made from various place* in the
^ach And the intestine showed no changes beyond considerable atrt>phy of the itiucous
nubrnnt* und of the eubmucous ti^i^ue The thymus gland wa* atrophied. There wn* iin
lon^ivc bn>nehitis in the poiitcrior portions of the lung», while in some parts there was a
rtial and in others a coinplute atelectaais.
Elimikative, — Under the term eliminative diBturbances of the intes^
le are included a number of UDex plained and obscure symptoms which
m at present are unable to eliu?sify elsewhere. It is pnilMble tliat they will
t moi'e fully understiMjtl in the future. It seem>4 as though the intestine
ften acts as an organ lor the elimination of varit>UB nmrliid pnxluetti from
|e econi>my. The diarrljiea wluih n^ult'ri from the irritatii^n of tlieni* fort^^u
tements i.s not dktiu,u:ui!?hable from thatwhieh iKxnn's when the irritation is
riniarily in the intt-stine itself. Our knowledge of this elai^s of dL^tiirbances
f however, so small that I shall merely refer to its possible occurrence,
ORGANIC. — The organic diseases of the intestine may be divided into
r'injhtmmalory and inJJammatoty,
Non-Ikflammatory. — The non -inflammatory diseases of the intestine
jav be divided into mechanical ffermentalf cholera infantum ^ cholera Atflaiicaf
111 nnr fjntwih^.
Mechanical. — The methauical diseases of the intestine are quite numer-
jfes, but, with a few exceptions, are not of especial importance mt^lieally,
pd belong rather to the jimvince of surgery.
Uilaialioti of the Colon, — I have already spoken of dilatation of the
ilon eo far as it relates to the diagnosis of dilatation of the i?t*>maeh. In
piSipariaon with dilatation of the stomach, dilatation of tlie colon is very
|re, exoept as a temj>orary condition which Is liable to occur at any time
km an over-production of gas.
I I have here an illuBtration (Case i2t^ page 876) of dilatation of the oolon which wat
pmingly caused hy a congenital itncture^ and in wliich »n artificial anui wu made by
mu Hahiiead. The child recovered from the operation, but later, owing U> tdll Airthcr
Etfbriiotion, he had to be operated upon a^raiti, and died.
Ml show you this case so that if you happen io meet with this rmi« pathological con*
koo you will reoogtii:&e its presence. The extreme distention of tho abdoman, which
- -ttr**3^..
878
PEDIATRICS,
md til* abteooe of tymfiUtfiii pouitini^ towmnU gaftUic di>«a^, wuaki ^|-«i:
of iome part of the intatiiiflv {VitiiiDAblj of thm cnhxk*
4_:a>l 4-2}
DiUtAtloD of cvlciti. Male, 12 reai* oKL
Volmthis. — By volvulus is Dieant a tvi^gtin^ or bending of Af •'^
tine. This ocmditioii i>^ more apt to oc-cur in €?arly life than k*rf»p^
liec'ause of the greater propirtionate length of the moseoterr at Ai**
which allows the intestine greater latitude of motion. It iwtir^fltb!*^
itself or in e<mnet*tion with the next disease of which 1 shall >|**i.f^
wlneh it h to be differe^utiated hv the aliseuce of blood and miKit ^^
diseharges.
Intusmtse^^piion, — Intnssus<ieption or invagination is a <t>iiditi<:« b i^
a part of the intestine ha^ passed ilown into another imri. Under tb^^
cmnstant^es there is an outer layer of intestine within which i:* ibfp*'*'*^
the intestine forming the invagination. Only a small mutioii tif thp i*^
tine may be invaginated, or it may extend from tlie ileoKvcil nJ«*
the rectum. Small invagiuatiuus are frequently tbund at the |»*t*a>^**
DISEASES OP THE IKTESTINE.
877
^PBkninations of infants and young eliildren* These probably take place
Buriiig the death-etriiggle, as no pathological eonclitiim is found in connec-
Mon with them. This form is usually multiple and io the small intent ine»
H^e form <>f intussusieeptiou which iiwrurs duriug life is very rare under
^mree tuonthri, and is mo^t common fn>m the third to the sixth month. At
Hbts age the large intestine is shorter in relation to the small intestine than
Hi the adult, while the mesentery Ls relatively wider, and thus allows much
Hreater latitude for misplacement^ especially of the caxnim and colon. The
Htiology of intussnsoeptioD is obscure, but it is probably directly due to in-
■Rressed loeal }>eri8talsis.
H The jjatliolngiful wnditiou depends ujk>d the tightness of the oonstrietiou
Imd the length of time from the beginning of the obstruction. In some
iBmtu* the ineaiTerattd jmrtion of the intestine is so little eonstneted that the
^powel remains pervious. In other cases tlie constrietiun is st> great that the
Heosion of the intestinal capillaries ipiickly beei>nu>i ni extreme tliat hemor-
Hrhage ocx^urs, and inttaiom:iti<»n, with resulting adhesions, is apt t*> follow
vapidly. The intestine may not only Ix* invaginattxl, but may he bent on
Btself, an inipurtaut |Miiiit to rememl>er in regard to treatment
B Symptoms. — The sym[»tora8 of intussusception are usually more acute
Hn infants than in older cliildren. In infents they ai^ often at first rather
lohscure. Paroxymal pain and discharges of blmwl fmm the retium ix>cur.
KLaler the blood is mixed with mucus and looks like currant jelly. Tliere
Bs usually v<miiting, which may be sterooraceous. The mind is clear, and
Kn young infants the face is often trancpiil between the paroxysms of pain^
HO that on hwking at tlie infant it would scarcely Ite supposed that a serious
■condition was prt^s^^nt. Later, luFwever, the face grows haggard and the
Byes become sunken. Daring the first twenty-four to forty-eight hours»
pSuid even longer, tlie infants will often take tlieir food qiute readily.
Tenesmus is at times present. There may be fever, especially when
■ inflammation has occurred. The pulse is usually quickened. These
wr^niptoms all vary, and deiK'nd on the amount of the invagination. In
Momr cases titese are the only signs which iodimte that there is abdominal
disturbauft?. In many instances, however, either at onc^ or within a few
t hours, a tumor can be felt in the abdomen.
Diagnosis. — The chief points in diagnosticating intussnsfx'ption are the
CKvurn^nct* f»f disehai^es of bltxMl, vomiting, aMomiiml fiain* and the deti'c-
tion of an alxlominal tumor, usually on the left side of the alxlomen. In
these cases a careful n>f*tal examination should always be made, for a tumor
can often be found in this way w here an external examination has failed
-to detect it.
I PnoGKiisis, — Without treatment the prognosia ia unfavorable, though
nhere are a certain number of rect) verier by spontiuieous n-duction, or rarely
■by sloughing of the invaginated portion of the intestine, which is tlien
Kiassed by the rectum. If death tjikes place, it usually oci^urs alx>Qt the
■hinl or fourth day, or at any rate within a %veck, after the incnrc^mtton b
'"^"'"^ PKDIATUICS.
rniiipl.tf. WluTt' tho im-ariH^mti**!! is not ooniplot*? the inthn: n.
i!Kiii> \\tvk>, aiul in oKUt rhiMmi in nin- in>tanft»s the ais.:!- :
rhroiii**.
Tkka r.MKNT. — T\\v tmitnient of intussiis<t^ption \\lm\ ti.-.l ..
iHtn ilrtinitivtly luiulv >\nm\d U» innniKliaU', as in n- orht-r.!:/.^
.IrhiN nsiilt in nit»iv s^rions fonstNjnfnci-s. ImxhI an<l ratlian!- .
:i!v oMitni-intlirattni. If tho infant sliows si^r„<: ,,f n.llaps*.. *:u::i
ot* i.r;i!i,lN-ant|.wattT slu»nia U- jjiwn. In the early hoiiiv .:':... :
aiirinpt^houM U- uuxdv to nnluco the intussu^ivption hy hy.lr..-v
tin. Thi- ran In. t-a^ly tlont- hy liavintr tin* nitantV lifitt-k. .
r:\\-'A aii.i intPHlncinL' watiT umler a pivs^un- of aUnu 2"":..
hv iM.:n.^ ..r :i touutain >yrinjrt.. Tht* watt-r shouM U- kk-
.i,...i'hl l.aNr ai^^Mlvtnl in it -alt in tlie pn>iH»riion of on- i.a^s.
.J .:iri. rhr aU|..n!. n -liouM U- grntly ruhUiI at tho ^an^ Tin...
,:-.- tl.i^ pr.Mv.lniv rrMilt> in a mluetion of tht- intus>usiv|.:i n.
IS:! \\!u r. inrlaiiniiatiMn has not hetrun and adht-i. n^ kv n:
!•.. ]—•'.:!•. ..[■ t!i. .-..hnini of watrr may ihil to i>nh.;.v ihv ::•.:> -
..■ >• :•!• MMijiiiaT.il |HUti.ni may Ih^* Uau on it>«lf. s* t:;.: !:-
-:..::. :.r. •»-.::•. i:. ■;•.:,-»•- tli.- Ml»>trnoti..n rathtr than roli.v.^::
.. : .-. •> !.;i\. tjtk, n phio- an«l wht-re thvr»^ i< iiivar ♦v!o<::.:>
• ^ • •■'* * '■•'•^ *^' ■•r^' tutnty-four h«.nir- .»f rut- atta. k. . .
'^•* • >•>:.i^ 'i:>'i'v»'^-i':l ami may Ik- danirvroi;^. Ir'-.j-J-.
:. • •.•:;:- ^:.-;:.l U- phi-x^I at ..n«v in thv iiaii-N .,:" i * r.
' -•.:•:•- aii»arly lapar •t.«iuv w-;; -ivv :..• •• :
DISEASES OF THE INTRSTINE.
879
to Mmus surf&oei were firmly adherent through their whole vxt«int, mud coniiderable force
r«quiri«d to reduce the itivajfiiiMlifjo without tennnjaf it. The reduction, buwever^ wu
MsenfuUy ftcoomplUhod, the ndhcftiotus jc^vitig wny »nd the int«*tine being left, uninjured
I App»rently he<hy, ThU cftte illuntratos how necessary it ii to employ the mtmi
lied surgical aid in these cades.
' Heniin, — I have already spoken siifficiently of the pathological eon-
ion reprf^sentetl by herma, in my lecture on diaeases of the new-born
Ige 430).
There are a number of lesions which occur aljout the anus in infants
d young children which, Uiough somewhat rare, should be ret^gnixe*! for
ETposes of ditferential diagnosis. They are, however, so purely surgical in
nt treatment that they nee*i only be mentioned here.
flstturiJi. — One of these eouditions is that of fissure, whicli occurs either
the anus or more oonimonly a little distance from the orifice. Pruritus
d reflex urinary symptoms are common. Defecation b often painful^ and
idti[iation of the spasmodic type may thus result
Protapue, — Prolaj^se of the rectum is not uncommon in young children.
is usually pn>diiC(Hl by siniining from various caudee, eapedally in
fcreme consti|iation. The wall of* ttie rectum c(»me8 down through the
Ujs, and is ea^sily rci^^jgnized by the appearance of the muooiis membrajie.
lie prolapsi' is ortlinarily tmnsitory, but in the more severe fomis the
Cttim remains down.
• The treatment is to remove the cause. Constipation should be relieved
wt by enemata and then by keeping the movements of tlie bowels semi-
luid by means of gentle laxatives. The child should l)«? kept in be*l for
ttumber of days, tlie pn>trusinn l»i*ing gently pushed bick each time that it
ines down. After reposition it sliould be kept in place by means of a pad
|d a T bandage. Under thin treatment a large numlier of cases recover,
le more serious and intmetable casas, however, should be referred to a
rgeon.
Caak 428.
Ctangmltal pRdapie of seeCim, tanalo. 22 moatlu old.
tl have here a case of prokpee of the rectum to show you which hit
\ Qtider the care of Dr* C B. Porter,
880 PEOIATBICS.
Tho infant (Case 428) » a female, twenty-two months old, has h*d n-
pn»lup>i' ^inci' birth. Lutely the prolap«ua has been increaifini; in size. 1:^ _
fn'tt'iil, uiid M'fin.H viTV wi-ll. Tho movements of the bowels are n-.-rma! ur ^: .-
lapMsl |H»rliMM t»f the nrtuni. This is one of the more severe types of iLr >a
Mj- thut ihr pnthipsus foniis a large rounded tumor covered with reddi?h ^.i^z-l-l'
pn»j»«tini: fnini ihi- anus. It is alxmt 7.8 cm. (3 inches) long and 4.0 ctj .'.«.
Thi* tuiin»r is n«>t f*<*nsitive to the ttmch.
Pitff/pi, — Polypus of the ni'tum is more oommoD in eark 1:': -.
any othrr jHTiiHl. Hemorrhage from the rectum, when noiduet' ^v:
tion, diarrho^ji, or fissure, usually aris€*s from polypi. AcarerDlui-
titni lor this growth should be made where rectal bleeding i? nv.,.-.'
larp'. KiM'tal iM>lyi)i are of various sizes, and may be myxo-iib: lzl
adciioinata. The surface of the iK>lypus is usually smooth, and i^ ;-.
is oftvn lon^ and thin.
T\\v diagnosis is i-asily made by a digital examination.
Thr treatment is simply to twist or cut ofl' the pol\*pi. Tht p^s"
not apt to ivrur.
Iliimn'ritaltls. — Hemorrhoids are rarely met with in infancy ":--
<*hildh<M»d, but ejui (xvur as in later life, and should be treated bvic
nu'th<Mls.
Fisfulif. — Fistula in ano is not a very common condition Id infiS'.
early chiKlluMMi, but is at times met with. The cx>ndition ha< the an- -I
a4't< n>tirs as in the adult, and should be treated in the same way.
Fermental. — The non-inflammatory conditions of the intertiiir.r.-
i\)\' wMiit ot' a U'ttrr term we s|x*ak of at present as fermental, iirivi* •
whi.li nri-r fnun a<-id lennentation and alhiunintai.s deconiitoiti":.'
AVi' \\nn\\u'ti\ by inirro-or«ranisms. The <listurbaue«-w which ari-*;':'n^ '
«;mM- npnxiit tlic ^rpcater proporticm of the diarrh<eal dix-ait^ ■
oiMMir dmini: the warm months of the year.
KiH)L«M.v AM) Pathology. — The causes of ferraenial ffeurto-
the intt-tinr lir in impure or improper foods anil bad hvjrieuii- i-UT-';:-
in--, in hnth -m-'uI Irrmeutation and albuminous dt>comp4.»sition i: > p' • I
aMr that thr -mail intestine i^ most affwted. The condition ol'tikiO'
nirriil.ranr may Im- nnrmaK or there may be desquamative catan-L T-
pr.M-.-^ may -'» no lluther, or it may be followed by inflammat.)ry obs.-
1.-; ::i' int«-tinal nnicnns membrane.
111.' fririirntal da-s ni' cases holds a position midwav ktwtrr: *-•
nrrv.iis U^vui^ n{' intestinal disturban<*e and the inflanimat'un- tl.m>"^--
tli< ir |»i«in«nm«'(Ml h^ioi^.
>v\ii loM-.— Yt>n can well understand from the great varierj'*'i' ^J-"^
wlii'li L:i\" rlsr t.. tlic^e fermental processes how varied may U'th. v-:-
tnm^. rhe niKrt may be subacute, with little or no fever and ^H''
v.-miiin- nr it may be acnte and accompanied by a high temjieratn^'
a.tivr v-mitiniz. After a variable |>eriod of general discomfort and n-t^^
nr.^s .JiMrrhua srt< in. Nxhich varii^ so greatly as to its frequence, lit :-^
^•^•I'T. and rnnHMrncy that it would be imijossible in the present suj:^ ^
DI8EABE8 OF THE FNTESTINE,
881
ir knowledge to divide the^ variations clinirally. The onset of fermental
firrhcea is, however, so often charaeterixed by the toxic symptomB of
idden rise of temperature, fblldwed after a day or so by a normal tem-
siuture, that when we meet with this ocenrrenee we are usually justitied in
iminatin^ the iuHammatory ami mure serious intei^tiual lesions. In H<»rne
isess the diarrlicea, al though a^xx)nijianied by much pr*)«tration and variouj%
Brvous distnrlmnces, disap|x*iirs after a few days ; in others, ettjjecially in
le warm weather, it may last for a number of months. In tliia iernienuil
iarrhcea the color of the di^harges is commonly some shade of green
r greenish yellow, and the txlor is often very offensive, jiometimes lx*ing
excessively sour one which is supposes! to arise from arid termenta-
n, and at other times the extremely foul one of albuminous decom*
ition. The dist^harges are usiudly acc^jmpaiiiKl by con^derable |»ain
id a large amoimt of gas. The symptoni^ arc uiten m severe that the
fteeaee has a serious aspect, but in a c^nHiderable numl^r of ca^es after
be intestine hafi been thoroughly emptied the tem|jt^ratui"e falls an<l the
prvous symptoms subside. There is usually rapid and great loss of
Ireight In cases which are not prolonged by fi-esih irritation or by
tciwise treatment recovery often takes place quite rapidly.
I D1AONO6IS. — Where the attack i» subacute, with slow onset, without
fomiting, and with infrequent discharges, the diagnosis is not ditfHult,
id is to be made from the nervaius disturbances, which can U4sually .srw^n
differentiated by the alisence of fever anil by rapid recovery. Where,
lowever, the f»nset is acute and is acituup3inicxl l)y vijuntiug, the diagnosis
nuet often be held in abeyance, as the symptoms of high temiierature,
romitin^, and diarrhnpa may be present in infant** and young children in
le initial stage tif a numlx^r of acute disea^ses. The disease from whit^h it
to he es|)ecially differentiated is cholem infantum. In fermental diar-
oea the prostration is much less, and the tera})eratui'e after the early hours
the attack is much lower. The senius discharges and tlie c»nitinuous
miting which scK>n arise in cholera infantum are quite ditferent from the
nlsh discharges and the less frequent vomiting which occur in fermentul
liarrha^a. We must rememiKcr, however, that <'holera infantum and the
!Ute inflanimatory intestinal diseases are usually preceded ft>r a niunljcr
days by this fermental form of diarrhcBa, and tliat the s])e<*ial micro-
nisms which pnxhKn:' the fornipr disense gain an entrance for thcms*.4ve8
r their toxines by means of the abnormal intestinal conditions pniduced
the fermental changes. You must also remember that gastm-enteric
jjrmptoms are often so pronounced during the early days of a pneuinouia
rt tliey may mask tlie pi'esentM? of that disease.
PaooNoeis. — In previously healthy children the prognosis of fermentul
Barrho^a is good. It de}>ends, however, upon the degree and kind of the
brmental process which Is causing the disease, and also on the amount of
psistance to these processes which tJje individual possesses. It alscuiip^nds
■pott the vulnerability of the individtial to the other bacteria which may at
[ ' 66
cliM-asr is tn'uUil.
'ritKAi'MKNT. — The tK^atnient of fermental
niicr the sonnt* of the distiirbauce by thorough
Wh* re tlie voiiiitinjr is excH»8sive it is sometimes
stoiiiarh, Imt, as a rule, this procedure is not in<
oil, niif teas|NH)iifiiI for infants under one year,
older clilMn'n, is the Ust initial treatment. ]
a I It I Nvlitn* then* is a tendency to a pndongatio
irriL^atioii of the intestine is indicated. Food
mnnlHT t»f hours, — at least half a day, if posw^il
oatiil wlu'n* then» is miieh |m>stration. Where
that it <i«Ms not strin advisable to give castor oi
or J |Ln*:iins) of t-aloniel can be pven. The onl\
rx|»(ri<'iur st'4*nis to be indi(ated is bisnnith, \%*hic
doH- until the disiiisc* has run its oourse and the
1 liavf found, eontrarv to what has been s
can Ih- ^ivrn after the first twelve to twenty-fb
motliticd. It should contain from ten to fifleei
and at first shouhl have the ]x.>rcentages of its
dnr«Ml. riu» milk which is used for this pur
it i- n«»t -ntlicii'ut to sterilize it, as the toxic
>till 1n' pnx'ut in it and thus add fresh irri
aln:i<|y U't-n jinwlueiHl by the iernientation. In i
in til*' jn-rMiit state of our knowledge to detem
Irrnii-ntntinn is present. When.* acid fermeutatio
tlu' milk >lionld Ik* so modified :is to contain a lo^
lilt, wliilr wlirn* albuminous dee<»mi)osition with
nni \\itli.tln' prot<'ids should l>e recluced to a frae
n.' ni will ifi tlir intnrc be nroveil to h*» tlw» Iw*^
■V DISEASES OF THE INTESTINE, 883
H^inktration. The |>eristal8iB which occurs ns the result of fermental
^Bbn is a coo^rvative prooesa of nature, intended to earry away the
■la jirfxlucts which have resulted from the fermentation. Under these
lions the administmtion of opium prevents the elinii nation of the
^ from the intc^itine and allowB it t4> i-emaiu and produee still further
tion, or to be abst>rl)ed and give rise to still graver septic symptoms.
Vtaio cases where the intestine has been thoroug-hly emptied, small doses
aiurn in the form of tint-tura opii camphorata may be n^^ed with caution
^minish pain and control the eiccessive peristalsis which may result
h nervous exliau8titm after the disease has run its course. In these
hy however, stimulants are more valuable than opium.
When a child in the warm weather has once had an attack of fermental
trhcea, it is very apt to have a number of attacks : its diet should there-
I be carefully regtdatcd for a considerable period, and, if fM>s8ible, it
lild be taken to the sea-shore or the country until the return of cool
ther.
As especial illustrations of the great variety of fermental diarrhoeas
,ch yon are lial)le to meet witli in warm weather, I shall call your atten-
I to thc^se cases which have come under my notice.
A child (Caj&e 424) « three jear? old, and perfecilj weU, wm attucked suddenlj with
Dminal pain, nausea, pallor, and pri:>straiion. He vomited once or twicei and was
Hd U* have a temperature of 40** C. (104® F.). Within a few huure he began to have
ruent («h.'&] dejections of S4jiir odoft lessened conststeney, mtiderate amountf and a
aliar dark i^reen co]ot^ a ^pf^cimen of which (Plate HI., 18, facing pAge 112) I have
\ U> ahaw ytni. Thi» green is one of the more eommon colors met with in fermental
rfacM. At first the discharges took place every hour, and Inter every three or four
H- After the fir»t Iwcnt^-four hours the temperature became normal, and in three or
r dtt3rs the diarrha^a ceased entirely.
I Iiave here a c-ase which i» also illustrative of this form of fermental
Irrhcea.
iThia infant (Cose 425, page 8S4) is thirteen months old. On entering the hospital
fas much emaciatedi and had a slight diarrhcea, eaui^ed apparently by improper food.
Llempemture wa« only slightly raised. On examining it nothing eUe abnormal waa
The diarrhc£a was infrequent, and was not accompanied by any other especial
ptoms. It aiKm began to impnivci gained in weight, and bad a normal temperature.
|r it had be«^n in the hospital one week it suddenly began to liave diarrhcsa chamctei^
by large frequent discharges, of IeAflene<J consistency, of foul odor, and of the color
th you see in thiif i^peeimen (Plate IIL, 19, facing page 112). The discharge would
fVtim its foul odor to be an illustration of what i^ called albuminous decomposition.
1 will notice the miiture of yellow and light and dark gr<.^en, which is so ditferenl fri»m
I dark-gr»>en specimen which I have Jtist shown you (Plate IIL^ 18» facing page 112)*
I ooHon Are» however, only relative, and are not diagnostic* In this acute attack the
I wiu imiaed at flnt, but soon fell to n little nb^jve aonnftL
^The infant has lost greatly in weight, has become extremely emaciated, and looks as
would die. The skin often beootne^ cold, and the pnistration is eittvme. These
Iptoms have continued for three or four days, and the number of discharges in the
lity-four hours vanea from seven Uj ten. Thi» i* the seventh day from the beginning
kt loate attjkckt and joa tee the condiUoQ ia which it has left the pati#nt«
PEDIATRICS.
(BulMqiitnt hlrtorjf.) The §fmpiQtm hcGmm^ Jf** ©crc^, msm ^
L few <ky» Utcr the dumttE* itopped eotiivljt •«* *^* ui&m^ Aa fi
Fennealiil airiJxhaBa. M&ie. i;i n • ia^.^ oi<L
weight and BUeQgtb, Thia picture (II.) fthow* the great uapwroaw
in ft month*
n
iiilh J4A»:-T lx<'« Tvrv.
These cases of fermental dialThct^a at times are ^^n^lonp^i
weeks or even months, and thus jirmJiice a rlironic form of diar^
i>C€urs especially in children who are the subjects of rfaachiti^t ^
general tuberculosis ; also in thiji^e with chronic bioneho-pi^*
have already told you that the continuous administration of in
raay prrxluce this condition ; so also may improper extxisim ir
ficient clothing.
a
turbjD
mfazitfi
not be
and dif
disease
de^Tib
Etj
by a sj
deterui
its devi
noticed
as brei
that tb
Pa
satisfac
of the
tnative
St
rule, i1
<ausiu|
ble. '
s^
DISEASES OF THE IKTE8TIKE,
888
liolera Infantnm* — C'holera iufantiini is an acute gastro-enteric dis*
ice characterbsed by intense choleriform sym ptora.s. The term cholera
irnjn should l>e exclosively restrirtod to this clas?* of cases, and shouhl
f used t<» dasignate the many acute and serious attacks of vomiting
ourhcea which are so often depiguated cholera infantum. It Is a rare
EeoDiparison with the fermental diarrhoeas which I have just
to you.
^Y, — ^There is not much doubt that cholera infantum is caused
i^ecific niicn.vorganism, although this organism has not as yet bet*n
:SDed. It most commonly occurs in the first two years of life, and in
^lopment is probably clost^y ai^txiated witli the food, for it has been
L that infants who are fed exclusively on pure and sterile foods, such
anst-milk, are ntit liable to be attacked by it. It is also significant
iim disease occurs ouly in hot weather.
ETHOLOGY, — The pthology of cholera infantum has not yet been
Gorily dctcrmruixl, but it seems to be a uou-infiamniatory di^turbatice
E* ga?itro-i^Dteric tract, without any gross lesion beyond a des^jua-
*rh, and sometimes hypenemia, of the mucous membrane.
MB* — The onset of cholera infantum may be s^udden, but, as a
s: ig preceded by some form of gastn>eutenc disturbance* which» by
^ an irritation of tlie muwjus membran€% reuden^ the iufaut vulncra-
^Vhen, however, tlie disease has onee gained a foothold, the develop-
^ f the symptoms is ver>' rapid.
fcer a variable but generally short jH^riiKl <»f restlessness and apparent
inal diseomfort, the infant begins to vomit. The vomiting is either
f-jauied or quickly followcnl liy profuse dinrrhrea. After the *^tomaeh
^testine have l)eeu cmptitHl of tlie fbcKl which may hapjien to Ix* in
%t the time of the onset, the vomitus and the diarrhteal dis<i4iarges nw
^ serous; and it is this watery t^nsistency of the disf4iai"ges vvhi<*h
ftlly characterizes the disease. As a rule, the dischaq^es are <Klorle*-s,
2t>n8ist of serum mixtKl with epithelial cells and many bacteria.
mgh the disease Is more likely t<» attack weak and debilitated infants,
t oflen attacks tliose who are lu^iUhy and robuj^t. It may run its
le to a fatal issue in from twenty four to tbrty-eight hours. The ex-
itiee soon l)(*ci>me cold, the skin is |)allid or even cyanotic, and the
pinchwi The aUlomeu nuiy be a little distendtxl, but is i^ift^and soon
nes rather retmcte<l. The |»ulse is nijiid and dithcult to ttiunt. The
rations are somewhat quick and sujierficial. The temjieratnre of the
e surface of tlie body Is low, but the d«»p n^Hal tem|jerature is high,
\ 4ir, or 40,5° C (ioa°, 104^, or 105^ F.). The thii^t is great and
I'eiy prominent symptom. The fontanel le very soon be*^omes depressed,
urine is suppressed, and nervous sym|)toms, such as twitching of the
and great restlessness, are present. Itapid emaciation takes plaee, and
be symptoms increase in severity. At first tlie intant whimjH'rs, but
it become listless, tails inU* a stupor, or may have ci>Dvulsions. The
1
l)iA(JN()si8. — Tho (liagnosLs ot cliolera mlant
<•hn^a(•tl'ri^^ti(• syinptoras* are borne in miiid ; these
vninitiiig, trcMiiiont serous diseharges, intense thirst
Inw siirfaw tem|R>rature, collaj^se, depressed fo
w< i^ht, and distressed, restless expression, sugj
dc'Vf'lopiiig III from twenty- tour to forty-eight hoii
Pu(KJN()sis. — The pwgnosis is bad. The mc
hi^luT tlu' t<*miK'ratiire, the less the vitality, and
the woive is the projruosis. When the infant ha
syniptoins whkh apjK^ar in the first two or three d
inon* favorable.
TuKATMKNT. — Cholera infantum is so formic
must bo trcatal most enerjj:etieally if we hope
inliuit's lite. The indications for treatment are (1
iinturc is makinjr to free the stomacrh and intesti
is in them ; ["2) to restore* the surface eirculati
intcrCrrcd with ; (:$) to supply water to the tissues
to so «rr:ive an rxtent ; and (4) to supi>ort the i
liM> run its course.
The |H»ison sii^ns to aet with esi>ecial viruh
tlic rcoiiomy whiM'e it is most eoncentrated, — nam
int«'-tinr. We therefore liave at first extreme
Nviiirii raust's incn'as<'d ])eristalsis, and later va.so-n
ti:rn<u<l:ition of scrum. This eondition of the gs
oiMMMMlly borne in mind during the whole course
In tlii> disease we should not attempt to use
sl.»\Nly. The condition of tlie mue^ms membi'ane
tiiMt al)-or()tinn of drup* do(.»s not take place rexu
<•!' <lrim- i-, tlienfor(\ contra-indieateil, for thov m
DISEASES OF THE INTESTINE.
887
At fii^st
biild bt» allowed to suck sterilized ice-cold water from the bottle.
Hliing else should be given by the mouth.
'* The infiiDt should hv plact^l at once in a warm pack. Thii* tshould be
%ne by wrapiiing it to the i-iiiii iu slitH'ts wrung t*ut of water at IriLst lus hot
^ 38^ a (100.4*^ F.). It should then be euvelojjed iu a hot blanket,
his proceduix^ nhould lie rejK'atiHJ a*? oilen a8 the iufaut shows sigos of
>lla[»He or much cyauoj^is and cHiMnesH of tJie skin. This Is the best
letliod that I know of to restore the enrfaee circulation. Iu extreme cases
BuhK'utaneous injc^ction of salt solution can k^ trit^d.
While die infant is in the hot pack, water can be given freely by the
louth, and, if ne(x^sar)% small and frtn^juently rejx'ated doses of stimulanta^
less they apj>ear to excite vomiting, iu which case tliey should be given
ypodermitrally*
If the vomiting and diarrhoea still continue excessive ailer this treat-
ment, small doses of mivrphine, 0.0<KJ6 gramme {j^ graio)> and atropine,
I.00008 gramme {j^ g™i^)j 'or ^^ infant a year old, can Ix* tried hyp>-
ically. The effect should be carefully watehtil, and the dr>se n^peated
tieoessary, as ret^mmendetl by Holt.
If, after the vomiting and diarHnea have ceased, the heart's action am-
linues very weak and does not nspnnd to stimulants, small doses of digi-
bdis should be given. The greatest caution should Ik* cniplovLHl in using
drugs, however^ a^ they ge^nerally do ni»*re harm than g<Mxl»
If an absolutely fresh and sterile milk can Im» ohtaiueil, it can l>e u.st^d
18 a food, as in any of the other forms of gastro-enteric diseasis wliich I
liave ali*eady describcnj, but for some days the percentages of the elements
ill the milk must Ix* much Icssc-ned, and the child's strength must be sup-
|»orted mostly l>y stimulants fWly diluted with sterilized water.
Cholera Asiatica. — Cholera Asiatiea is a highly inf€?etious disease,
caused by the comma bacillus of Koch, which manifests its most v it i lent
lymptoms in the gastroH*nteric tract. Its syuiptoms very closely rt-scmlde
Ibose of eholem infantum. The disease in infants should be diagnos-
ticated from cholera infantum, wliich is done by finding the c<»nima
WhUus ill the vomitus or iu the discliarges. There art» no esjxinal <lif-
ferem:es between cholera Asiatica in the uLlult and the same disease in the
Dfant* It is exceedingly fatal during infancy and childhood, and young
tifants who are attacked by the diseiL*^' during a cholera epidemic sehhtm
live. The treatment is tlie samt^ a« tliat which I have just descrilxii ii*r
pholera infinitum.
New Growths. — New growths in the enteric tract are verj' rart^ in
Infancv and childhcMKl, and are mostlv tx>nfined to myxomatous |»olvpi of
he rectum.
Inflammatory. — The inflammatory diseases of the enteric tract may
Se acute or chnmk\
Under acute inflammatory diseases may be includeil upi^idkUU and
888
PEDIATRI*^.
AppeDdicitis, — luflammation of ttie apjietidix
^ea) diheaiR^ and ifi one which under all circuntstanoK ibooUb]
inimetUatcly Ln the hand^ of th^jse who are skill^^d in
Fmm my observation of this di^^ease I nm so strongly impRSMlnil
fact that I euns^ider an extended description of it in tDfidkal kpnil
by [ihvi^ieiuns out of plaee. I ishall tl it:- re fore confine my mDiiii«i|
dii^m.^ to a very few wonk, which will aid yon in making a <iji^^!ii|
you meet with one of fli s.
Under the term u|))h - we now include tboee inBiiimmwf ■» |
tiona tn the oetgliborhood of Uie i3seeum which were Ibmierly mlM (
and perityphlitis. The reas«>n for this ij^ tfiat there is little (lfjdAili|
moAt in^tmice^ the a|}[)endix i^ the (lart primarily involvnl. TV fail
oceufB moet commonly afler the tenth year^ aiid is rare in the ctd; i
of life, but it may occur at any age.
Etiology. — The cause of apjiendicitifi is in mo^t csi^eeaQ i
of the lining mucous membrane of the appendix arising Sram final ao^ I
tions. It uiit seldom caused by any foreign bodies^ such as needs oriAT*
I have here a specimen of tlie ap]3endix (Fij^. HI) wfaidi ra fiiU
from a girl nine years old forty -eight hours from the hegimm^f^'
attack, the first she had ever bad. The operation was perfonsd b^ ^
8, J. Mixter, and was followed by complete recovery*
F[.t 111,
Appe&dix rexnaved fronn femAie 9 yeuB old. (Na^tuiml «|^ j
On o|iening the appendix this fecal ooncretion was found (Fit. Ul^
Tool ocmcretioD lii apt>eudU, (KftXuiml siae.)
Pathology.— The jwithological lemons which o<>ur in tbise c«i^
from a simple intiaminatiiry condition, with exudation, itKliiratioiuaiidtttt
ening, to gangrene and neem^is.
Symptoms.— The symptoms of apjx^iidiriti.s are, as a rule, ilie ^
obscure the younger the individiml. In infants and young chUdwi-
dominal pain may he diifieolt to loealize, and may l)e referrwl to mrm^^
part of the body. In like manner pain in the thorax may be wfcrn^ ^
the abdomen, so that it is often imims^sible Ui be guided by Uie a|>[amtii
m
DISEASES OP THE INTESTINE.
889
\
the pain. There are no pi*odronml symptoms which are esj^eoially ehar-
teristic or of much aid in determining whetlier apjx^ndicitLs is prej^ent.
^e temperature is often verj' mij^leading. 1 have seen a child with a
ere attark af apjK^ndieitis in whonj the acute &yniptoms disapfxared in
few hours and tlie tein|)emture was mii?ed very little aUive normal.
^r. Mixter, whose Hiurgical knowledge wa8 called upon to determine M'hat
lould Ih» done in tlii.s i-a^ie, decidKl to oinn^ate, and on opning the alKh»nien
le ap|>tnulix wa^i found in a highly inflamed etaidition : pas had lijrintil
%d di.Htendt*d it, and j>eHbration had almost taken place. There ih nothing
■specially ^^ignifieant in the pnls:^ or the lY'Siiimtion which will aid yon in
diagnosticating the distiise. In a number vi' causes, however, vonnting,
miu and tenderness in the region of the wecum, and later a sensation of
esistant^ and dulness on percussion, c^jnstitute a group of symptoms which
-hould lead u.^ stnvngly to sus()ect the prcsc-nce of this disf*as*\ The vomit'-
ngy a** a rule, is nut sterc<iracc«>us, and in young infants diarriKea Is a(»t to
r as often as consti{*ation.
In caj^es of ap|x*ndicitis which recover after 0|)eratir»n various inHamma-
tory Ie.sion,s aiv left, and the disease* is liable to recur from time to time.
\B condition is known as ciironic apfM^-ndieitis. Where the symptoms
ntinually recur, the patients lose in weight and strength, but often can be
entirely cured by having the apjx'ndix removed*
Diagnosis. — The diagnosis is to be made chiefly from intussusception
and volvulus, eepedally the former. In intussusception, as I have already
told yon, there is usually an alxsenee in tlie beginning of pain and tender-
ness, and the tumor which is onlinanly ibnud is to the left ol* the median
line rather than to the right. The vomiting in apjxMidicitis is not sterciira-
ceous ; in intussusception it is often so. Pain and tenderness in a varying
degr€>e an* always prtm>nt, but the timior is often m^t Iclt until late in the
disea^ic. The tem]KTatuiv and pnisc art* generally slightly miaed. The
Dame anxirius cxpn'ssioo of the face <x*cuin in appendicitis m* in intussns-
€3eption. Yi>u must n«»t de[>end u|>on the locality of the tumor and the pain
and tcndemt^ss in diflercntiating these two dLscas4:s, for in some instaut^s
tlje inllaincd apj)cndix may l>e found to the left of the mctlian line, and in
intuKsusc^'ption, es|>et*ially if not of the ik^j-aecal variety, it may be on the
right of the median line. All these questions, however, are for Uie skilUd
Burgeon to decide ; and when this group of symptoms is pr«*ent we are
justiHed in making a |>rovisional diagnosis of apjx^ndicitis and in at once
summoning surgical aid,
PnoGxnsrs, — The prognosb of apj>endicitis under judicious tn^tmcnt,
cspt^^ially if o|Hjrative uiterfcrentv i.-. iustitutixl early, is very favorable; but
when njx^ratiim has l)een defernd until i^Tforation has taken pla»^ the
prf>gnodi8 becomes unfavorable. Even luider these conditions, however,
luauy t*ascs recov^cr. The pmirnosis of cast^ which an» o|)erated nfM»n when
mmation is not presiiit Uawec^n nnunvnt attacks of apiHudicItH i- in
loat every instants favorable.
of Dr. Crocker and wus oi>erttted upon by Dr. Gel
A child (CtM 426) » twenty -eight months old^ had
riAUBen, vumttirig, iligbt diarrlia^ii, iind abdozniDal pttin.
lunior hud hoen found tn the k(l lower part of the
pfiich«Hl expression and a ho wed much pAllor. Her puUe li
C, (108.6° P.). On the duy when the opemtion was p«rfoi
which hud first liecn ftHind^ the Hght half of the abdotneo
wbttt irrei^tilar uutlliie, with t^viftc walU^ und i^ivitigr an m}
Chftn^cft of postutv prodiict?d nu efl'fct on the physical m
thpfiui;h the middle of the tumor» arid about tk pint of pus
of detriiU-N imvini; a slrtjrjglv fa«cttl odor. The child tecow^rt
I happen to have here in the wards a litite fpH (Case
trates one of the mild cai4» of appendicitis which often i
whom I have placed under surgical supervision in »eoordan<
this subject.
Case 427,
DIBEA8ES OP THE INTESTINE.
891
Bbie inirpection you will notice that there is slight bulging iu the area mariced in black*
pPhe temfK-mture has been abt^ut 39 4° C. (108** F.), the puls« 100, the raBpiratiom 28,
W With symptoms of this nature there is not much doubt that we are dealing with a case
|.i>f appendicitis. Morphine, 0.004 gramme (|^ grain), was required a number of times to
^ralieve the pain.
r (Subsequent history.) On the day following the child's entrance U* the hospital the
Hempemture began to fall, the tumor b«Hjame less distinct, and there was lea* tenderness and
I not much pain. It wa« decided not to openite, but t^^ watch the cuae carefutly. On the
third day after entering the hospital, the seventh day of the di94*asi\ the temperature becnme
, normal, the pain and tenderness di»appcnred entirely, and the tumor became indistinct.
I The bowels moved naturally on the seventh day, and in the ihinl we^k fn>m the onset of
I the attack the child was perfectly well, and only a little resistance could be felt in the ansa
I which had been occupied by the tumor.
Heo-Colitifi, — Under the term ileo-colitifi are included all the more
markc^d and grave lesions of the intestine. These legions are so varied
that it would be irapossible to classify thera in detail, and practically we can
divide them in only a very general way,
The divisions which have been adopted to siaiplify the subject are (1)
simple witarrlial inflammation, which includes the non-ulcerative form of
follicular iuflumnuition, (2) follicular ulceration, (3) an inflummation charac-
terij^ by a |)seudo-membrane, (4) an inflammation cau.sed by the typhoid
haci litis, (5) an inflaniraation can.^ by the anneba cnli, and (6) an inflam-
mation caustni by the bacillus tnlxTCulosis. The lirst three of these
divisions, cfitarrkidf lUcerative, and manbranous^ althoutrh differing essen*
tiallv in tlicir prognosis, are so often rt^presentrHl by the same symptoms
that they can be differentiated only in the most general way. A symptom
common to all these diseases is that the temfK^rature, although not neces-
sarily high, is, as a rule, rnisrd thrnutjli the whole e*)ursc of the disease.
In this way we can usually flitrereutiate tlk^se diseases from the non-inflam-
matory conditions of which 1 have already sp<r*keD. There are so many
varieties of pathological lesions found in a^nnection with the catarrhal and
non-U Ice rati ve follicular and the ulcerative follicular inflammations that the
clinical distinctiiin Itetween the two c*;iud it ious» until our knowlcilge of tlu^se
' diseases shall have been greatly increased, must be very limited. In lx>th
the lesions are so varietl that they prolmbly arise from a number of organ-
isms, and their pathology must for the prcst^nt include all forms which
cannot be classed under the pseudo-membranous, typhoidal^ or ama4)ie
forms (if iler*-colitis. They may iKxnir a** acute primary diseases^ but are
usually secondary to the fcrmental diarrhceas, and siitiii^imes U\ tlie infec-
tious diseases, esiieciaUy measles.
In the p!^nido-mcrabran«^»us form of ileo-CMliti»? the ileum and the colon
are chiefly nflWteil. The lesions are probably due to a nnmlx^r of organisms,
but its pathology is more definitely known than that of the catarrhal and
oloerative follicular forms. It is characterized by the presence of a mem-
brane on the surface of the mucous membrane, which extends into it, due to
a combinati*»n of fibrinous exudation and necrosis. That is, there is a defi-
nite pathokigy. The disease may be primary or secomlary. In the primary
«
il
iH
SOS PEDIATRICS.
fi>rm it reprcsente" what i« usually s^xiken of as epidemic otspwbir»
tenr. The sccontkry furni k that which follows ccrttin inywi»>
Midi 88 meanles. All those forms ar«' wmm(mWsp<iken(i (Aw
but fmm what I haw tohJ you you will set that the widdnwtrw
no huiger l)e rvtatiu'd in our nooienclalure, as it has beeo used krj.
difTerent pathological onwlitions.
Ik'furt* eml««voring to t^Jl you what little is known wptfct
8yiii|.t.ira8 «if these di»*ses, I shall show you o fewsptmtwfc-. '
suDU- of the jiathologital wnditlon* which occur in ikxtitiM^
Ueo-eotitu ulcerativa JoU'mtlam, and ilto-cjiiti* f»mi(Hiaknm k
mon> pxteiidixl stutlies nf thm- conditions, both as to tWrp^i*
their Im-teriology, mu,st I* nimle before aiiAtliing more tlii« lb ^
view of the subject am bt- used for clinical purp«*s. Yftuiilrf*
undc.r8tun<l that these sptH'imens which I am about ^^l^""
re,.n-Mnt all tin- lc..i..n. which o(*ur in thffie di«as».l>ut «B««»
of th.' principal o,u^ only. The notes in .-ounection with tto **
bow witli onr present knowk^ it is usuaUy impossible for »to 4^
ticate tlic 1< ^inii^ rlurin^ litV»
Fio 113
^^ «fihp colon ^*f*"
This first spmmeii (Fig. 113) is a portion ol m^
during life had only a slight diarrliiea.
i
Cjl»sI29, Fat). Il.'i
Colittefnlliculariunon-ukemtim Mule, i* >f »r> « ^ ■ ^y
and SuiKCOtis. New York. tn««^
oftheCdW*^^
Muf. MenL, muutms membnine ; Fol., foUlcles ; dtibmtic..
aiU» ulocmUvii fullJ* ulniU. Infant. 1H mouth* old, Mnwoi of tl» CoU^ of Pbf»lci«ii
iitut StlfK«*'»*, ?*<?* York, (nifeMI*)
Acute ulcerative entarrhal colllb. Feinule, A mouths ol.l. Museiuu af iht* Cbik?*^^ i^T«^
and Surgeons, New York. ( Pu^e *p>l *
DISEASES OF THE INTESTINE.
893
H You see that the lesion h quite marked and simulates closely the hyper-
Hlasia of Peyer* s patches which is commonly hcen in typhoid fever ; but in
Bis case it represents meanly intestinal irritation.
■ This next specimen (Fig. 1 14) was found at the autopsy of a little girl,
■iree years old, who had l)ccu under tlie caix* of Dr. Wcbt>cr
■ The child (Case 428) wtu^ attacked with excessive vomiting after eating
Kigs* feet, and the vomiting continued until her deaths five days later. The
Besions are cliiefly in tlje upjier part of the colon, and consist of a gf*neral
Kion-ulcerative (bllicular inHammation. The hyjH?rplasia of Peyer's patches
■a, as you see, extreme.
I Through the kindness of Professor W. P. Korthrup I am enable<l to
phow you some inttTosting specimens of lesions oJ' colitis which m^curred in
Biis practice, and which are now preserved in the Museum of the College of
■Physicians and Surgc^ons, New York.
I This sptM^'imen (Fig. 1 15) is one of acute catarrhal follicular inflamnia-
ItJOu without ulcenition.
I Th^ infant, a. male [Vma 429), two ye^n old^ enlpred ProfpMor Norlhrup'9 servioe
I witb A hUioty of diiirrhwa and ^t^nt^ml debility Lasting two wei'k». Whik' the infant
I WHS tn the h(:>«pital there wus ii eoiitintied high tempcniture, which at one time rejiehed
40* O. (104** F ) The syniptonis wr**re mostly of a cerebml type, and the abdoriiinHl cymp-
lom* weiw not severe or pn>minent enough to iiidicaie the marked leiions which were found
I *l th^ auU»p^y. Tho post-DK>rteni examinAtion, made by Profe«aor Nortbrup, showed the
folio whig conditions:
Brain nonnaL
Stomach congestL'd-
The HmaU intf^tine contained a larce amount of thick mucus. The solitary folHclct
were enlarEjcd, mthiT more in the upp-r lliird t>f ihc ii»tf*stine, P*'yer'» patchea wtT*
markedly swollen « and n few aolltjiry rollide« ap{N<arod to be ulcerate. The meMoterio
lyrnph-glandiv were eidar^eil.
The mucous meriibmnt' of the colon wna BwoUen t the folHclea wen» enUig^d Aod tome-
what pfgnientedi but not ulcerated.
Here is another }K>rtiou of the colon (Fig. 1 15, II.) taken from the same
infant (Case 42U).
As you see, the solitary follicles are very roiteb enlarged, and in Peyer's
|>atches, which are in the middle of the specimen, the hyperplasia is of a
very high deforce.
I have alno here some microscopic sections of this form of follicular
inflammation. In this first ft[*eiinien (Fig. 116) you will see the great
enlargcmient of the lymph-tollic]e«.
In thiH next specimen (Fig. 117) you will notice the inflamed comlitlon
of the mucous membrane as well as the enlarged lymph-follicles.
This next s[>eeimen (Fig. 118) was taken from an infant (Case 430) six-
teen montlis old.
The intmti h**tf>re onteHng the hr>9pital hud hud '"c* ji-^inriiil nttn* ka im iliarrhnc^a for
Ihrw mofithp, pr***uniably t^u*rd by improper fr?oding Soon aA^r entering the? bo«piijil it
rapidly |^w wane and died.
Sl» \ PEDIATRICS.
I'll. :iiii- •!»*>. iijjulf l»y Dr. Northrup, gave the following n:f-i.
l.-j. ii- IJr.M.iliial lMnpli-lMllirli."s «*iilar^iil. Small iiite>liii»- sb'^fi _ .
.•.■liii. -ii.'ii «•!' lV'\iT.«. |iatrlu/>. lull no uU'oratioii. The ctAon st-.^-u i.
nil. niii'ii-. In tli«- Miiull iiit4'.«tiiM' and the cvikm were luuud lusi^li«^ *: j *:•
Tliis lU'xt siHrimt'ii (Fig. 119) wast takeu from a I'l'nni./:^.
\'.\\ », I lint* inoiitlis t»lJ.
Til'- iiituTit on ontt'ring tho hospital was somewhat rharhitic, €a:ki.a.-. ..
lis. r«- \\«n' !!•• vomiting and ni» iVvtT. It tiK»k very little nourishiuH.: a . .
\\:i- li:i\iiii: i»in' liiri^i', watery, favul diseharu^e daily. The fafcal in»«v.L:-.
i-li \.li..w. Tin* infant iippurt'iitly improved for about a week. I.-. .
\\;i' lilt 11 i'..un.i In havr rUrri, und durini; the next week it varied fron. • "
.'.♦^- t" l<Hi K ). Durini; tht* next wet*k the temperature waa ioiuflini'- •...
ill.- . i,.l ■•!' ihni' wcrtrk-H the infant l)egan to fail rapidly without any dix . \
an>i «li' •! ^utiilcnly.
Til' :iiit«»i»sy wttH ina«h' by Profwisur Northrup, and showed the tV>lI •ii-.i: .
nnn-.ii- nimibrane of the ileum was swollen, and the lymph-fullieli»5 Tt:- •: '.
i.'l nil 'Tatt <I.
r.'.- p j».-ri ..f thi' fxainination of the colon, made by Profe^or Dt'ii^.!: -.
i-w- .Nuiii- r-u- uJr.T^. sonn' round and rtoTne irrv'i^ular in shap^: an ir.<.^.i-.
■ ■: jtiii.il-: :i jir.'fu-" i:r.»wtli nf ronntvtivo ti.ssue betw€»en the tubulrs. '*i!'. l--'
.'I iii«- iiil»ui'- ; ^^■(■n»^i..< of tlie new tid.sue so as to form ulcere ; the solitirv!- '....
l-ui Mill .M'!ii-.rn«<l in th*' fnrinati'm of ulcers, which are simply mvriic' N •
!• -..I..!. Tli- pr-T.-- i- one >%hiih would 4irdinarily come under the bt-ad ,'!' *:-
. •■i;:i-.
The iirxt -iM'i-imcn ( Fi^r. 120) is one which I am enabkJ t" •'
tlmui^li tlir kindiu'ss uf Froles^sor Holt.
I : . •: ;..! ' ('.- \-\'2) WM- thre.. numth.v ..Id. and wns in tlh- b.-^pital m: -
!»• II ;: It ii:..l M) .i.ut.- -Miipt-'nis, l»ui had never boen well, and ki'...^
' .. ;. ■■! : -t i:i w. i-.:lii mm. I -in-MLTtli. It ontertnl iht- hospital for voniiti::^ •■ ' -'
N ■ .■ A i^ f..ui:.l MM |.}j\..i<'al ••\aininali<)n. AVhile in tht^ hospital it h.ii :"■ -
• :.• :■■. ui-' in>li .li^.huru"- in iIh- Iw.-nty-four hours, and vomil.-j 'Xra.-: :■.:
t....|.. lai.i'-. N:,.i..l iPMii :;:.-J i..:i8..rc. (Vn)o to lOl** F.). it graduslly i^il^i. .
t'A-.' i.i\ - .i?!' r •■iit.'rJMi; tin- hospital.
I !:■ |. -!-:i...:i.ii. .•\:iiniiiation. as you soe (Fisr. 120), shows extensiTO ♦'■.:■. -i' " • "■
•i.T. : lii- .•..;..'■. . -|.. ri:,!l\ ill th,' l..w,.r part of the spi-rinien, wheiv thm. i-. .-.•:
Til. •.--■.:■- i: i:-.] 1 1.- i-ilirli-s are al.-o involved, and thi> pn.»cess has ijone on u :.■.*-■■
riii^ iHAt ^jMvimrn (Fiir. 121) was taken from a male iuiaiiii'i^*
.-i.\ niMiiili- ..|«l. mI.so m pjititMit of Dr. Xortlirup's.
T: . : ■ .M uli. I. if . ht.T-.l th.' hospital was in a very wast.-d nrndiii'-.n. isr-i : -
!• "v^ ■'.'.■:■■ •,•.■:. ;i' i!:\ r-jM ••i.ij alulotninal ijymptonis.
I' :■;■ |.~x. »...:,.!.■ }y Dr. Northrup, showed numerous superfieial aV --• "
I- ■•: ■..: I-..:.. li:i-. an.l a lH.iri„„i„ir l>n>ncho-pnoumonia. The :*-^i.':.' :■
I- ■ •■ ■ •■•' i;.ilMn,.i.-,tiMr, ..f th- solitar\- tollich-s of the ileum and ..f tb- ■- "
•:i.-.:: ■•:.. ■ :r--r.- m th-- api.-f^ of the folliok*s in the colon, no ulcers beinir p^^--:-
ii. iM. Ih t:.. .p...iMMM th.M- uloTs an.\ a.? you see, pigmented, which don-u-s.:-
T!:- Ml.].- ..f ;1..- i'..i]i.l.-> an- son,.-timo.s found pigmented as the result of pK-:. '•-
« l;Mni:' - ;i;.J lii.n -injiJMt.- ili'.-«- uK-rrations,
k
PlRiiiented follicular iili^re of colna. Chnvni^
College of Physiclanfi ani
f,^Uc«larcf*
Cask 4^, Fio. 12^-
DI!^£AB£6 OF THE INTESTINE.
895
next specimeu (Fig. 122) is one of |Meudo-iuembraiiou8 cx>litis.
t child (Com 434), three and a hjilf yean old, a pnticnt of Dr. Northrup's^ entertni
pitJil in a very reduced condition following un attack uf whrH^ping-cough, It woa
lod with diphtheria, and during: the ten days that it wiia suiTeriag from this diseiisi?
IwftA a alight aniouni of diarrhti^u, but no pain and no tene?inuu.
F autopsy Bhowed this piR^udonienibrHnnus inHamniatiun thTY>ugh the whole It^ni^th
colon} most marked in the lower third. The other organs were normal. The
opiQ <»xaminaMon of the colon contlrmed the diagnosis of pieudo^tnembranou» colitis*
"-I havf liiTe u mitToscopic sectioo (Fig. 123) of another caae (Caae 435)
ivweuclo-metiibraDoms colitis.
'This child* a female, four year? old, was a patient of Profetsor Northrup*». It had
lya been delicate. It had pneumonia twice in its fourth year. Eight dayd bt^fure ill
h it wa» attacked with vomiting and diarrhcea. There wa* bl(M>d in lh<? fa*cal di»-
"3gc8. The pulse was nipid. The loas of strength and the pallor wen» marked. The
were sunken, and the tongue was dry. On the la^t day of it^ life it became very
ti and died in convulttions. Early in the diaeaee the discharges wen! fn.^quer}L I^KTi
were from four to &iz daily, and were accompanied by ten^miu and tendernoBS of the
TOe autopsy iihowed that the mesenteric lymph-folliclea were not much enlarged ; the
lolei in the colon were iilightly enlarged. The whole intestine wa£ injeeted in patches,
contained fwcal massess of a yeHowi^h color Th«* litrge inbeetine waji fllled with tai^
mtitiea of IboeftOff foul odor and colonxl by biiiniuth. The whole auHkce wia rough,
, did not ItHik like a niuci»ua membrane, but rather as though a thin layer of gelatin had
n |)*>ured over it. This film could Ue pulled away with the forceps. The 3<jlitary fol-
B wen' i»rilarged.
The microscopic section of this specimen shows a marked fibri nonpurulent exudation,
IV^iig a membrane which characberixoa the diBoase m» pMudo-membranous colltii.
I have also here to show you, through the kindness of Professor North-
5, an interesting speeimen (Fi^j, 124) of an intestinal lesion in eonueetion
ith the pseudo-membranoos condition which you hav^e jiLst seen.
This child (Caae 436), three and a half years old, had whooping-cough. It wa^ then
lucked with diphtheria, and during the eoume of the diseai^e the temperature was miiicd
tinuoufily, at times being as high ns 40° C. (104'^ F:), During thb attack it had diar-
ira With blood in the discharges, but no pain or teneAmui» and no other symptoms of
^iti«.
The autopsy showed a bpnncho-pntiumonia, and a norma) condition of the stomach and
all int<^tine. The colon showed an api^arent exudation, which simulated that of a
»udo-meii)branou8 colitis so cUmcU' that before the microscopic examination was made it
a supposed to be identical with the pathological lesions found in the case of pseudo-
fmhmnous colitis (Case 435) which I have just shown you. The surface appearance in
^ fW«h specimen was identical. Under the niicroscf»pc, however, the lesion proveij lo be
\iy a BUjH^rUcial necni^is of the mucosa, with swelling of the lymph-follicles.
This *f»ecimen *hould imprc** upon you how important it ii not to rely upon the
ciM«*e«»pic Hpp«'Hrfttic«'j» of int*^tinal lesions with*ait microscopic corri»b«>ralion.
Now that you Iiave seen these pathological lesions, you will understand
by it is often impossible to differentiate them clioically from one another,
fiball, therefore, speak of them together.
HW
PEDIATRICS.
i
A- illnstratHUis of tho difficulty and in many injstaiicvs tb •
nt' <li;i^in»sticatiiij; intostiiial lesions I shall re|x>rt to y«ni sun- -
liavi' Im'i'ii nnilrr iny can-.
Our I't' tli«-i- ra-fs wii'- lliiit «>f a little j^irl (Ctist* 437). tivo vf a> ■ " !. ..
h..t WfniliiT in Aiiu'n-i lm«l Imm-h Inivini; u i«li;;ht nttufk **f tVrrijiM.tal ^\:x'r\
\\'i\\\ \.'!iiitiii:;. Ii«:ui:uln', :iii<l a sliijhl rise t»f teiii|MTJitupe l:i-li!.:r a r-w;.
^,..■r^ 1". ■lii'Wf.l l»y luiir nr tivr i;rf«Mii-h-y<'ll«»w di>i'hiiri;e.'* in i)if '.w.:.i;.-!' .- .
iifiniMl I- inp-niiurt'. Thr ilitirrbu'a iliiniiii^lu.'d in two or thn-»- ilaw. :.:.':
iiiutli l"!t'r, l«iM altt-r :i frw clays she wa*' suddoiily attack^nl with a Tr-rnv--:
10" {'. (lo:;^ \>> ln|-' F. ) ami with tn-'im-nt dischurir»*?» of mucu.i ati«l M....1 >l
ifi u-iulit. aij'l l."»k«il vi-ry .-irk. Altor tw«Mity-t«iur hour*, h'-wwr. ••. .
l"..i!i.«- iwriiial ; ami mi tin- tnll«»wint: day, ultliouirli left w«-ak ai.-i jt--:.:-.
].i rl". . il\ w\\. ari«l hail ii«» rftuni of iln' attiiok. Durini; lh«' acut^ -yii.j:.:.. ■
if -h'- vvn- attaikiil hy Mfu« of thi- iiion* sJi'Verc fonn» of colilis. hut i}.< r. | . •
ill. il::iu'ii"-i- v«ry ilMuhtful.
Tijf iiivt «a-«' \va- that ••!* a child (Caso 438). seven y«.-ars <ilii. wh- ••■. •
at ill- City Ilo-piial with a hi>i«iryof havinir httd a s^light diarrha-a f-r ji:-- .
i«iiij»» ratup- wa-. hut ."liLchily niiM'd. Tin* iiuivcineiitH >vere iijfr»N|Uor!t. «.''•. c"-'
.■■;■:■. a! •! •■•■iitai 1 lu' bl«MKl ur incinhniius and scarcely any nmciir. T;i ■:.
\n\'.\\ \\.ll "11 iiiti-riiiL' th" hospital, but diirini; the followintr f»'W d'.r.s ■- ■
haiiM..l. Allhi'iiu'li ni> «ilh»T iiilL'Rtinal tiyniptoin^i appl.'an'd. )i»' fuiiii -j ■.
appaniiliy I'miii «"\hau-ti'»n.
Til'" ant"p'y .-.h'-wi'ii <'\trnsiv«' U'hions nf the wh«>le colon, the mui j* l-
i:nail\ iliii U«iii<l. ami tln-n- wrn* nunK'nms uloemtitins.
Th.- ihini •a-.- wa- that of a Imiv (Case 439), four yoarss old, wh" wh.i ':: .
CliiMr-ri - Ilo-pital I'-r ln-«juiMit viniiitiiif; foUowinjr an attack of diphih'T.'* '.
tii-t ihn- w-tk' that In- wa^ ill tho hospital the voniiiiriir wu-'? the cbi f •}•-;
wa- !• .1 hy iiutritiv.' I'lMiiiala ami improved in hi> irenonil >trt*riffth. Li'.-' .
: . . II . \. .'N iiiu- !i • iiiafiai'«l. tin* voiiiitinj^ inon-aM*d in fr»M^u«Tj»y. a!.-'. . " "
'• ii'l t'l. t" wa- a 'ii-^hl iliarrhu-a. Tin* tiMnpenttun* was intrnial '-r fu*-. -r:..
•a},. .- . -.i:-.- ..!' ih'- 'li—a-.-.
1 >.;:■■_■ th.- la-! f- iir ..p tiv»- day- tb«' sympti>nis ha«l p.'iiii.-..] al;: ■ •' ■
•t ■■ 1 ■ . l:it ih.- p.--t iii'-ri'Tii ••xaiiiinatioii -httwed nothiiiir abn-'msa; ;:■ i. • •*. ■•
in.iri .x,!i.. \ -. ..r -pl.-.ri. Tin* im'-entoric irlands were !-wi»lh'n in th*- r-!:-..
. .. . il \.i:\.-. Til.' \\aiN ..f til.' ih'uni and tH»lon were* tliieki-ii.'d arai r» .i..!'.!: .:
;i -ii. i.t il.p-ii ..| lil.rin ovr part «»f tho niuonus nu'nil.mn.- *»f th-- ii-u::.
i:; if ■ : i" ili" <-«-lon w.-n- found V^ be niiielj thirk.-n.-.I, th" iv-"
•1 ■!^-.:i''iii-l l..r. ami h.-n.'ath it the tissue was di-t-ply ii.ji vfd T:.:
t-. an rxiidation nn thi- mucous niernhnm.-. whi-h .. ':'!
!■ ■ iM. Ix. • i:.- .'n.i.il iiuitr >hnrply, ]iut on somo ..f ihr valv-.i!.^
.Mai,. .11' Mi'po-it couhl he found. In th.- i'.«h':. Th-::!
. :i. inn ami tin- n-ctuni, and lea.-S't so in th«' tmn-vr^..' c"
pr Ill") <']<!. r than in thi' il»'um. Cultures fr<»ni tlie variiai* npjuii"' v-.:
\'.i: ■ ; ■ !ni-!T!- wv>- f 'Uml in thi' ik-uni, but none that -eorntd t'» ?-.- I-.
If •
ii-li
I '■'■
• In.
.i.Ix
1
■i 1
■ n
. tl
KnoL.x.v. — Tlie etiology of these cli.<oasc'$ I have aln-adv •iv
im«!( r ■^riicr.-il ••ti'»I(ioy.
SvMi'DM-.— The symptoms of these forms of arute inflaraniai":;
r.illtl- v.iry oivMtly, a> a riihs hut in a general way they can \^ rcs^'^-
I'v n -jroup of* -yin|)toni«; wliich differ from those of the non-iiiflanir:^'
«li;irilM.-;i> -.|H»k.'ii of ;i< fermental diarrhoea and cholera infantiir..
Imm \s..rk \\lii<'li lias hcen done on the symptomatology of thei^e d>-'-
DISEASES OP THE INTESTINE.
897
p that by Holt^ but we fitill find that the symptoms of these different
I rms of ileO'Oolitis are very unsatisfactory and unreliable for differential
I agnosis,
L The onset of the disease may be preceded by a fermental diarrhcBa, or it
tay be acute from the beginning and have prodi-oraal symptoms of no
mffB than a few hours. The temperature is elevatetl, the pulse is quickenetl,
pa the infant loses rapidly in weight and sti-ength. The discharges are
Krhaps ten or twenty, or even more, in the twenty-fimr hours. Where tlie
Lsions are in the rectum there is tenesmus both before and after the dis-
Liarge, and in the beginning of the attat^k an almost continuous desire to
fSLve a movement. The dkchargcfe contain ftecal matter at first, but soon
pecome small, and consist of mucus, with sometimes pus, bhxxi, and shreds
rf membraue. The odor may be very offeuj^ive, but when the mueug pre-
Lomi nates there isn very little odor. The color and consistency are extremely
rariable, but generally the consistency is lessened and tlie color is a mix*
bure of green, brown, and yellow. The bhxxl is usually from congestion
if the blood-vcHsels and straining, rather than fn>m uhx'nition. Therefore
■re cannot determine from the presence of blood whether uh^ration is pres*
mt or not. At first the alxlometi may be soft and not tender, but later in
Ihe disease it beoonit^ dii^tende«l, tympanitic^ and somewhat tender, espe-
cially along the ct)urse of the coU>n. Vomiting may otvur at times. In
■e\*ere eases the child is very restless, and there may be delirium and <x>n-
inilsion!^. The ap]>etite is usually ranch lessened. The urine is nearly
always lesseutMJ in f|uantity, is Ingh-colored, and sometirai^ contains a
■mall amount of albumin, especially when the temperature is high. Acute
liephritis is, however, rare in these cases. Where there is much tenesmus
and straining, and where the distill arges are esjiecially frequent, prolapse of
the rectum may occ^un The dis*^;harges often cause great irritation around
Ihe anus and on tl»e buttocks.
I Diagnosis. — These forms of ilco-colitis are diagnostinit/^l from the
fermental diarrhceas by the continued heightened tcm|x'niture, the nmre
frefjuent disrliarges, the small anitnmt in each, the presj^ncc of blcKxl or
piembrane, and the tenesmus. They may be diffcrentiatctl from cholera
infantum by the continuous and excessive vomiting and the serous dis-
diargt*s of the latter disease.
Prognosis. — The prtignosis of ik>o-cf>litis, where ulceration has not
jDccurred, is usually favonible, the duration of the disease being a few weeks,
pome cases, however, are more severe, and sometimes prove fatal in a few
pays. Where there is ulceration, the prognosis is rather unfavorable,
fWhere there is a diminution in the frequency of the discharges and feecal
blatter begins to reappear, and where the nervoaa symptoms and exhaustion
lessen, the pn>gnosis is good ; but where the symptoms increase in severity
knd the face knjks pinche^^l, where intra<'table vomiting arises and the ner\'ous
bympioms pn^lominate, the prognosis is very unfavnmble.
The progDosb is less favorable where the ileo-colitis is orimplicated by
8*J.S PEDIATRICS.
bnmrho-piu'umonia or tuberculosis. It is much iniluenceii n. - -
till' yi'iir at wliicli the attack takes place, the pro^fihsU btiQi: v. >
clisi'iis** <>ccurs at a time when the eonvalesoeuee is duriiig n 11:..
IMTiod. The pnipiosis is also worse where the infants haw* t-/i:* ::
<'n)wiliHl cities and in the midst of unsanitary surnjundintr?.
Ahhnn^h thei-e are no symptoms typical of the dili'erMit f.«r:>
ihM>-<i»litis, yet their elinical pictures ditter somewhat.
It is usually iound in the simple catarrhal ileocolitis, wl>re. :
has not taken placv, that the symptoms are milder and that i>: •.
to Im' vnniitinjr. Tlunse eases gt»nerally Ix^gin to improve la .Lt ::
w<i'k>, and ni^iver entirely in another week. An intestinal ifei;::':.*
a mild rharact«T may result, however, and prolong the disca^. Tii- -
ilnn are usually a long time in regaining their strength, and r^lii--;
tiuite enunuon in this fcirm if the diet is not carefullv RKrulatiJ,
Sometimes, however, simple catarrhal ileo-eolitis may l»e rf|.n^r':
symptoms of a verj- severe tyi)e, and it may run a rapid iDiirs-ii. .
ratal ly.
Where fl»llieular ulct»ration has taken place the stomach isin-i;:!:: ■
much iiivolve<l, tla* temperature is not, ajs a rule, highland theivniivc :.:
ili>rase is rather slow, irregular, and prolonged. The infant tlii!? v'i-
and commonly di«*s. X remission in the symptoms and an imprvrL :.
the eliaraeter (jf the ileeal discliarges should lead us to infer thatul>r^
hasinit taken ]»laee. Where the inflammation is simply follicular. 'Jb
uleeratiou, the cadi's are very apt to recover.
IVciKlo-ineiiihraiKMis ileo-c'olitis is rare in infants, but wIkj i: ■'
it is the iiio-t severe of all th(» forms. I have already .^tateil tbi!: -'
t'onii \s!ii«li is u.-ually s|M)ken of as epidemic or sporadic dvrjfuien. '
temperature is hiirh,— ;{9.4°, 40°, or 40.5° C. (103°, 104^ ur I'X J
There are apt to l)0 hhxxl and membranous detritus in the di-^'iii'^
Tile prnnress <,f the diseju^* is usually rapid and without remb?i'3.i:
<leath may take place in a wei'k or ten days. The ner\-ous svmpti-rar-.-
as n-tle-siiess and delirium, are quite prominent. The diagu.:ri^ -l *-■
ela-.- ot'eas<s, as I have just told you, can be made positively only by n^h;
-liretU nf nuiiihraue in the dischargt^.
Tici: MM i:nt. — The treatment of these forms of ileo-colitis shmilJiH-
Ih' ill th.' iMLnmiinii: the same that I have already described for ttrr:-;-
<li:nrh.ea. It may in this sense bo sjwken of as pmphylactic, for in a lir:
MuinlMr oi" ra«.es the opcrau isms which produce ileo-colitLs fiml a mi.^i:-
♦ fitraiiee ihr..unh the irritated mucous membrane i>roduced byapi^n-i'^
tJnn.'iitai (liarrh.ea. Where the case is seen in its earlier sta^.v, :> r: '^
laxative ^liniiid bo ^rivcu, lu ordcr to clear away, as far as p^i!«lr.::
paihoireni<. ornanisms, which an» present in large numbers. Small A*^-^
ra^or nil act iiin.t cllicicntly, and can usually be given, especially to inti:i-v
without eaii-inu: nausea or jrastric irritation.
In addition to this treatment by the mouth, thorough irrigation or^^
DISEASES OP THE INTESTINE.
899
r
B^Ki should be eniplinTd* This should be donv twiw in the t\vent)'-four
^^|p» with warm Httrilizi'd water cijDlaiuing 3.75 grammes (1 drachm) of
Drate of sixlium to the [nut of water. One or t^vo gallons of water should
allowed tit flow in and out of the inU'stine at each irrigation. After the
ligation, 8niiiU eneniata of thin mucilage, abuit 120 e.c. (4 ouueei*)^ cou-
ining 15 e.c* (J ounce) of binrauth in suspension, may be given once in
or f«»ur hours.
Aeeoi*diiig to the degree of pain, restlesaneiab, and general discomfort, a
light amount of opium can be given in these injections, but in all ca^es
ift drug should bt* aAlnuniHtenxl with great care ; one drop of tinotui'e of
pium in the first year, and two dropj^ in the second year, onc-e in five or
IX hours, will ui^ually be sufficient to make the infant tXKnifort4*iljle. The
fleet of tlie opium should be carefully watched, and tlie d<jse luoreased or
ecrea^ed a8 is necessary.
W'here the teua^ani8 is extreme, it is well to use supp^^isit^jrieis containing
m 0.015 to 0.03 gramme (J to J grain) of cocaine. These supp^isi-
ric© will often give great relief if the pain fill lesions are mostly in the
^tum, but where the ksi<ins ai*e higher in the txilon they art? not of much
alue.
The use* of antiseptics by tlie mouth I do nut recommend. Bir^oiuth
be given by the mouth witli some advantage in tht^se cases, but the dose
lUst be considerable to accomplish good results. One-half dmchra in the
fcTnty-four houi'8 ^'hould be given to a child a year old, and for older chil-
ren the dose should lie proportionately increast»d. Ak^>holic stimulants
be given with benefit at all stages of the di^^eai^ if there Is evidence of
weakened heart, or if much exhaustion is present*
A very limited amount of ftmd of any kind should bt^ given during the
it t^\Tnty-iour hours. Sterilized water ci>utaiuing an alcoholic stimulant
barley water had better be given at first, as it has been found that
here a sterile liquid is takeu by the mouth the number of bacteria in the
ntestine diminishes rapidly. When a j»erfectly fresh milk can lie obtained
can be used, if sterilized and mf>dified in its various elements so as to be
"adapted to the digestion of the especial t^ase. A moderate percentage of fat
id sugar, such as 3 aud 5, and a protcid ^>er€entage of about 2, is a very
prescription to bt^gin with. Weak broths can also be given.
In some f^ses of ilco-colitis, after the actitc symptoms have ceased the
hcea continues for many ni«mths and the disease betx)mcs chronic. In
ese cases the tem}x^ratnre may lie normal, and there is no esf)ct*!al pain or
ndernt^ss. The appetite often returns, but the child does not gain in
ight, or it loses. The dist»harges an* not so frequent as during the acute
of the disease} varying from six or eight to two or three in the twenty-
nr hours. The discharges ha%'e a lessened consistency, and contain mucus
and undigi^stcd ftyi^L ThcR^ may at times l»c cxaccrUttic^ns of the syrap-
toms» and the children are very apt to die of some intercurrent dist»a^.
[ The treatment is change of air if poeiBiblc. and otherwise is cf^wntially
900 PEDIATRICS.
dietetic. The rules which I have already given you id sfeii:: .
tit'atmeut of fermcntal cases are applicable also to this cU^ of a^r
The {>athological eoDditions most commoiily found in these ilt'I :-
of ik'o-colitis are great thickening of the muscular tissue, pigm^x.
the mueou.s membrane, and very extensive ulceration.
Amirhic I leo-Oolitut. — ^The next form of ileo-colitis which I-i^v
t)f is the ttiiuMc, It has its own definite anatomical letiioQ:.?.:
usually in the I'olon.
The disease is caused by a well-recognized organism, calkxl ilt
ritfi. It is very rare in northern climates, and is moK*t frdiuom.^ : ■
in tri>|)i<*al cHmntries. A frequent source of infection by the aiLt -
drinking-water.
I have here a sjKvimen (Plate III., Fig. C, facing page 112 ir:
iiit«stine of a iiwi* of ama>bic ileo-oolitis. The laige ruimd !>•-:•<■:
yo\i SCI' lyinj^ in num» or less clear sfiaoes are the amoebse culi. T-r -.v
ism ran also U» detei»tod by directly examining the discharge ai::.
nucr(»S4'o|H'.
Thi' eharaeteristie ])athological lesion of this form of ileinciJi:!- i-
ju'<'uliar, iindcrinineil condition of the edge of the ulcers and of i-.z.
nienil»rani'. The am<vb(e are found not only in the inte^tiDe. ki i.^
\\ir various organs, and with es{)ecial frequency in the liver.
Tlir (lis(us<* is usually acute in its onset, but sometimes it nii"
^nulual. The <Inration may be two or three months.
Then* are no c^iHX?ial symptoms by which to distinguish thi- 1"
iI.M-<«»liti- tVoin the others of whieh I have just siH>ken, and tht :. ••
iiv« |»n'«»r n\' tht' existence of the disease is the pres<.»nee of ihoir-:- •
lln' «li-rli:ii-M,.^.
'lilt tlixa-i' is niiH' in ehildivn, and the prognosis is very unfavi^r: /-
Thr trtatnunt whieli has been followed by the most favoraUo n??-!'-* •
in a<Miti'»ii to fr(M|uent and thorough irrigation of tlie intestine, irtV*
ui" >nliiti«»ii> oi' sulphate of quinine (1 to 5000). This treatment, iif^
Mtl'rtt- Miily the annrbie which are in the intestine, and not those wLk^
<iiiIm«|i1»«1 in the tissues.
'I)il,l,nnh,l / A v>-ro//7/x (Typhoid Fever). — The typhoidal fomi-i'-
ilro-.nliiis is an infectious disease with a definite imthology, and b 'Lv
trii/r,| l»y constant <'han^-s in the lymph-follicles, chiefly at theWer :
«.t' ill.- il.inn, in the niesi*nterie lymph-glands, and in the spleen. Ta- '-
vw^r U \)ViM\\\ri^\ hy the bacillus of Eberth, which is constantly pn-it:- "
th. I. i<.ns. Infection takes place largely through the gastnventtric r-
TIk' ii>ual mode of conveyance into the body for the tvphoid ixjis^/ai^ ■'
lirhd milk or wat<T. Typhoid fever is exceedingly rare in thefiN'
\v\\v< (.f lifr, is uncommon under three years, and after the third visrir
cnrnr- m«»rc common as the child prows older.
1 liavr hrn' a specimen (Fig. 125) of the bacillus of typhoid, ji^ii:
its miii'j)iu)|nMy.
WWEASES OF THE INTEStmE.
901
It is about three times as long as it is broads and is about one- third as
ig as the diameter of a red blood-corpuscle. It is rounded at the en^L^.
The pniuouncod [mttiological lesions^ severe symptoms, and great vio-
boe in ty[x^ whicli are so **baraeteristie of the typhoid fever of later years
so rare in infancy' and early life that I shall confine myself in what I
ive to say concjeroing this disease to the coodltioos which it presents in
latter period,
Fio. 126.
~v ^^^^^
n
Biiclllae of typboid.
severe lesions of
later yean* of life,
PATHOliOOY. — Although the more advanced and
rphoid fever may CKxnir in the early as wo 11 as in the
its eharacterisdc lesions in young sobjects are the milder and less severe
ithologiml changes of the disc^a^^ These ainsist essentially of a hyper-
, of the sf^litary lymph-foll felt's and Fever's patches, and the pn^cess,
of going on to nleeratton, usually terminates in early resolution
jHth fatty dcgeneratinii of the cells. Hemorrliage and perforation ait' there-
pre rare eotuplimtioos in the typhoid fever of early life. There is, how-
trer, nothiug d instinctive of typhoid fever in thh hvfierplasia of the lymph-
bllicles? in children, for it is not unc»<jinunon to find this condition where
atli has oci*urred from other diseast^s of the intestine. It may also be
esent in such diseases as nieaslt^s, diphtheria, and scarlet fever* Very
irkcd hyperjilasia of the lymph-follicles may be produced in children by
ritating substances and by foreign lK»dies, not only food, but also «Irugs,
Inch as turjietli mineral. I have, in fact, seen, at the post-mortem exami-
wtion of a child, marked enlargement of the lymph- follicles caused by
loses of tiiqieth mineral given during life as an emetic. The patholfjgical
^nditions in typhoid fever in the early years of life may be said to wirre-
Dod to those which are met with in the aborted forms of the discus id
er lifr.
Symptoms, — The stage of incubation of the diseaae lasts from one to
weeks. The symptoms are, generally^ not severe. The prodromal
is uaually short, young subjects having less power of resistanoe to the
>o ii'LTular as wiiort* the k'sions are pronounced.
tlioiijjii it H'turiis to the normal by lysis, does not she
wlirri' inarktHl It^sions have occurred and where otl
liavc (>(»in))li(*atiil the disease. The pulse is usual
spondtMni* to tlie heijrht of the teiu{>eratare. The res
cially incn'as«'(l. The ner\'ous sym)>tonis so marke
prominent in «'arly eliildhood. Headache slighter th
o<-<*ur. Delirium, convulsions, and vomiting niaj
syiii|)toms, however, are not common. In some ca
siinuhitin^ somewhat those of meningitis arise, an<
crniinil congestion or to toxic action. Aphasia o<
• jui'iitly in y<»unjjr eliildren than in adults. Its cause
ap|>eai*s usually when the disease is declining. It i
weeks.
The characteristic of typhoid fever in young chilt
is ai)athy. The child takt^ the nourishment whicl
espcfially n^th'ss, and usually lies in a half-somnolc
<li-rase |)ro^r(ss<»s, it gradually returns to a more nati
Although it is probable that in most cases of tvpl
enlarL^enicnt of the spleen, it is often impossible to
palpation, and percussion of the spleen in young chi
Im' very mislead in;:r. lu some cases the rose-colorec
alMlninen. \mi in quite a number I have been unable 1
i> apt to i)e a slight bronchial catarrh. The bowels
tlioiiLrl, sometim(\s diarrhcea is present. The tongu<
dry a- in ohler subjects, and, although coated, it sooi
tip and ('il^i'es. The alxlomen may be somewhat disi
l)ut this symptom is often not marked, and pain and
Kpistaxis is rare in the ty^phoid fever of
nupMiiirnt.
DISEASES OF THE INTESTINE.
903
rly stages of tubercular meningitis*. It is therefore often im[K>seiible» in
\e early days of the disease, to make a positive diagnosis, and iti some
we are left in doubt as to the diagnosis for a week or ten days.
characteristic symptoms of the acute diseases already referrtil to, and
tuberculur meningitis, will later be so api>arent as to leave the diagnosis
longer doubtful Jacobi lays sti^ejss on the probability of typhoid when
Bre is a c*jntiuuous high fever which is well borne by the iniant, and
rhen the intestinal symptoms are not violent. We shoidd also rememlier
lat the differential diagnosis l^etween the t>^hr»idal form of ileoH-olitis and
aria is at times, especially in children under two ye^rs of age^ very
cult, and perhaps impossible, until the blotxl has been examined. Epi-
lemic influenza may in its onset simulate typliriid fever, but the jieriiKl of
loubt is very short. Acute miliary tuljercul(3sis may in its typhoid type
imulate t>"phoidaI ilco-colitis very closely. Where, in the latter disease,
rose-colored spots do not appear, the delirium, distended abdomen,
mlariTcil spleen, and even the irreirular temperature, at times n>mmon to
b*>th di^ascs, may muke tlie ix'scnibluutt.^ so close that the ditfereutial diag-
■losis can not l>e nia<le until the |3ost-mortem examination.
m Prognosis. — The proguf^sis of typhoid fever in early r^hildhood is go<xh
P^be complications, whether ari?*iug from local disturbaue*.' of the intestine
br from cardiac and pulmonary disease, are rare in comparison with those
■kiet with in later life. Yon must rcmcml>cr, however, that the dt^ease
karies very much in iti^ severity in ditferent epidemicg and in different indi-
widuals, aud that a child may have a severe tyjie of typhoid fever and ilie
■from it.
I Treatment. — The treatment of the typical mild form of typhoid ft^ver
Kn young ehildrt^n is to ki'ep the child in IhmI and tv iiH'<l it ivgularty every
mmo or tliree hours with fresh milk, modified acmrding to tlie c5ondition of
■todigeslitui, aud prepai*etl by heating to 75"^ C. (167*^ F.). As a rule, and-
Wpfreik* drugs should not Ijc used. The child should be bathed at least twice
M day with water at a tem[>erature of 32.2° C. (9()° F*), not nect^ksarily for
■the purpose of raliieing the tenn>erature, but as a hygienic mmsiirc. lo
Ituost of the c^ses which I luwe seen this is all tlie treatment that ha^ l^een
■found necessary from the beginning to the end iif the dlsea*^^. Where there
m^re great ix^tlessuess and delirium, with a high t4^m{>t»ratnre, 40..')'^ to 41° C.
■flOo*^ to 106° F.), baths should be given cmce every three or four houre, but
Ithe ttmpcrature of the water i«hould not l>e bt4ovv 2G,6° to 29.4^ C\ (80° to
■5^ F.), as this is usually sufficient to allay the symptoms. If the tern-
roeniture remains high and there are symptoms of serious impc»rt, such na
■Dccur in the advanced stages of the adult type of typhoi^l fever, c^>lder
■irater can be used ; but, as a rule, it is not wise to employ water of a low
■temjM'rature in children to the extent to which it has l)een found uj^eful in
lllduits. Alc*>holic stimulant.^ ^^luuihl 1k^ given when* there are r^ignw i>f
Bxliaitstion.
■ The virions complieatioos which arijst* should be treated symptomatimlly.
tended iind tyrnpanitlci t
l9pt9k'^
Case *40
Tyi
2.5 cm. (1 iDch) below the border of the rib«, and on pereussic
a» the seventh rib in the lixiUiiry line, I have marked tim <
the lower border of the ribs iu bhick. The upper border of i
by a hmkeci line, and the figure 7 mark^ the eeTeoth rib, Thel
You »ee that the pupih react equally to Ught, You will mlfio j
of the child '» fuce, and that he takes very little notice of anj
urine shows the color U* bu nurmal, the reaction neutral « the ni
there is a slight tnu^e &t' albumin* The sediment shows occ^aaic
and 0brinous ea^Cs.
{Subaeijuiiiit history,) On the third day alter enterii
the disease^ the child became veiy etupid, and aotnetii
cough.
On the twplfth dny of the disease the child cried out at
skin was di^ and hot. There were
Cxsr. 441. FiQ. 120
V, S. Amy Mecli<iil MiMeum.
Hip nSEASES OF THE IKTB8TINB. 905 ^^H
^ough the kindDC8s of Dr. Billings I am enabled to show yau this ^^H
tine (Fig, 126), which was taken from an infant with typhoidal ileo- ^H
y CHART 31. ^^H
Days of Disease
5
6
7
3 1 9
iO
11 12
I3{l4
16
16i<7
18 ioliao
21
22
23 24 25
C.
MB
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ME
ME
MB
MB
ME
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ME
ME
ME
MB
MB
ME
ME
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ME
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41,1*
40 6*
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,
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36 3*
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37.2'
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441
1
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PEDIATRICS.
Irritiitkm ivn<l**rw! the di^no«is §o obscure that *
' day* iH'ftiiv ileath. Tbo ptist-tDortem exjuiiinttn
bmiti, chi«'fly on tho ri^hi iidi\ Tbe left hemisphere
which fllU-U the* iiuki mid waa efpecittlly iibund«nl Broimd tL- :^ -, i*^-
wiiii nonuftl. The lungs ahowod nmrkcd hypcj&tjitic coni^edticm. Hi'
The gall'hUilder wm i5mpiy and pali«. Th« ipltNsti wm& etihir^g«d. T;
ttmL The gtotniich was congQatod. The mo»enteric glatids wtero roU^.
imwtim^ contained it quantity of yellowish wntery (ikwb» The '
tbU qiccimen are in the ileu-(>oUc ponton of tli« intavtine. You »«.
«i)d ulcenii&on af Pejer'a patches, and ta « ksas extent of Ibe BoUtAtj fnii^w
In order to impress upon yoii that in infanta swelling arPmi)i
and of tlie f»(>litary follicles is not distinctive of typhoid f<ntr, all
this oomiition frequently occurs from irrltatiand of vairioits khJk,li
you under this microscope (Fig. 127) a ^ectiou taken from thei
« child.
Ealaiyeil Peyer't
I olowly Biuiuiatliig Ui»- lu&iuoji of O-pboicWl il«4><wlUia. Mttu )k^
miemhtane ; l^t, enhitKed foUiclea ; Mua., muade
The macrfjscnpk- appearance* of thia intestine so chxselj fiimiilaicd th» «!.-:» '*Jr •
typhoid fever Hint cuHures were made from it by Dr. Prudden to MMtI# llus tjasi^*- ''
bflctlli were found. This oondition i§ often fuund in children in ACttte nc«j-typ\»^
colititi.
Chronic Ileocolitis. — Under chronic ileo-colitis we in >
appiKlicitis, tliose forcLLs of iki>-ooliti.s which follow iicnte attii--^
colitis, and tutercular disease uf the intestine, I have alresulv sj^ka*
chronic appendicitis and the t-hronic form fcdlowing acute ilwUofitk^^
shall, therefore, devote uuly a few words tc* intestinal tulierculosiic
Tubercular n©o-Colitis. — Tul^ercle of the intestine in inftn^ ^
childhood h quite (:H>mmon, The small iatestine is most fn
volved. The disease may be primary iu tlie intestine, btit itn-
J
CAjiE 442 Fill. 128.
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^H
^^^^^^^^^^^^i^QkL.* .1^ . ^'.^^^^^I
^H
V Tubercuiar ^^^^^
uleew of colon. Fcnuik", h*^ jeur*. o1»l Mitfoum of
the Oillcae of ^^^1
Tttben'ylar ulcer* of snmll iu»e»,tiutv FeuuiJe, i^i ytmn uW. \ti><iiiii
ColI«g« of liiysiciiuii auU ^^ujgeoiu, K«w Votk.
BIBE48ES OP THE INTESTINE.
907
At tbe Boston Children'*? Huepital I have had one case when? the
ETCiilar k^sions were confined to the intetstine and to the meisenterio
In thU tiisw> Professor Councilman considered that the evidence
i in favor of the intestinal tuljercle anti<latiiig the tidxrele of the glands.
the great majority of cases the tubercular ileo-colitis is secondary to
klx^rciilosis eW^where, and in such cases frequently follows tuberculosis
the mesenteric glands.
Pathology. — According to Oler, the ulcers are situated chiefly in the
ieuni, and involve the solitary follicles and Peyer'^ i>atclus. The tulxT-
ular ulcer has the following characteristics. In omtradi^tinction to the
rphoidal ulcer, the long diameter of which coincides with the long axis
f the intestine, the tul)ercu]ar uloer is transverse to the long axiB, rarely
froid, and often irregular in outline. The edges overhang, and the base is
Ifiltrated,
I Tlirough the kindness of Prt)ft*ssor North rup, I have here some sjieci-
■0B of tulx»rcular ultvrs. This first sj>ecimeu (Fig. 128, facing page 906)
^t taken from a female (Case 442) eight and one-half years old.
This cliild, a patii-nt of Dr. Nurthnip'Si was uttHckfd^ two month* before her deiith,
Ith chiUfi, fever, und prostration. The temperHlurt! at fli^t varied fb>m 38-8** t*» 39 4® C.
p2? to 108*» F.), bat as the disease pr.>^n*4!ied th<^ tetiipcmtur*? ^mduully ffll There
■0 npid emaciation. The alidonien wit^ '•unken iit flr^l, hut later beeame ten^e. Thent
iro pahi, tenderness, and re>ii9tHnce in the ri^ht ini^iiial re^on. The ^uhmaxiUary, oervi-
jl, and inguinal lymph -glands were enlarged. The urine contained albumin and hyaline
jftla. There wa« diarrhoea. The autopsy showi*d the lung* t^> he normaK The bronchia]
reirt>peritone.a| lymph-glands were enlarged and chee-sy. The colon «howj> two large ^
ighin^ ulcers, one in the region of the eieeum and the other in the ascending portion.
911 aee that they are tranavense to the axis of the o^jlon, and that their e<li:e.< are over-
Eiging. The entire membrane b thickened, and there ia uorae follicular uleemiion.
I
Thid next specimen (Fig. 129) was also taken fn»m a patient of Dr.
forthnipV
I The child (Case 448), a female, two years and eight months **hL hm\ had diarrhoea
^Hftionully for a year It had alat* had convulsions* It died soon after entering the ho*i-
(tJiL The autttpsy showed these extensive ulcemtionf in the email inteBtine (L) and this
ji|^ ulcer in the €«cum (IL, page 906). There were also tubercular ulcere in the middle
lird of the colon.*
The pfritoneal surface showed mUiary tubercles. The me*enteric and bronchial
rpiph-gland» were markedly enlarged and cheetj.
Symptoms. — The symptoms of tubercular ileo-ooliUd are varied and
lltlier indt^fuiite. The most eommon j^ymptom i.^ a jiersistent diarrhtea.
^hv diarrhtea dfie*? not, however, <x>rre$^i)oud to the extent of the lesiont*, as
^TRC tdeers may exist and eonstijiation he |jresent, egpeeially if they are in
be ilentn. In eases of primary tnl>erdeof the intestine the only sure means
determininjr the tiibennilar eharacter of the diseiL^e h the fintiing of
tie l»aeIlluH tulx'reuIoHis in the di^ihar^es. \\liere the dificase i? secondary
tulx^renlo^is elsewhere, the tubercular involvement of the intestine mav
Tho progTiosis m very unfavorable, and death may occur eitli
severity of the int*^tinal symptoms or, as pointed out by Oder* Ui ^
by perffn-ation or heniorrlui|^e.
ANIMAL PARASITES.— The animal parasit4!s which an M *
the intestines of infants and ehiklrt*n are the same that i^ccur m«J»W^>
jects. The only one^, however, which aro c'timmon juid importwt coff^'
to speak of are tlie oxyuris vermicuiaris (pin-vi'orni), the (wcom fcu^i"''*^
(roundworm), ttie fwma solium, and the isenia nietltocanrllnki,
OxYURis Vermicularis,^ — The oxyuris vermicularis is a minutr »^
which looks like a little pietje of white thread. The female i^ fnicj
L2 cm, (J to h inch) in Ien|;:th. The male is about one-third m^IaiiP^^^
has the tail rolled into a s|)iral.
I have here &c3me of these worms to show you (Fig. 130)* Vi^^
DISEASES OF* THE INTESTIXE.
009
^aat takes place in the large mtestine, and the mature worms depot^it
ks in the rectum. They enter the intestine through the mouth, and
"en are veiy apt to reinfect themselves by carrying the eggs on the
or under the naik to their mouths.
Fro. 180.
heae worms sometinies exist in kirj^e nii miners, ana their development
ra|)id that it is often eJiffinilt to ilislfxl^e them oomjjlrtfly. The nio^t
ion symptom of the nxyuris i.s an iiiteiis*; itching ul»out the anus. The
of the child is dt^turlx^il by this irritation p and various nervous symp-
develop in children who are itifc^ttHl with thrt* parasite. Thus inwn-
:e of urine sometimes results. In girls the (mnisitef by migrating
the anus to the vulva, may causi* a vulvo-vaginitis,
lkGNO(!^fs« — The diagnosis of the presenet* of thtise^ aa of other intes-
Parasites, can be made only by finding tlie worm or its ova. Where
ire suspected, an enema of clear water should Ik* given. If tlje para-
k present, they will be dislodged, and careful inspection will disclose
fhwisnce. Wherever there are symptoms of reflex irritation in the
borbood of the anus or the genital organs, the oxyuris should lie sus-
sought for. The parasites can often be found in the fwcal dis-
yiO PEDIATRICS.
»
chaiyt's, ami in some cases they can be se<.*n by simply stntui:;: ;
linns and examining the mncH)ii:s membrane of the recium.
TiiE.vTMr.NT. — AltlKuijrh most of the worms aiv in tbi' n.<i'i {
also inti>t the npjHT parts «»f the intestine, and then»l'ore <tiuii ■: - ^
l)v eniMnaia. In many ejLstv enemata of salt-and-water aiv ifuni :• i
<lu(t' a rnn*, hnt in ?M)nie (ust^ the salt, even in small aniuiim. i-* .J
tliat it rannnt l)e ns4il. Inliisions of quassia may alsij beomp!---; j
inata. One of the most effin^tive methods of dislodjring tin- i^iy I
jtrivi' I'vcrv evening at U'dtime an injecrtum of 60 c.c. (2 uiina-?: 'i •
Tliis is all«)w»il t<» renuiin in the rectum for five or six minutt-, ij-
iiu'nia «»t' water is then used to wash out the oil, which iLsualK q:
it tlir parasites fn>m the l»)wer cidou and the rectum. Care iuik > .
in n-^ard tn cl«»judinc»ss, s<» as to prevent reinfection.
Wlirn* this treatment is not .sufficient, lozenges of santonin, •.'.■
granmu* (,V tn i jrrain), according to the age, may be given m- :
tiuu'-- daily.
Kvtry two or thrtv days a cathartic, such as castor oil or ihLtj^! •.
Im- «:ivrn. ('an» must 1k» used in giving santonin not to priMlinvn.:
ot' |H»is(>nintr, surh as ^stro-enteric irritation, dizziness, and y<l!.-.ir.-
This oiTurmiee, however, will not be conimon if in each casi y u -r"
wnt«*li tiu- etlW't of tlie drug on the child. You must als«:» l>rt:r ii :
that Mrious symptoms, such as convulsions, have been caused bvi ai
<:iri' in u<inj^ this dru^ in young children.
rinltr this treatment, aided by high rectal injections, the wi.-ri:^ >
iiw-t in-taneis 1h' eradii-at^il. I have, however, met with v^tv iu'j-..*
• a-i - win re months and even years had elapses! bcfon^ trtatii:*::*. ■ :
kiinl \\a< -^iHM-e.^sful. In such cases teni|X)rary relief c::ui !»* 'inji: ■
liiviiiL^ tli«' <l»ild eaeli night, or two or three times a week, a ?aui.l :•-
ot" oil.
As( A IMS LrMnHi(Y)ii)i->. — The ascaris lumbricoides is alouLMyli: -"
yellow i>li-\vliit<' or reddish-yellow worm, pointecl at lx>th extit'inire^. '
m:il«- i- di-tiiiLiui-lied from the female by the fact that it is sraallr :::•'■ -
alway- rolIiHJ ii|>on itself, while the female is straight. The k-iurtn "' "
nialr i> Irom 10.4 to 18 em. (4 to 7 inches), and that of the loma!- -^
lo,.") to *2><.i') <*m. (<) to 11 ineli(»s).
Iliiv aiv some s|M'eimens (Fig. 130, page 909) of lumbri<viJ t-'-*
TIm- lar-er worm is tlie female. The €^3:gs of this worm aw i»viil i:: •' •
o.nTo nun. loiiir and i).i)')X mm. wide. When thev art* first jia*.--*! i^- •'
alino-i traii-parmt, hiit they so<m Ixx^ome yellowish and ojvuiiie. Tl-
rM._.^ ;,iv ii<»t drvrlojMd witliin the intestine, but may pass out with tht---' *
riicy are \rv\ t^naeioiis of life, and may dev^elop under favorabl*' '•• ■'
-iaii<v< after many years. The embryos are develo|>ed outside of ibr *•
and ivaeli the intestine with the drinking-water, where thev develop li.'" *
matniJ- worm.
The haliitat <»f the worm is usually in the small intestine, h ^;
DlSEAfiES OF THE IKTESTINE.
911
irever, pass through the rectum either with the feces or alone, and may
ij^te into the stomachy cesiiphagus, or nose* Instantaneous death has re-
Ited fnjtni tlie entninee of the^* worms into the air- passages. They may
k> at times enter the iHimmon and eys^tie biJe-ducte, and they hav*e even
^netrated fartJier and eiiused abscess of the liver. There is no dan^rer of
eir perforating a normal intestine, bnt where ulceration has been present
trforatioo has ocxinrred.
Symptoms. — ^There are no especial symptoms produced by this worm,
id we can diagnosticate its presence only by seeing it or by fiodiug the
jgs in the feecal discharges. The worm may in mme instsimvs prtxhu^ a
eling of discomfort or even colic in the I'egion of tlie iimbilicus. Neither
these symptoms, however, can be de|iended upon, and an anthelmintic
rc*quired to determine whether the parasite it? present, Ab a rule, the
rt^ionc^* of thest* iiarasites in the intestine, unless in verj' large numbers, is
t tspeeially important
Treatment. — The most efficacious treatment of this fr>nn of parasite
with santonin, which should be given in the same doses and witli the same
,ution as I have already described in speaking of the treatment of the
lyuris.
In addition to santonin, tlie freshly prepare*! fluid extract of spigelia and
BDna, in dones of 1ml f a teasjKMioful for a child two years old, and a tea-
K)onful for older ehilda^n, can be given two or three times a day, eare being
iken not to prtjduee too mnc^h irritation. The oil of rhenojHMliiim, thrt^- or
)iir droj>s on 8Ugar for a child two or three yeai-s old, ami eight or ten
rope for older children, can also be given. A cathartic should be used in
jnnection with these drugs, as well as with santonin.
T*?:xuii: (Tape-worms). — ^Two tbrms of tienite ixxur in elijldren. One
f these is the tosnia solium, the j^irk tape-worm. It has a slight projec-
on at the apex of its head, ar<jimd which are a series of hooks, and l:»elow*
rhich are four sucking-disks. The other form is the tsDuia mediiK^ntUata,
le beef tai^e-worra. It has a blunter head than the taenia solium, and dcn^
(ot have the circle of hooks.
There is nothing espc*cial to be said concerning these worms, and I
Ifer til them merely because at times they occur in early lite. They are
ever met with in nursing children when milk forma the exclusive diet
^ere are no especial symptoms pnxluced by this worm, and tlie diagn(»!«is
I matle entirely by Hnding the segments in the fiecses. There is no esjitvial
inger to life from the presence of the taj>e-worm.
» I have here two s|>eciraens (Fig. 131, L, II., page 5112) of t«nia to
how you.
The worm in tlie bottle was from a child from whom the entire worm
fas expelled, and you can see, by means of a magnify ing-glass, the head.
lie absence of hooks shows it to lie the variety called tienia mediocanel-
lata. I show yon the other worm in ortler ti> impress uf»on you the imiK>r-
■Doe of obtaining the head. You see tliat tlie bead is not present, and
912
PEDIATRIOB.
that it has evidently brDken ofl' near tJtie extremity of the mk. hk]
case the head reoiained in the intestine and the worm ^!*w \^> tL» n
length agaiu. Thest: worms vary in length from G05 to ISli^rajJ
50 feet).
The treatmeot emj^loyed for exjxjUing this worm is the siinta^
B3 in adults, but we should be ver>' careful not to irritate tnoi
fteusitive gastro-enteric murotL^ membrane of the young chili Tk^
should fir^t be treated mth laxatives^ so as to free the
FiQ. 181.
Tif nLa, L. wiihout hcjad ; n., w^ith head.
should be withheld from the early eveninor until as late as possible the «Bi^
day. An anthelmintic sliould then be given, followed in one or t^i> !»•
by a fothartie. This usually i-c^ults in the expulsion of a lai^ «»'*
eegjraents. Great care should be* taken to pre%*eot the head fc»mbf«k«
off before it 18 expelled. The anus should be earefiilly dilated dwiK t^
expulsion of the Morm. Sitting on a vessel of hot water aeemn to bJp»
prevent the head from breaking off.
DISEASES OF THE INTESTINE. 913
There is no anthelmintic which I have found especially successful in
filing the taeuise. One of the most harmless is the alkaloid pelletierine
m pomegranate. One-half teaspoonful of the tannate of pelletierine can
given to a child from three to five years old. As dizziness and headache
sometimes complained of^ it is well to have the child kept in bed and
Dg down until the effect of the anthelmintic has passed off. The oleo-
in of male fern may also be used. The dose is 0.94 to 1.88 gramme
to J drachm). The cathartic which is most useful in these cases is
flom salty 7.5 to 15 grammes (2 to 4 drachms).
It is hardly worth while to mention the other numerous anthelmintics
idi have been recommended, as they are usually inefficient
68
DIVISION xrv.
DISEASES OF THE LIVER. PANCREAS, SPffi
AND PERITONEUM.
LECTURE XLVI.
LTTBR.— In infants and vouno> «i.;ij l , '
larptr than in later life. In « ««S: , " ^ ^'''" ^' P"'P^'^
l£ 1-24) I have .shown b/^^Trthe ro"f S:?"'^ "^^^
and I shall thm>fore now merely r«for w. I . '>^"«<l>ff«ii»,
IcTK.as.-Icten.s is a symptom n^ ''' u'' ^ ^ ''^'^"'^ '
of ,li..u.^ of the liver, but it ^'^^^^Lt """"**' "' <W^, --^
.lir..tIvor inclir...lv affected thatTrS^.'^T '*'**"^'^^"'"^"l
h.pati.- «li^-a<.>. The i.^rus which arisesTt K^k -^i" ^ """^''"'"
i;.r,n,su<h as icterus ueoimtonim or J^**.^!^**' «*'»«'• «f tl^ J^-^?^
hav. -,.k.... ..f in a p.-vious le.*;. J(^ r07r™t°. "^^ ^'f "1"
i..,..n.< :w a s.vn,,.t..ni when <le«Tibine ^^ i" . ?'' "'"" "'''''
,i..„. Y.,u nu.st not a<stnne that theretnlT^ ■ 'T '*^ ^"'"" '■"
i..t.r.. is ,.n...nt...anv slight mech^^,^, 7?T^-'' ''*^'''*'^' '^^^^ '^"•
thnu.J. tl... liver n.ay \^ somewhat enlZS T™'- ^" *''**''^*-^
in.pur.. an.l th. liver is soon restored to i J^' *', "*'* * symptom .f i:> .
tlu original .liseas.- i,as clisa,>,>ea,S^ Z '^ "*»'*™i«»"dWoo, pn.vid.i-.
,1.- u.nl.ili.al vin. In thc^ c-a»«es the li^er ^ *° ^^^' ''^'^^'
(•..nv.il>ions .•.,nun..nlv (K-eur. Vomiting 'J*PV** *°''"^*^'*
,.ain. ana fn-l.Tness are present, "^e L ' ^"^"^"^ "^^-^l ^
linn- an. in-na...!. an.l clLh usually c^™'^™*""^ .^ ^?^- Tl^^^l-
i"-l-una,i.,n ..f the pleura, ,>eri«»rdium, ^ oZTr^^'"''"" '"'"""'
I)im:a>is of the Liver.— Diseases of fK^ i-
■'■'"'> ' :'"'•"■;"';»' •"' T'«°« -"- of J^LTi^ r^=
n..t pn-.nt m earlv life. When henatio ,._P*™ ««*«>*«* >«-
M.....n.larv to .onu- jr^neral disease, and theLft!^^ Tf*' " ^' '''^^'
at l,.n.,li in a .-pa,;,.. leetn.x>. "^^^"^ ** °«^ notbed«vi..K
.....uin.l pathological l^ions which occur in the liver in i.»'
Til.
'Ml
OF THE LIVEB, PAKCREAS, SPLEEN, AND PERITONEUM, 915
bood do not differ from those which are met with iti later life. A
■Bse and decrease in the size of the liv*er are not infre<]iiently met
PlBea^y and careful mea^un^ments have shown that even a very
iburbance of health may cause in youn^ children a variation of
[4 cm. (J to li incliei^) in the ^Ize of the liver.
|b Yellow Atrophy of the Liver. — It i& untY>mmon for the
p decreasefl in size, but this occurs in the rare eases of acute yellow
I limes met with in children. The disease^ is iiisiditiu^ in kf^ onsc*t,
{j^Bcterized by general symptoms of malaise, with icterus and bile-
Hne. In the l)eginning of the disease the liwr is enlarge*!, but in
ilages it is det^idedly diminished. Cerebral symptoms and vomit-
lite prominent, and death invariably occurs,
tet diseases w*hicli are aceompanie*! by hepatic disturbaiice it is
te common to find the liver enlarged than to find it diminished in
b enlargement may (xvur from a mimljcr t»f causes, among which
\bial congesiion, arising in the courBe of cardiac disease. I shall
rehow you, when s|ieaking of diseases r»f the heart, a case (Case
f 1042) illustaiting this form of enlargement,
iorbid conditions of tlie liver which are most commonly met with
nfift ration, anu/loki iafilt ration^ tuberculoMt^^ and inierntitifd hepittttU,
BT form of hepatii' disease may arise under various pathological
i. Thus, it is a fret|uent lesion in syphilis, and may oet^iir in a
f systemic diseases. It may also result from the use of alctidiol,
lues it occurs apjnirently una^^xiated with disease of any other
► pathological lYJiiditions of the liver, such as he|mtic abscess, para-
i as hydatids, and new growths, such as carcinoma, atlenoma, and,
d in a case at the li<>ston lulaiit Hospital, sarc«»ma, are Uu} rare to
fcred in a general clinical lecture on children.
V Infiltration of the Liver. — Fatty liver in early life does
* pathologically from that which is met with at a later |)erioi
\ may or may not be enlargefl, and there are no especial he|mtie
I whicli obanicierize tlii.« <:^tndition, the symptoms iM'ing thrise
lieral disease fnun wliieh the child is suffering. It may be found
I with a nurnl>er of diseases, especially rhachitis and tulxTculosis*
I liver is enlat^'d from thta came its surface is found to be smootli
is painless.
MBf unless the disease is dependent upoD aome incurable dis-
e, is fairly g^wd.
iieatment is esst^ntially dietetic and hygienic.
|lciTix)6is OF the Liver. — Tubereult>sis of the liver occurs in
^ with genend tul)ercular disease of other organs, and does not in
pent any esjKH'ially chanicteristic clinic^al manifestations* The dis-
rimonly found in the fcirm of miliary tul)ercles and dieeey nodulea.
rare instances where large caseous masses csatise obstruction and
916
PKDJATRIC3B.
later disinti^ratioii oi' Uit* tissues, i«itb hepaHt- t^tiliu^eiiieitt hk:^
not usually reei>gni3Et*d durinj]^ life.
Amyloid Livkr. — ^When nmylokl changes are pft^m 11
Other organs, mvh m the ©[ileeii, kidneys, aiid inteliiie, jit 1
Amyloid infiltration may ocjcur in tlie course of tuliemil«,i
rlinuiio tliat^as<Mif the bones, Mith extensive 6tip|>iinitiTm, mAihi
i»as<«. A ver>' iironiiuent symptom in thisi ecMiditi-ni ii? eiuwi
Vhti liver is, as a rule, verv- much enlargixl, and commoDiv nmmi
any of the other hejnitic disturbances. Itis surface is sinoodi, ai I
rarely hepatic tenderuess or pain. Ascites k rare^ and tlimtii
icterus.
The diagnosis is not difBcult if we find that the child laiwit^
di^c^ases which I have just mentioned m being the causes of am vUld
When thew changes occur in the liver the prognosis i* viiy |
there ig no treatment which will be of more than temp>WT ioA
treatment, therefore, is simply symptomatic.
ThU bo J (Cue 444) is seven and three-^juaner yemn old.
CAsit 444.
AmylwUl liver. Pulmoaary tubensiilQtfs.
>i«le,Y9Cf«Hi«ll
There U no hUtorv of tubcreulosis in hie fkroilv w*.ij ^ «.k_«l
ftnd ti quarter yeara old, nnd ineasle* when he was three veare oM Uw „t,M-^|
strong until seven months ago, when he became lUtles. and »«ai, u> ha., f^^lr
spire profusely. Four weeks ago he began to vomit ,»cca*ion«nv ta ranlsb^^i^
andtooouglu You Bee that although he haa evidently b^t in 'wei-*t heTi-^af-^
eiui^iat^d. Bu entire skin « extremely pale and haa a wmy h,ok whiek (snoi^
due U> jaundice. His mucous membranea show much anemia Ili4 lai«VlU
coated and his breath i. offensive. HeU dull and apathetic. The «^r»-*
enlarged and filii^htly tender, hut do not fluctuate Tii*. ^i ^ . t VL»
.1. -11 J * OTL - ^ . A n^ glands art. iii.%|#tfM#1frL*jH^
the axiUie and groms. The percussion of the rij^ht Im,^ eapeciallv tl
there are numerous mles. The area of cardiac dulne«s U not enWrl '
systolic mumiur at the apex. The spleen is aUghUy eaIamc«L Tti j »
IKA8BS OF THE LIVER, PA^CMJAS^ SPLEEN, AND PERITONEUM. 917
below the line of the utnbilicus. The area of hepatic dulnesi ia increafie4| aa i*
bted by this broken line. I have also indicated the lower [lart of the sternum and
Bf borders of the ribi bv blnck line^. There is no bepntic tondemesg, »nd the child
complain of pain. The lower part of the abdamcn is dull on perciuifiion ha high
line which I have drawn under the umbilicus. Thie is due to a flight amount of
The le|^ are «vollen. The urine has a specific ^ravit^' of 1010, and cont>iin« s
< of albumin, an occasional hyaline east, and renal epithelium. The temperature
fmra 37.2* to 89,4*> and 40.5*» C. (99*» to 10a*> and 105^ F,). The increafled
i liver k probablv due to amyloid infillraiiun.
^tient history.) A few days later the child grew rapidly wisaker, and died of
TEitSTiTiAL Hepatitis (Cirrhosis). — The syphilitic form of hepatitifl
^ occurs in infancy I have aln^ady describtd in my lecture on HenxUtarv
>hai9 (page 489)/
Interstitial he|3atitis iur it occurs in childhfM)d tnay be atrophic or hifper-
^hic. The general symptijniatology (lifters but little from that of the
yk In tlie Wgiuning the symptoms ai'e very apt to be confounded with
Bf>f i?implo C4iiijxe.-tian arising fmni digestive distuHmnees, There may
abdominal [min, slightly augmented by pressure. Diarrhcea and con-
iHtion alternate. Tlier*^ are ui^ually ascites^ luid .slight jaundiw, and at
■ dilatation of the siilx'Utaneous alxlorainal veins. Stigmata com |x>sc?d
tioUections of dilati'd minute veins are sometimes observed on the faoe«
le tem|M»rature is irregular. As a rule, it is not much heightened, and in
rt is of\eu subnormal.
The pi\)gno*is and treatment in early childhiKid are the name as in adults,
certain number of ea^^^s heem ti» have folio wtxi scarlet fever and measles.
Alcohol is sometimes an etiolotuieal factor in infancy and tmrly child htxid.
bere the disease is caused l»y alcohol the pathological condition is, as a
by atrophy* Enlargement is not commont and the symptoms are the
pje Bfi in the adult, the aaeites l)eing es]Kvially pniminent.
Where the hepatitis is apparently nr»t de(X'ndent on disease elsewhere,
3 is not due to alcohol, there are no characteristic sympt4>ms l>eyond the
largt^raent of the liver. In this form the ascites is usually small in
nount, and the diagnosis t^n be made i*nly by eliminating tlie other forms
enlargement,
I have hei^ a case of hepatie enlargement which scimis to represent
pically that form of hepatic disease which is commonly spoken of as
pertrophic cirrliosis.
^■Kt little girl (CaAe 446, page 018) i« eighteen months old.
^Here ifi no hiitory of fyphtUs or of tuberculo6ifl« She had pertuwiia when she wai ten
BB old, and the ooU|;h lasted for several month». She haa never taken alcfthul in nny
pa. She wa» well until Ihree month* ago» when «he began to ormj plain of piiin in the
loDitn and to became pale. Two woekii before enterini; the boAprtal ihe bad diarrlMaa,
I h«r abdomen whm noticed to l»e swollen, On entering the hospital aail being placed
ia firopcr diet, the dmrrhflM ocaiedt but the ewelUn^ of the abdomon increased. The
|d« •« you Me, i$ well developed, but pale. The nbdomen is much enlarged. The edge
Ibe liver can be felt netrly a« low at the line of the umbiliou*. I have marked out ibe
918
PEDIATRICS.
ftrv« of duln«il on pMOOidon with blsck lines. The lower one flhowf the Miit0tt||
right »nd Ihi leli lobe, which U distinct And cji&ily pa If table. TUir » DdHfn
neM on pra«»uz«. Th<* spli««^u U Alighll y «'til«ir^ed. I n tbe low^er paft of ybtiklaKip|
It ft modentUi amount of dulncM and fluctuj&tiofi, ahowioi; ihe pv^s9eoe»flC M ^
nrt glanduti&r frwdlin^. Th<^ h<^rt is nonnal, biii k pu^hod up MTnievhil bi q» t^ I
rml distention. I havo indicated the cardiac i»n?ii of dulne«i by a hUci rii«,uik«|
border of the rib* and enftifortn cartilage by a broken Utie,
Cjluk 445.
.y
Hypertrophic clrrhofiteL F-iiul. is m.-^tJ.-. . i
Th<« child has iniproved in iu geneml health ninc^e enterini; th*> b -i ' -
fkir iippetiU. Phy.%icat escauiirmiion shuw:? tb<? pnseuoe of no other JL-^-
an aulops>% however, the diagnoeia must necessarily b^ held in aWyanc*
(Subsequent hi^U>ry.) The child remained in the tifjmital for a few v^mi. W «
proved in \U general health m that it seemed quite hrtc^ht, Thc^ aicitcf 4id mitmt^*^
amount, but thu liver remained enlarged. The child waa taken away f»m ^ ^^ |
and its subsequent hi^ti>ry could not be obtained.
PANCREAS. — Diseases of the pancreas are prs^-tically mhxm »
infanty and ctiitdlKKHl, with the exception of the gt^neml tis^anMiiiir
which may be mit with in syphilis, anrj winch I have alRodydwsW
(imiTi^ 490). New ojmwth.s of a malignant nature have beeo reportrf.
SPLEBN,— The splt^ii may be involved in tulxfrculfisis, andmiT^^
amyloi<l changes in eonne*'tioii with other organs.
It is fm|uently enlarged in the course of a number of diswt** •l'>*'
have des4Til>ed elsewhere.
PEEXTONEUM.— Diseofles of the peritoueum may he of non-initf^
tory or inflammatory origin.
*tB£ASE3 OF THE I.IVER, PANCREAS, SPLEEN, AND PERITONEUM, 919
The jion-inflammatmy diseases are mostly represented by new gniwlhs.
may be of a maliguant nature, such as carcinoma and sarcoma, or
may l>e liixjoiata or nf a cystic character. In this connection it is
^to say that tiim<»rs of tlie omentum are rare, bnt that cysts and hyda-
aay occur lu this region.
lie differential diagnosis of these various forms of jjeritoueal and
atal gnjvvths can scarcely be made during life.
The treatment is ei^seutially surgic^al.
The injlamvwttory diseases of the peritoneum are represented by peri-
itis.
FfiKiTONiTis, — Inflammation of the peritoneum may be acute or
>nic, and is a eonditiou of great importance in iufancy and early life,
gritonitis may CKiciir in the infant and eliild as it dws in the adult. It b
rare in infancy and childln*od a*^ an idiopathic disease that the cases in
ioh it has been stntlied |)ost mortem have occurred almost exclusively
iring uterine life. Many of these, moreover, have presented a history of
philitic infection. The septic form of jieritouitis is not infi-eciuently met
Itli in the early weeks of life, and I have alreatly referred to it when
iking of phlebitis umbilicalLs (f>age 425).
I bave here an mfant (Cft»e 446) who wa« hroughl to the hospital jesterdajr to be
I of extreme dieteDtion of the abdomen.
Cabk 446.
rn»t«li)c Intrn-uti^ri^e pehtonUlfL Iiifiutt, h wv<cki old,
The infiitit weighed at birth 4600 gmmmes (10 pmindi)» fot'ined ttronjar, <^od nurw^d far
\fm wcfeks* There Is no history uf *yphilb or of tutHcreulotit. AfUT birth it beg^n to be
leric. It passed nit'Hxmiunii but the faecal rnovi*oieriU since then have always b^^^en white.
few days after birth the abdomen begnn t-j fweU. and it hn* *ince continued to ineppajie in
'jtf, Tbo nkin is very t^riAe, and the voinM i-nnnecte^i with th*> p>rtal circulation stand out
marked n*lief uU over the abdomen. The infant vomited once fi^Kit day? ago, and again
tnnrfiinjf. It h>ii* l>econie much i^maciated. Thoh^ U distinct flucluatiMn in every part
the nhdnmen, and dulne«« on pf*rcujs%ion. An examination sbowt the heart and hin^
be ntirimi).
(Subsequent hi!it*>r}\) Lnparolomy wa* perfonned by Dr L<ivett on the following
f. On opening the abdomen a stream of pale fluid wb« thftiwn into the air with coiiiddeN
•urlait' <»t' the liver.
Tip' I'liiM rulli<*d well fnjin the (»penition> and thirty-^
y«-ll"»w liile :t|i|M'Hn'd in nne uf the white movements. After
larlv und th«> iiKiVi'inenu became normal. The child's gen
i!ii|ir«'Vi'il.
At th«' v'IhI ot* ten days it was taken home, but it soon
\vi'«>k> (lied nf niulnutrition. No autopsy wu« allowed.
Acute Peritonitis. — Infants and children of
l)y lunito iKTitonitis. It may occur in cases of tub
(liHaxs, of syphilis, ami, most frequently of all, of j
ill any ot'thc alH)ve forms is exceedingly rare bet\v<
aiul two years. Where some definite cause, su
rinini<*rat(Ml, cannot be fonnd, the diagnosis is at tii
4»f proiuiiicnct' of some of the symptomL.s, such as t
PA'riioLCKJY. — The iiathological manifestation
nddcninjr Jin<l 1<>^*^ of the normal glistening api^et
<oon folIowiKl hy an exndation varying from a s
juinilcnt character. This exudation glues the cc
fnrniinjx adhesions, which, however, can be readily
of a kniic.
Sv>[i»T().Ms. — The symptoms of acute peritonii
|)nMcs< is «r(.ii(.ral or localizwl. The localized form
ill its syniptoiiis to what I have already described i
ti*^, \vhi<li is its most fiiM|uont cause. In general
ill intimts, as I have already stated, are often ol
>ynij)tuins arc usually pronounced and characterLsti
with alMlmiiinal ])aiii and with general abdominal t4
iMvnin.- (li-teii<le(l and tympanitic, and tlie child as:
will mn-t relax the alKlominal walls, — that is, wit
I DISEABEB OF THE LIVEU, PANCREAS, BPLEEN% AND PEBITONEUM, 921
k||c. When improvement does not take plac^, the pulse becomes weaker
^H quicker, the breathing more super^eial and rapid, there h chilling of
phc extremities, and tl»e child die* uiiimlly within a week.
r Prognosis, — The pri>gnof^Ls in the^se forms of acute general peritonitis
Lis alwaytj serious. Constant vtmiiting makes it especially grave.
i Treatment.^ — In treating eases of acute general peritonitis when set^n
liii the early stages, a saline, such as sulphate of magnesium, can be given in
Moees of L87 c,c. to 3.75 c*e* (i to 1 driiehm), aec<»itling to the age of the
[child. When, however, the disease Ls more advanced and there is great
[pain, opium will have U* be resorted to. Whei-e the jMritonitis is of a
I high grade, where repeated dos^ of opium are demaudetl to i-elieve the
[pain, and where from the severity of the sympti^ms it is probable tfiat a
I fluid beginning to Ix^ purulent is present, the cn^^ should at onc(* Ix? pla<^
I in the lmn<ls of a surge<jn, as the question oi' laparotomy will then have to
I be decidKl.
I I find in my notes the record of a case of general peritonitis :
L All itifant (CiSL&e 447) i nineteen nioDtbs old, praviouilj Apparently healthy, wm •ttncked
I with vattiiting and diarrhoea. On lh« following day the fac« wa^ pale, the ala* nasi weru
working slightly, the respirations wen? 36, and the tempjeratur© wa* 30.4* C. (108"* F,).
f The respirations gradually increa*ed to 74, and the teinp<*ratiire nt^a to 40.3^ C. (104 6® F.).
I The[ abdomen became ver^^ much distended and tender, and the fuce pinchtid and anxious,
i On the evening of the second day trum the onset of the difiease the temfierature ro6e to
I 41*1" C. (106** F.), the infant became very restless, the pupiU were contracted, and dtitth
took place a few hours later.
' The autopsy was made by Dr* W. F. Whitney.
The heart and lungs wero DortuaL
The spleen was enlarged, and was covered with a dbrinous exudation.
The kidneyt were pale, and normal in sis^.
The liver was covered with flakci of recent lymph, and on section showed the at'ini to
' be red and their periphery yellowish and opaque. The meftenteric lyniph-gland^ were
ilighily enlarged, and the smaller onei were tr&Daluoont on section and presented evidence
I of hypcrf>Uu^ia. A »mall pocket of the larger glands was found to have become cheesy in
the oentrul portions, and in two of these the process bad extended through the sobstuice
of the gland and had bn»ken through it* peritoneal oovenng. About thcie points of nipcura
there was a eniall zone of reactive inflammation.
Fatho LOGICAL DiAGNOaifi. — Acute general peritonitis, which, fr^m an absence of any
i other souroe, must he considered to have been caused hy the rupture of the cheeky, de-
I generated mesenteric glands.
' In this case the high temperature and the distended abdomen rendered the diagnosit
I comparatively clear. The case i^ impc»rtant on account of the cause, for there i» «*'ldom any
noticeable enlargement of the metenteric glands under the age of three year»| and these
I |{l|uids seldom soften, but either retn?grade or hardea from calcification.
Chronic Peritonitis. — When acute [RTitoniti.'* 18 I^x^lized in one j>or-
I tiori of the intc^stine it may Ix^ome ehn»nic and form fihnm^ adhe^ionA, but
I in the majority of eases eJironie ixfritonitl**, ej*p>ciaUy when general, U of
I tubercular origiii.
' TSibercuiar Periiomils. — The original source of the tubercular pmeese
is often olj^ciire. It n>ay 1m* primary in tlu* j»eritoneum, but is more likely
to be seeondary to tubercular mesenteric glands.
(liarrlura an' (Nuninon, and an* apt to be paroxysmj
at tiiiM's raised, osjKH'ially in the lattor jMirt of the ds
symptom^ havr last^nl li)r a nnnibor of weeks, the a
<list4'nd«d. A physiral oxaniinatiou may show that
nial in tlu> thorax, and that th(* morbid couditiou is
alKlt)nu'n. At first the abdomen is resouaiit on |x»i
Ih' dull, owinLT to inassis of tul)ercle or ti) the prer?<
>eldi>iii any tenderness notiee<l cm exaniiumg the alxl
Diagnosis. — In a typical ease, where the symp
inentioiieil are presi-nt, the diagnosis is not diflieul
ever, there aif no definite si^ns by which a dia^i
only tantrihie sij^n U'injr a st»tMuing abdominal tun
vvhirh !«• «)tlier alnloniinal tnnioi^s is so close? tha
made only by lapan>toniy. Yon must neverthelej
douiitrul eaM'> of alKloniinal tnmors in children are
ruocjNosis. — When untivatinl, the prognosis of
vrry vai'iniile. In some eases the disease after a u
l!i:hI«'«., :nid the patient n'eovers. In most instant
lMruMH'«. morr and mon- \vaste<l, the fever Ix^ciinK-s
<li:nili«i':i i'Dniinn*-, the emaciation IxHX^mes extrer
ii>n:ill\ it\' r\lian>ti«»n. 'I'he snrj^ical tn»atnient of tl
pr«»L:no-i- nni«h nmre iiivorahle.
Cask 448.
I.
? /> .
Tiitu.riMiliir TM>rititTi{tia XTaI^
OF THE X^IVEB, PANCREAS, SPLEEN, AND PEBITONEITM. 923
{colored boj (Cas« 44$, I., page 922} is nine ye&ra old.
kther died of phthbis. He has never been strongs but htui bad no acute iUnesaea.
ek£ ago he began to have diarrhoeaf And e»«.>on alter enUrgement of the abdomen.
I no pain T vomitings nor cough. He has lo^t greatly in weight. You see that be
He has a temperature of 38,3° C, (101 <* F.). UU abdomen U much di*-
,, and then; is a distinct wave of fluctuation. Physical examination Ahowi nothing
Cass 448
IL
K Tabercular perllonitii. fbur moottia ailer operation.
^k|MBl|l^l^>'y ) Laparotomy was performed by Dr. Bradford, and the fluid
^^^i^mrclf^bfteilti wer^ found in the peritonettl ti^uiue. When seen six months
b« wound had healed perfectly, and he waa strong and well. This picture (II.) waa
• months after the operation.
Tubercular f«ritonltta. Male, 2 years old.
I next caae (Caw 449^ I.), a boy» two yew« old, ii eapecially interetting in tfftld U>
934
FKIilATIUCS^
Uo bfti not IuhI gtnMml mympiGUMB af •«rtoa» Impurl, tet lu» bit tJi^i » t- {
•|ypetlt«i atid itrefigth. From time tc» tim<i dunng the Uun itx r ' \
iif abdnmiiukl pain unci U!tidt*niee«. An t^ntniSiiaiiun of tlu* «t
•UgfaU^ lirrigulftT in*«« exU'mlirig ' n>roi» the ahdoTnen frticu ul^ i^w ^
i> em. (2 iocboi) ^Wvi' iintl tbe s 4nci« below the* luiibilkiu^ It ii ai^«f I
tmiltii oii prMHin Nothing dse «bot»n»ttl u di^tectcd nl»tHit Uie cbUiL Aii**!!
the lioA of potomiioti df>es not chani^ti wlufii ht' i» tvintr >ti liu Wk. ui^ tksf-v^ |
denoo of ttteilM.
^
Tubercujju- perltoaltte.
(Subsequent hwtory.) LnpuroWjruy wa* perforoied by Dr. Li^>vi it, a; i i .:i
Qodulei matdng together the* intci^tini^ was faund. An cxntnination of t c n
man* showed the pre»trncc of the baciltuj tuliorculosia. Ki» flui
recsovered, but sutiici<<nt liint' hua not elapAcd stnc^ the opeiu:.
whether Uic" difieuAo will rettim.
TubercaUr peritoultia. Male, i yean old.
ThU bo J (Om 410), four yean old, was brought to the bospltaJ iooie
the extreme diiteiitloa of the abdomen which jou se« r«»r^o«iled ie thk
Tuberrutar pnltciciit]* (after
PISEASBB OF THE LtVER, PANCKEAS, SPLEEN, AND PERITOXEUM* 925
I A physicttl ««xaiiiinulioT) ftbowtnl nothing Abnormal except in the Abdomen^ which was
|l on pcrcu^^^ion and showed fluctuAtion in ^v&ry pnrt. The child hfid graduiillj lost in
bebl^ Appiiu?, And «tr(*n^ih.
^^hMiroiamy wiis performed by Dr. Lovett^ And a Urge Amount of ascitic Huid ovic-
WF TubePcle-bucilU were pre*ont in thv diieiiAed penUmeurn. The wounil hcAled, but
the course of a few wec*k/i the fluid reiiccumulated* And Upurotomy was Again performed
Dr. Lovett. Tou nee his condition now (Ca&e 450, ir^ page 92i), some we«kii t^ifr the
imd opemtiori. No fluid can be det^tcU'd.
(Subsequent hifltory.) Tben; was no recurrence* of the iiHcites, and the child reooTered
ly-
I boj (Case 461) fa eleven jr«M* old
Cask 451.
dar perlloaiUa. Male* 11 yvan ahh Wuxu yernii AA«sr opemtton, ahowlng tear under umbilletia
He is, as you seei we]1 and Ptrnt})^, and f howf no aymptrjtns of tubercular disease. You
|l notice the scar undiT the umbilicus, which mark^ the line of inciiioii made when the
puotonty waa perlbnned.
Cask 451.
Tubermlar porttoiUtti.
entered the bi»spitiil four yt^An Am*^ and hert> ht a pictim' (II.) of him which was
; that timv.
926 PEDIATRICS.
He had l>een perfectly well until four months before cominsr to the '^>x^ r
bewail to l(«e in weight and appetite and to show an increase in the $12^-.: :-...
Although he wa« not especially emaciated, he had lost in fleeh and wis p^- Ti 7.
fen'iice of th<> abdomen was 76.4 cm. (80 inches). On physical ezamiur/i.:.::
normal wtis detected in any of the other orgmna.
Laparotomy was perfonned by Dr. Bradford, and a large amiHintcf -^r...
dark yellow color was n^moved. The peritoneum was found to be thickly r::..-
miiuiti* tulH>rcles, and tubercle-bacilli were demonstrated. The peritontjl o»'
^Htcil and drained.
For some months before the boy was attacked with tubercular pehtoniai 1- l
drinking the milk of a tuberculous cow.
\
DIVISION XV.
DISEASES OF THE KIDNEYS, BLADDER, AND
GENITAL ORGANS.
LECTURE XLVII.
DNBYS. — Dieeai^es of the kidneys may be congenital or arf|uired.
Congenital, Diseases. — The congenital abnornialities, such as ct3ii*
^nital cystic kidney » absence of one kidney, byjKTtmphy of the rc^mainlng
idney where one 18 al^sent, anomalous fehajx^ of the kidney, and nmljxjsi-
»ns of the urc*ters, are important, but are so eloeely connected with purely
ur^ical questions tliat they neal raerc^ly be referred to in a medical lecture,
riie lobuIatt*d kidney, which I have already detHTibtnl (page 44, Fig. 9) as
normal i^mdition in intra-uterine life, may to a greater or less degree
ntinne into infancy and fhildh<K»tl, but ha8 no pathohigical significance,
ilovable kidneys are rare in early life, but have been reported.
Acquired Disel\se>i, — Renal disease as a primary affection in infancy
id cliildln>od has been consideiY'd rarf\ but this view has been nK>difit*d by
ater Imt'ticnologieal investi^tions^ wliich have shown that nephritis is not
li2C<;>mnion in teases of genend infection. 8e<'tindarv renal lesions are com-
vely common.
Renal diseases, with the exception of the nephritis following scarlet fever,
lave not l^een satisfactorily stndie<I in children. A series of systematic ex-
inationsof the urine, in connection with later ^>ost-mortera examinations of
he kidneys in the same eas«^, sufficiently extendc^l to give us data for a pre-
JIM* diagnosis in an es|>eeial cas\ has not yet been made. Owing to the varia-
in the symptoms, the diagnosis of renal dist^aj^ie in the child must for the
>rc«cnt do|)end upm the systematic and routine examination of the urine.
The disi'asi^s of the kidney in infanr^y and ehildlKMid are nr»t sc» varied
in adults. They are chiefly repn-sentc*! by active hyj>enemia (acute
*arcnc*hymatous degeneration) and the nephritis following sitirlet fever,
hich I liave alreiwiy fully dt^seribe<i in my Icf^ture on scarlet fever.
Phvsioukhcal Albitminitria. — Befon:' sjx'aking of the diseases of
lie kidney I shall descTJbe a condition which is usually culletl physiological
Ltbumiouria.
927
Mfiii to In* in ^<nnI hoaith, but suiuotimes tlit'V i
«lia;:in»sis ran 1h' nia«lo i»nly bv rt»|x?attil exuiuiuati<
ilitlrniit linu^s in tho ilay, anil by ul>aorving the t
u|H»n it. Tlu* prt»s<Muv of bK>ud-corj)iis«cle:$ or al
anmiint from tlu» kidney slums that thoix* is^ a |)a1
fHia>i«>nal liyalinc cast and albumiu as high as one
intervals may U» pn^sent. The albuiiiiii often d
nuirns ai:ain. Cliildivn between the ag(>8 of thru
nearly donlilr tli(» ijnantity of urine and of un»a for
wriiilit that ailnlts do. The amount of un*a exc:
tin- ai:<s of thnt' and seven years i:* 0.973 granini
tlirir Wii^ht. This fai-t is to be borne in mind ii
ot" una |)a<'^'<l in i-jises of nephriti-s, beciiii.se othe
ai»|M'ar to U' excri'tinjr a normal amount of urea
al)n««nnally <mall f«»r the age.
riu- |)n»^nosi> in tlicsi* i*ases of physiological n
M» tar a- I know, no rose's have been reix>rteil in
minatcd in nephritis.
I ln' tnatnu'nt of this condition is to reguUit
♦:• 11. ral hy;L:i*rir ran-fnlly. If the children are am
(il.M.UAl. l*ArHOL<K;Y AND EtIOIXKJY. AcC"
wiioiii I am inilrI>t4Hl for much iuforiuation on t
ili- a-- "t thi- kidnry in childhood show consider
r. '\:\\ .Ii- a-r- oi'thr aduU. In childhood there is i\
;j. .1!- a:V. rt:..ri-. -iirh as s«-arlct fever, measles, and
■ t N\ :. ii II. |»liriii«i i< apt to appi*ar. Cliildivn
\..::^ ;;!■ ! nl.j.tt to many ]uithoIogical conditi(
:• ■:!. wlii.li in tlic adult friHjuently li»ail
DISEASES OF THE KIDNEYS^ ULABDER, AND GENITAL. OfiOANB. 929
'(bt patliLilogiail coDditkiuS| au action from which the child^B age protci^ts
One pathologkul lesiou not perfectly recovered from, moreover, makes
kjihity more prune to disease, and a greater effect will be produced a
[id time by tlie t^ame ranse, and chronic disease will result. In the
\y of the adult, with tlie advance of years there is a gradual decline in
jMiwer of regent-nit ion, and slight tn>ubles are not readily re<*<ivcred from.
le kidney of the child, on the either hand, is au organ which possesses
power of growth and rc^generation. For this reason a ainditiou
nch in the adult t>rgan is either not rccuveixxl from at all, or lays the
lation fur chrtjuic disease, will in childhood result in complete recovery.
, the child is not exposed to certain conditions which are pi^xlnctive
chronic lesions, or which may lav the foundation for them. Among these
ay be mentinncd ali'ohnlbni and execsscs of various sorts. Many cases
nephritis in the adult arc to be referred t^j causes acting not through
blood, bnt through the urinary tract The child, on the other hand, is
►t exposed to the dangers arising from hydronephrosis and pyelonephritis,
ecpt to a very limittxl degree, Altliough the causes of disease are less
timerous and less common in children than in aduttd| yet when the same
iological factor is pR^ent the sauie morbid cnuditiun Ls prmlnced in the
idney. The various cachectic conditions will lead to amyhiid iniiltration
tlic child as they do in the adult, and amyloid infiltration of the kidney
mki'S np by far the larger pai*t of the chronic cases of albuminuria in
ildren. We may also meet with certain chronic lesions in the child's
idney, such as are seen in tuberculosis, and thetk; may lead to albuminnria
ud nephritis.
The acute diseases of the kidney, as a ride, either tend it\ rt»covery or are
I themselves fatal ; &d that only a small numlx^r of chronic diseases are
let with which result from the acute diseases. These are not to be referred
I the eontinuous ai-tion of the {xuson of the acute di.sease, but to the ett'ect
m the kiflney of the lesions produced by the acute pnx-css. An example
if this is the condition of chronic nephritis after scarlet fever, where the
ute lesions gradually jmss into the climnic. Tht^se chronic lesion? are to
! attribntetl to the disorders in the circulation ol* tJie organ brought about
)y the destruction of the glomeruli.
General Symptomatology. — The general symptoms connected with
Jie various forms of nt^phritis are so similar that it will be leas confusing
%) mention first the c<^)mmon symptoms which may occur in any of the
rms of nephritis, and then to describe tlie etiology, pathology, and urinary
pcaminution of the ditfcreut forms.
One of the most common symptoms in nephritis is cederaa, which occurs
m|uently in acute nephritis and in chronic pareu<4iyniatous nephritis. The
' generally apiiears first in the eyelids, and then in the hands and feet,
lay be general anasftrca. Not infrequently, however, (edema is aljscnt
not marked. Vomiting is not infre«|ueiit in the l^inning of tlic disease,
td in dome cnaes is, perhaps, due to the heightened temperature. It may
69
I
WM PEDIATRICS. -I
oitur lairr in tlic <lisciisi» as a s^yniptoni of uneinic jK.»wnii:iir. I - t
tin IV is iHarki'<l iliininutioii in the amount of the nriui\nr vvj-
A iHH'uliar dull white ei»l<»r of the skin isi not iiuei.»miin>Dly ^o
paninliyiiuitniis nephritis, ami is qnitc strikinji:. In acute dm :.r"- •.
f»t'trn i»iv>ent to a greater or k»ss extent, but i.s a variable rym;.v .\
<if apjM'iite, and weakness, art* common in iKith acute anJchn :i : j
Ileaihu'he is a variahk* symi)tom- It is a eommoii :iym[Hi.!L ■ . >
and sonu'tinies the only one. AniaurosLs may <.Hx.Hir as tin* r-i.. ?•
nuiinrie ntinitis, or it may Ix? a iunetional symptom uf the ur.iL: i
iniT an«l disjipin^ar hiter if the patient recovers. Hyj)ertn»|'hv ■ : . i
vcntrif'lc isa])t to(Hvurin interstitial and chronic pari»uchymari.-L-: l
r>«»th dist'ast's aiv, however, very unc<>mmon in chiklhtXKl. katj:. \
\\< fnllowinjx searlet fever dilatation and nuKlerate hyj)ertn»phy :v.
vrntrii'lcaiv not nneommon. Transudation into the sert»u^ (avD- :-• -
n-portiil in a unmlKT of rases, as has also oedema of the lannx.
lU'lore I mention the details of the urinary analyses in tlirvir:'.-
ia-(»i, you should understand that in all eraser of nephriti- thr id .
una should lHM'an»fully c^timate<l from time to time, as a Jeiv^^
una always shows a ]xitho]ogical ctmdition, and a return tn d- 1 '
amount i-^ usually indicative of recovery unless there is a rt^mpH -r i
>omc' otluT dis4*jLse. Any interference with metabdLsni. whttW
livrr «ir in the lung, may diminish the amount of urea iu the ~r^
<hiMnn durini^ convalestvnc* fnmi acute nephritis the un^a rvt :r.:- '
c'X(('«'<l> the normal amount, while in chn>nic nephritis it is idwavs ilin.;
:i- it i-^ in adults. A suddon and cxtx?ssive diminution of tlh'ur.:'
n(|»hiiti- is su»rir<'stive of uneniia. In acute and elm»uic n'|'-i:.-> \
r\]\nv'u\r^ iwr diiuini<h('<l when an effusion such as iiseitt^^ is ii:"njN . j.
Ln-Mdnaily return to the normal amount as the effusion is al>s«'»rUJ.
Active HypersBmia (Catarrhal Nephritis. Acute PareD^i;::-
l>c'L^( iirratitui). — IvnoLoGV. — An active hyix»nemia of the kidiKyru;. /
ill the roursc of various acute infectious diseases. It mavak>l^">'
i»y Mil rxcc^s of uric aci<l, and by such irritating drugs as tuq^nt'^
th:iritlr-. :ind arsenic. When the action uf these causes k ver\'in&r:-.
a<iitr iH'piiritis may result.
lV\riioL()C;v.— The patholo^(«l conditions resulting fnnii atnivr ::r«^ •
iiniia '*\' x\w ki<lncy are a gradual degeneration and des<piaiiiati' n ■ ' "
ivn:il tpitlicliinn, and an injwtion of the blo<.Hl-vessels. Theiv i- ---
>niiir. r\triii :iii infiltration of niund cells. The i)nx\»S5 ?eem?t'
cliiclly the epithelium of the tuhiik»s.
SvMPioM^.— rnless the hyixTO^mia is very pronounciHl, thm-:ir^^'-
nilr, no -vneral symptoms, though oniema and other symptom"? may ^-'■■"
he |)re<ent, a- in aeute ])arcnchymatous nephritis.
DiACNoMs.— The diagnosis is made by the examination oltlit -'-
Tlir urine is elmr, and its color is often normal. The amount is diKbi---'^
The speeiile -ravity is higher than normal. There is a slight scdimea:.^'^-
nS£ASE3 OF THE KIDNEYS, BLADDER^ AXD GENITAL OROAN8. 931
loe of albumin, pcrha])S one-eighth per cent., or at times a little more,
'roscNjpie exaraiuatioii shows the presence of renal epithelium and blood-
muscles ; tlie latter, however, not in t^nftifiont number tn eulor the urine,
re are alH> It^utiorytei*, and hyaline and tine granular easti*, with an occa-
\nl epitlielial east and bl«ic»d cast; the last three varieties, howevei", are
ry numennLs.
^OGNOBis* — The prognosis in at'tive liypenemia of the kidney is good,
H the patliological condition usually disiippears when its cause has been
lOved.
Treatment.— The child sh*mid be phiced on a diet exclusively of milk,
fas to avt»id any further irritation of tlie kidneys, and should be made
drink a great deal of water. It should be kept quiet, and ita general
giene should be carefully regulated.
I have herr? a case (Case 452) which is probably one of active hypeneoiia. ThU boy,
id Ave yearSf had vanc'eUn when he was six months old, and meaftlea when be wa« one
^ old. He had no other diseases until three weeks ago^ when, without any ap^mrent
&««, bu h Biiid to have bad a convulsion and to have vomited. He has never hud any
ema, and a general physical examinMtiou ihows nothing abnormaL An exRmtnation of
t urine *bi»WB it to l>e high-colar«?d and cloudy, to have a specific pfravity of 101 ft, u krge
oe of ttlbumin, and a yellowifih-brown sediment consisting of amorphous uratea. A
leruAcopie examination show6 the preaence of uric acid crystak, hyaline^ granular^ and
ithelial ca^ts^ and a few leucocytes. The total amount of urine passed in the twenty-four
van h from d^iO to 450 c.c. (from 12 to 15 ounces). Heating the urine causes the high
Sor« cloudin<^s, and brown sediment to disappear.
(Subset]uent hij^tory.) Three weekfi later there wan only a iUght trace of albumin in
urine, wbich was of a normal color, had a ppeciflc gravity of 1020, and contained a few
fAline and irninular casts. A ftfw wetika iiftt?rwards the urine wai found to be normal.
b other nhnomml d3'mptoms «_K:vurrvd duriri|^ the whole cour*»? of the diseaae.
Passive HypersBinia. — In addition tti the active hyper«emia which I
►ve just described, a ckrmiie ftasinve hyperattnia may occur, dependent upon
ftninishcKl arterial or iuerea^tl venoit^ pressure. This eoiidition iMxnirs in
ronie airtlia*' disea*^ witii di^turhauft^ of n>m|>en8ation, in i-hn>nie pulmo-
disease, and where there is mivhauit-Jil hinderance to tlie venoui* eircula-
I, m from the presenct* of alxlominal tumors.
Symptoms, — The symptoms whieh <xtnir in the emirseof paiwive hyper-
!a are not referable to the kidney, but de|)eml upjn the disea^' which
luses the hypenemia. The urine in this ci>ndition is high-eolored and oftea
Onsideralrly diniiuished in ainonnt. It ha^ a high sjiecifie gravity, and
iften a hwivy stxliment of amiirplious urates. There is a slight trace of
IhiLmln, usually under one-eighth per cent Mieroscopic examination
bows a few hyaline east^ with renal cells adherent^ and an occasional bliMxl*
Orpnsele. There are, however, very few of the^e elements in the K^liment.
%e peculiarity of the urine in passive hypenemia is that it varies. If the
cart becomc*s stronger, the urine is passed in larger quantities, is not so
ighly colored, and contains a smaller amount of albumin.
L Prognosis, — The progiiosis in cases of poaslve hypera^mla of the
Hdney de{>ends upon the causr^ of tlie condition.
to tlu- skin, luul i'nini the internal administratini
as (•antharuks, tur|)entiiio, salit-ylic acid, and ar
iH'pluiiis liavt* Uvii rejiorted where no cause could
ilitliiult to r>tiniati- with wrtainty the importau
t'a«i.»r ill the ftiolojry of acute nephritis, and alt
that colli ran pnxlucv this condititm, yet num<
rxposnn* to wet and <N>ld. Many of these prii
prol>ahly diu- to micro-organ Lsnis, as the disease
ohsrrviil in connection with gt»neral septicaemia.
l*Arii()L(H;v. — I have already fully described
nc|)hritis which toUowri st^arlet fever. In the i
otlicr cau>4's which I have jtist mentioned, the j
chli'Hv in the ilejjiiH* in which the different p
allictrd. The imK*es.s appears to be a mixed one
kidney arc nion' involved than others.
Symptoms. — The symptoms of acute neph
alivady dcscrilnHl in my lecture on scarlet fever.
arisin»r in cases due to other causes than scarlet fi
Hvrre tlian thos<' which I have described in coi
Tlic amount of albumin and tlie quantity of the
tlic decree to which the glomeruli are aiFected.
('|)itlH*lial cells dcjKMids chiefly upon the degree
tulmN-. 11ie interstitial changes cau scarcely b
it is vv<ll to l>ear in mind that the urine may vai
atlictiun n{' the kidneys. In one type of the on
mine | ) roe nts the follow ing changes. The color
i-h-nd, according to the cjuantity and freshness <
tjiiii-. Tin* >|K'ciri<' gravity is high. The amoui
i .! I ..,:« T^!>^^^ : . „ 1. _
r
B|>ISEA8BB OF THE KIDNEYS, BLADDER, AND OENITAT. OHOAN6. 933
Hft rings. There are more granular easts and detritus^ and fewer epitliolial
^Hblocnl casts. Fatty elements, such as fatty renal cells and free fat, b^in
'rBpiJcar. There are also in(»re hyaline casts, usually with a few cells and
^A adherent to them. Still later, there b a prcjxtnderanee of liy aline
l^ta, with fewer epithelial c*^\U and bhxKl-globul^. During this time the
lount of urine increases, until during the convalescence it finally rist^s
,ove the normal amount. The ccKlor changes to smoky, and finally be<x^mt»s
le. The specific gravity diminishes. The albumin diminishes to a trace,
^t this trace may persist for a long time. The elements in the si^iment
oome fewer. Acute exacerbations art* not uncommon.
PR<XiN08i8. — In geueml the prognosis m good. The disease rarely
KX)mes chronic. Death may occur in the beginning from the severity of
e disease, or later frnm unemic poisoning. Some cases end fatally from
me intercurrent disease, such as pneumonia, or from a nephritis micurring
the ci>urse of a general septicjemia. The majority of the cases, however,
er after from Jour to eight weeks, altbongh a trace of albumin and a
»v hyaline casts may j^ersist for several mooths^ the child in <»ther respects
»iiig f[nite well.
Treatment. — The treatment of acute nephritis is the same as tliat
hich I have already dt^cribwl in the ne[»hritLs following scarlet fever*
Chronic Parenohymatous Nephritis* — Etiouioy* — Chronic [laren-
ivmatinis nephritis is not a common disease in childlitxHi and its etitilogy
.still very obscure. Some cases have followed an attack of acutt^ ue|»liriti8,
\d in these thei*e has generally bc^^n an interval during whirh tlie urine
dimply contained a trace of albumin and a few casi^, the symptoms of
ehronir atlkliou of the kidney ap|x»aring later. Cast^ have also tMctiri*e<]
ctmnection with long-ci:>ntinued suppurative procjesses in the b<ines, joints,
elsewhere, arising in the course of tuberculosis or sj^philis. In these
amyloid infiltnition is also apt to occur. There are also instani^es
here no cause whatever can be disoovenxl.
PATHOLcxiY. — The pathulogicjil ttitulition is the same as in the adult
Symptoms* — The symptoms of chrtmir parenchymatous nephritis are
isidions in the l»eginning and are pn»loiigTLtl. There are marked pallor,
tendency to oedema, and a trausudatiiui int<» the serous cavities. Cardiac
ypertrophy, weakness, loss of appetite, headache, and at times vomiting
d diarrhren, are among the c<»mmon symptoms. Retinal changes s«uue-
mes iK-c'ur, and there is a tendency to intercurrent diseaftes, sucli as pneu-
ionia and pleurisy. Ursemic intoxication may be ex])ected later. The
ine may hv high or pale in c*olor. It is diminished in amount, but not
larkedly so, as in acute nephritis* The sediment is usually heavy. The
jecific gravity is diminished. There is a large amount of albumin, often
ne^half j)er cc^nt* or more* There are fre<|uently amorphous urates in the
^iment, which must Ix^ ri*movwl by heat Ix-fore the microscopic examina-*
u is made* M icrtiscopic examination shows a chararteristic prejKinder-
of latty elements. There are fatty renal uelk, free fat, fat in tlie coasts.
^F^l
934
PBDlATRfCH.
atid cells eoRi|>1eteIy fattv* There are alMi oamjxMind
graniilaiv e|nthelial, and hyaline cmslB. There are oAea icatii
in the kiduey, in which case the amoutit €\t urine \H%\mit» \
i»hed, and the seilimcDt shows blood, blood castii^ and t^ptthtlUi]
ttoti tij thu krge numlK*r of fntty elements. Wlu*ti the dlsrsM^i^i
with aniyluMl mHHration, the dtagnoeis of the lattJE^r ran brDi
fnini th«* urinv,
pROQNOHis. — The pn^Kisis is not good. Some cases hartnetb^
gym|itotns of tlie dl^eaHe have ap|»areutty recovered. Mo8t»i
die f'n>tii um'niic intoxication or from some intercuri^it dcB
pneumonia. There may be a remission in the symptoms fin ti
Tkratmknt. — The treatment is to restrict the diet tt farai
to milk. Good hygienic surn3undings, and as much i«t
mdicated* Diuretics may be need when the amount of urine kd
I have already deecrif^ecl in my lecture on scarlet fever die bat t
with (huiTtica (page 563)«
Etm i» » bay (Owe 468), ©Icreti years old, with nMjirinii* wmrD tu» iiiMM
The cxuminnlion of Ihf urine by Profefii^or Wi>od shows the ^rMkOi^dtk
pilVQObymRtoiii ti«phritU with an acute ^^xjicerbatioii.
*.'aj>e 453.
Pfobtible t liroiilc pftrenchytaaioos nephriib? with an ainit<^ exac!ertMaioii, MaIl It i^«i t-ir
Hher Iwluir om or tied at« dayK
TliL. cbild had pertuMW when he WAn thnee years old, ecariet tbrnvliMi W wl'l
yoiirs old, nnd meiiBlefl and piieumonia when he wii* five years old. H«- i» tvp<W v tr '
remained well from that time until nin..- rimnth« a^n, whJn, wiUi^mt *uv kn^TWftO* -^
EB exposuiv tn cold or BickneAS of amy kind, his face aud eyes Wan to be tsdm^^ *
WW followed by oMlema of the leg» and ankk^, and wa^ accv,mpam«d bT^^m ^
urine WAS noticed to be nearly of the color of blofid nnii *. i i *> ' 'TTil^
, , , , , ^ , ' , . ., "»^»u, ana ti» lir leasieiwd m wmtfasH *•
ki'pt in bed for Ki3t weeks, und is said not to hikVi^ oonipUip^Hi ,,f , |_j f^
Duniifr this attack his appetite remained fair. Si
grown 8omcwbat weak and become pale. Si
f^c*? tbf Viegir
^¥li
^ we«^k« a^, l^be |ial«m«ai aoil «aMiM^
ftXSEASES OP THE KIDNEYS, BLADDER, AND GENITAL OBOANB, 935
reaped, and the urine became Bmokj again. Thi& wiu follow^ hj cedi^nia of ihe
feet, and \e^^ accompanied by dyipncea. The bowels have b<^n regular, and tht'rc
no vomiting. He sleeps welL On enterini; the h4.i«y»ital his fiice hxiked pale
y. There was considerable opdcfina of the fuee^ e«pecially of the cyr*. His tongue
htly eottt4»d, and there wa* cpdenia of thp anklej;, ft»et, and \rp,. Nothing jibnomial
^ found in the heart or lungs, and there woj^ no^evident.^ of ascites.
He WHS kept in bed and given a diet of milk. Under this treatment the iBdvmu and
lemia disappeared rapHly, and in two weeks he was allowed to be drej«ed and about the
Ktt. Thin wa6 five day« ago. Yesterday he again had cedema of the face^ and was
liaeditttely put to bed. As you tee him to-day, the iBdenm under the eyes U espe-
lly prominent. From 700 to 900 c.c. (25 to 80 ounces) of urine uri^ posted in the twenty-
^r hours, An examination shows it to have a specific gravity of 1010, an acid reaction »
Contain urea 4J& gmins to the ounce, to have the chlorides diminished, and to contain
per cent, of albumin^ but no sugar. The sediment showi* numerous hyaline easU of
pdium diameter^ some of large diameter from the straight tuhuleSf many ooar«e and flue
Miular cu^ts, numerous fibrinous casta, and nmoy casts with renal cells adherent ; alao
Ihelial cai^ts and blood caaU; an exoett of r^nal epithelium ^ most of it granular or fatty ;
impound granular ccIIr, a large amount of abnormal blood, free fat^ and fatty casts< His
ip«raf iin.' has varied frtun 3«5,6*» to 37.2^ C, (98^ to 99* P,).
(Subsequent hist^^ry.) After remaining in the hospital for two months, with temporary
(mLs of imprtjvemenl, he was discharged in about the same ei^tndition ab when he enteriid.
I IB a girl (Cftse 4^), nine yean old« with nephritic.
Riv Kno nxic panfnchymatoaB nefiluitlii with an actiita «saei«rhatkNit Vbma1«t 9 fvaia old.
w€«k of the dliaiit.
lis child had roeulflt when she was two years oldt iOftrlet fever when she was thrN»
Utf varici^lta when she was sii years old, and piirtuiaii when she was ei^bt years old.
lie apt>arently recovered entirely from all these diaeasw, ftnd was well until one wuck
pU| wh*in, without any apparent cause* h**r face and feet began in swell. She complained
'nu pAin« and had no other eyniptotuK, A* V(»u see h»^r in It^l, you will notioe tht* marked
id extfnsiv*? a?idema of the i^ntin? fac?t% b»Kiy. iind limbs. You so«? that the a?d«*mtt it pro-
ftunc«5d under l»o!h ey*»s, but cwpecially *o under th** Hicht one. Th«>fe is grwat [laUor af
!• tkifi, and the feet and h^nda %n miioh awoUen. Nothing aboumuil haa b««n dtftcoled
fill mj tretfrlmeai of the
Sht it 1
of milkf 1
(t*go 646).
I fthow thi* child b0C«]i« fiho Dluitratn the i^ppe^rmne
with it« «xcQiiivv uitlv43isal ciMleniA and peculiar pallor c»f i
exiicl letion of the kidneir tn ibu cx^c^ is, however, veiy
pTQOtJiWH in the kidnejr ure not confined to any one part
amilysU l» ofloii for thii reuon unsatiifkctoTy.
After tj^eatoent wmm Is^paa,)
I hftve Droviiion&llv called it m, case of lamihttKlA aKi
OISEAHES OF THE KIDNEY8, BLADDER, AKD GENITAL ORGANS. 937
This picture Uken at this time (IL, p«g« 986) thowi how tbe general oBdema hai) paa^d
^jTf and how the Bkin has lost the extreme pallor which it presented on the child's entraooe
» the hospttal.
An cxaimnation of the urine three weekt later ihowi>d the color to be pale^ the rea<?t]oii
, the fe|»eciflc jfmvity 1014, the albumin J-f per cent, ll oontairied hyaline and fine
lular ciifcts of small diameter, many with oil-globulc« and r«nal et?lU adherent ; also free
^labule^, fatty and granular renal epithelium, Mome normal and abnomial bloody b.*uco-
, and squamous oelle. The casts were not very numerous, and there waf not much
aig« from what was found in the urine three weeks previounly. At this time the urine
Bbi became wianiy, and the cedema and pallor returned, but she did not complain of any
N>mfort. An examination of the urint? eight weeks later showed it to be pale and cloudy,
reaction acid| the specific gravity 1018, and that it contained considerable ^ediineiit, and
Itmin \-\- per cent. The sediment consisted chiefly of hyaline ctisU of medium and
til diameter, many of th(;m ha^'^ing renal cells and fat adherent. There were tdho a few
)\y granular casts, ooniiderable abnormal blood, free fat, fatty renal cells, epithelium,
tsocytes, and (x^casionally blt>od, epithelial, and fatty cajsts.
The diagnosis cannnt be positively established until the case shall have be<^n under
^Htoiion for a much longer period.
Chronic Interstitial NephritiB. — Chronic interstitial nephritis is so
Ct»ediu^ly rare io child hrnKl tiiat vcrv little need be said concerning it.
Ctw CHjn^enital «m8t*s have txH?n rejKjrtcd,
ErroLOOY. — Tlie etiology is obstnire. In some cases it seems to hnve
lowed a chronic parenchymatous nephritis. In others no cause c«:>uld l>e
[iid.
Pathology. — The pathology is the same as in adults.
Symptoms and DlAONtx^rs. — The diagnosis can scarcely be made from
symptoms* The <!iscase is prf:)grc,si5ive and elcnv, with no chara4:'teristic
mptomjf*. Cases have been n^porU^d in whirh there wen- geucral symptoms
headaclie, weakness, dyspnoea, palpitatitvn, and disturbance of vision.
^'|»ertrophy of the left ventricle (K*curs as a constant lt»si(»n. There is
tie tendency^ to anasarca; retinitis may l>e present, Bagiiisky refers to
lack of development of the children in these tu*^es, and tliis condition
IS notit^l in a case of this disi^ase w^hich occurred at the Boston Cliil-
en's H<»spitah
TbU child (Case 465), a girl, twelve yean old^ showed the developmoTil of a child
about M'v«*n year&. The only »ympt*»m until she died of unemic poisaning' was per-
tff^nt h<*adftche. The poat-mortem examination showed marked int^rntitiai nrphrili*, but
prai* not pi&sible to determine whether it witf primary or not, and no previous history
lid be obtained.
In chronic interstitial nephritis the amount of urine passed in the
lenty-ibur hours is increased* It has a low s{iecific gravity, a very slight
liment, and a trace of albumin. Th«* micniscYipic examination shows a
l^y aline and finely granular casts and ix-casional renal cells. Some-
Hp towanls the end of the disease highly refractive homogeneous cttsts
lembling wax appear in the urine. At tins time the amount of urine
ty be somewhat diminishtJ^ but the specific gravity does not rise, as the
ioredon of urea is interfered with,
Pr<x»no»I8* — The prognosis is very unfavorable. The children usually
J«38 PEDIATRICS.
iVw of <t»n'bnil honiorrha^ or of som
i.K'c'urriiijj in t'n)ni thive tii four years.
lit* of <vn'bnil honiorrha^ or of some intercurrent distant, Iuhv. l
Tkkatmknt. — TIh' tn'atniont is symptomatic. j
Amyloid Infiltration. — In etninection with amyloid cb-u-r. \
nrtrans, t's|Ri'iaIly the liver, spleen, and intestine, amyloid intbii. \
tM-fMir in tlu' kidiuy.
Krioi^HiY AND Pathology. — It occurs at times in ocm
<hn»ni(' suppurative processes in the bones or elsewhere, and alsi'ki:
lo<is, syphilis, jiml chrtmic ^'asting diseases. It is not bowevtj.*
<i»niuion iu (»arly life.
Symptoms. — The symptoms are not referable to the ki-hr^: ;
|>n'sru(M» <»t' amyloid chants iu the liver and spleen, shuwn i^hif
ruhir^<'uunt and by the examination of the urine, are the sign* bvii:.
<liatrnt»sis is made. The urine is usually passed in large qiumtitv tV.
aiuylnid chaup^s are advanced. The specific gravity is low. a&lil'H
piTMut. When the am<mnt of urine is not much increastnl. a< ira^ i^:
tiin|M»r.irily, the albumin occurs in large amounts Micros^xfi* tLi-
tinii >h<»ws no (-haracteristie sediment; but when, as may ofcn h^>:
di-«aM' is <iimbim'd with ehrrmic nephritis, the sediment will skivtrv
<»r {\i\^ hutrr disease'.
l*iiiM;N<)sis. — ()n aeeount of the usual causes of thi» i.v)miii- -
|»ri»L:ii<»>i-i is unfavorable.
I'kkatmknt. — The treatment is symptomatic.
Pyelitis and Pyelo-Nephritis. — ETioiy>r,Y. Pyelitis an-l :■
11. jiliiiti< may In* <hu' tt> an ext<'nsion upwai-J along the p^uiu^urinr
Ml Mil inhM-tii)!! (muxhI by eat he ten?, gonorrhcea, or f-vstiti-?. T;:^- :
til.-.- .■;m-.-. h.iwrvcr, are unc(»nunon in comparison with thi.k-:- w;:^;;:■
(^..nl thr r.\tnti<»n <»t* uric aeid by the kidney or from jielvi.'ra-.t:!!
«li-.;i^r may al>o Ik* rauseil by tuberculosis of the kidney and hy la-..:
L^lMW th-.
1'\tii(>ko(;y.— The juitholo^y of this disi^ase varies with thi ■:
Ait.r \\ir ]^yr\'\u^ has lasted for a time the kidney is adk-irtl in --^
t \ri\ ci-r. ;ui<l pyrlo-ne[diritis Results.
SvMi»r...Ms.— In an acute attack of the disease, as when it is n^i^'
nrir a.M or a (ulcnlns, then* are often pain and fever. Typii^Iaitt'v
r. ii;il r-lic. witli v«»niiting, pain, and fever, may r>ccur. If theotuhiii:
.111.- t.. im1m'iv1<.<, niali^rnant growths, or abscess of the kidnev. th.T:
Im 111.. IV or lt>s (a«hcxia and emaciation, and then^ may be lix-alpii^-
t.'II(l»l'IK— .
I'll. .lia-iKxis is to i)c» made from the examination of the uriiu. I-
iiiiii.- .nniains pus. which gives it a cloudy appearance, and the ^\lb'/'
iM'avy. 'l^lic colnr variis : it may l)e red if there is cimsiderable hem'^rrii."
Til.- mine <Mintnin< albumin, which varies from a trace to a o^niii^^-
aiiLHint, atvnnlinir to the amount of blood or pus and the presence or si**:''
m' a .nM.'urnnt atl'cction oi* the kidney. The microscopic examiiuiti^ffl i' ^^
OF THE ICI0KEY6, BLADDER, AND OE^ITAL ORGANS. 939
die whole field to be filled with pus-oorpusolps, at other times tlie
be in clumps; tJiere-are also present &mall ruimd cells witli single
lei, from the pelvis or fmm the kirlDey, and mnrc or lesv** blrHKl, The
loetic cx^U of pyelitis k the ** aiudate eell; ^ which is a Bmall cell almut
of a renal fiell, having a single niicleus and a tail. If the kidney
afreet<»d there are casts of various kiuds^ hyaline, granular, epithelial,
d bhx>d. The ca«its may not be easily ^een if the field is filled with [m^,
je presence of tubercle- bacilli in the sediment^ shown by approjiriate
thods of staining, establishes the diagnosis of tul)eivnlosi8. In the
\y paased urine, uric acid is often pr^ent in the fteclinient in the form
lar spieulated crystals. These may suggest the prulmble cau^e of
e pyelitis.
Prognosis, — The prognosis depends upon the cauae. Tn malignant
rowths it 18 fatal* This is true to a greater or less degree where tnbert*le
llie oanae of the disease, as in almost every ease it is present somewhere
16 in the body. When uric acid or a calculus is the cause, the prognosis
more favorable, and, as a rule, the outcome dei>ends upon the fact whether
e treatment is appropriate or not.
Treatment. — The uric acid should l>e treated by neutralizing the acid-
ic of the urine, by placing the child ufMjii a mild and unirritating diet,
ich as milk, and by making it drink frt*ely of distil lc\l water, Ojjcrative
reatment is at time^ called for where a calculus is present
Maligrnant G-rowthfi and Bnlargrement. — Tumors of the kidney are
Bore common and more st^rious iu the child than in the adult. The simple
denomata are prol>ably etjually common in lx)th, but the child is much
nore liable to ean-inomata and san^imata than is the adult. Sarcomata are
le most common in the first five years of life, and usually occur in one
Sdney.
SvMrroMS AND Diagnosis. — The diagnosis dejK'nds u|>on the recogni-
ion of a tumor of the kidney and the progressive emaciation and cachexia
rhich arise. At times there is pain, but, as a rule, pain is absent. The
irine sometimes gives evidence of a pyelo-nei)hritls ; at other times lis^ma-
ttria and alliuniinuria occm* at intervals, but gi^ncrally late in the disease,
t a time when the tumor can be felt thniugh the alxlominal wall. S^me
f the characteristics of a tumor of the kidney are that it is located in the
lyjMigastric and lumbar regions, that it is deejvseated, and that it is not so
Dinmnnly to Ix^ felt in the umbilical region as are tumors of the ri^tn>-fieri-
C^nenJ glands. The tumor is irregularly rounded, and usually does not have
, well-marked border, such as is found in enlargement of the spleen and
iver. In these cases of sarcomata of tlie kidney the hwdth at first is often
lot much affecte*!, but there are progWHsivc emaciation and enlarg*'ment of
pe alnlomen, commonly without pain.
I Prognosis. — The prognosis is verj* unfavorable, although temjiorary
pUef is often obtained by means of surgical interference.
^BTreatmsnt, — The treatment is essentially ojiemtive.
[)KEY8, BLADDER, AKD GENITAL OBOAN8, 941
klobliiuria have severe eymptomd at the time of the
eattremitits, and a rapid, small puW. Neither
bflpmoglnbiimria last very long, as a rule. At times
line the eause of* the haemoglobiuuria. A case which
uiy notice shows how difficult it l$ to determine the
when a pfist-mortem examination can be obtained,
t jeiir^ Hnd t?i)L'hl montbi old, had for jeveral weeks grown jmie,
fiynjptumii of indigestion. LttUT the urine wii« r«ducfd in
There wus nUo flight ludenuL of the eyelidi and feet. No
I nnd the child went out of the bouse m ii«iuil and se4?mv*d
' four davi before her death the paUor and <xdema increased
y leasened in am(»unt and became still darker in color. Alwrnt
['btoame very dull, and on the following day waa much blanched
that when &he w&£ aroused to be eiamln^ she would reaist
ired the couditiou of hieinoglobiiiuria. The child di^^i a ftrw
rii nation, made by ProfiMSor Coundlman, showed evidence* of
I t>'Hic-ruttrr«jw WM red. There wcrt* hieiiioijlobinunaj fatty de^ner*
I and kidneys, and hjemoglobin casts in the tubulea of the kidney.
rluria is a rare disease. Two forms are usually spoken
non-tropieaL
tropical form is caused by a jianu^ite, the filaria san-
» of ronnd'Wonu, Tin?? panisJto is finind in the bltMKj,
jine, es|M^"iaUy that pass^xl tDwartis night The exact
I parai^ite and the ehyluria ha^^ not yet been detemiined.
the parasite baa not Ix^en fiiimd. Casc^ have bvn
asite appeared in an individual resitling in the tiMiii<t?,
L his returning to a eokl climate, although the ehyluria
is supposed to get into the urine af^er it has left the
fsjrmptoms of this dis<»sise are shown chiefly in the
|aa a milky apiH?arance, Bometimes a sour odor, and tends
Uy* The roactinn is siliglitly acid, or neutral. Micro-
i shows the fluid to bt» fillt*<I with fine fat drojis in stispen-
(timea contains bkxxl -corpuscles, and albumin is always
ts are apt tu b*» imroxyf^mal, lasting for days or weeks,
lin recurring. A fatty diet may or may not cause an
Huria. The individuals atlected by the disease may have
lioe. Coagida may at times be formed in the bladder and
nd ditfieult micturition.
The pi*ognosis of ehyluria is doubtful. It is a disease
I long time and may c^use ansemia and emaeialion from
albumin.
-Thert* is no treatment w hieh is known to be beneficial.
u — Etiolcjgy. — Hydronephrosis may be omgenital, in
[be due to oonstriction of the ureter. Both kidneys may
n
940 PEDIATRICS.
Affections op the Supra-Renal. Capsules. — Theatfeii
siipra-rt'iial (•a|isuk»8 mlled Adduton's dise<ute has been met wiiL i
<'liil(lr('ii, but is excifdingly rare.
H.KMATUKIA AND H.EMOGLOBINURIA. — H«?maturi:i and br.
niiria art\ as a rule, easily recognized by the c^olor of the uhd ii >
bl^KKl is pn'sc'nt ti) color it. The color is red if it is due to I'r^i. Y.
I)n»wnish nil if due to blood-pigment which has been washed .^j-
enrpus<»U's.
To determine the source and cause of the hemorrhajirt L* -nr:
ditlicult. Hemorrhajre from the bladder may be cau:?ed ly a ca'.t .il':- :
])apiIIoniat«ms frnnvths, or may iKCur in cases of hiemophilia. \V:t:'
bliMMl (M)m<s from the bladder it w generally not uniformly diffu?t.«l:l:
the urine, and small elots are common. In addition to thk tLtfrvai^*^
tnms of disturbance* of the blmlder, such as tenesmus and fretjutnt n: :
haps interniptecl micturition. In hemorrhage from the kidney iL? b. ••
ditViistKl thn»ujrh the urine. The color may be red or brownish r^^l
nii«r(.s<'oj»ie examinations show epithelium and casts from tlu- ki-iu-;
the eliinents arc* staimnl yellow and brown from longer e<»nutt v.Il
blniul. There an* als<» normal bUM>d-corpuscles, and i»thers thuu wni-'
hu*nin^lohin has Ikhmi washed out, appearing as |xile rings.
Iljeniaturia may <Krur in hiemophilia and in puqnira. HjemaTiin:
al-i» Ik» a symptom of malignant growth in the kidney. It may U 2.: -•
symptom oi-t-urring at intervals, but usually it apix^ars at a latter]"'
when the presents* of a timior can be deteett<i by palpation. It niav .- •
r:m«^r(l hy iirje arid.
In ea.-es (»!' hjem(»»rlol)inuria, notwithstaiidinj^ tlu» n-d or at tiuh- i
Ma«lv ii»lor of the urine and the presence of alhinnin, ihen* arv ii"- :; -
rlr- tn U* toinnl. IleUer's test, which conssists in addiutr hvilrate-a ;• .--
>iimi to the urine and lieating it, causes a precipitation oi' tht* j»h •^p:ii''*
wlii<li carry down the bl(KHl-pigment mec*hanically a.s dark-ml d"'
A -iinihu' appearance may be given to the urine after the aiiminirtri"
nf Hiiiia and rhulwirh. In such cases Heller's test woidd give tlu -i:
re-iilt- a*^ it' hl(MMl-pigment were present- The nitric acid test lor ali' >:■
wniild. hnwever, decolorize* the urine, and the test for albuiuin wnill •
neiiMtivc. It is important to recognize the very dark urine rrsuitini ir
rarlnJie arid poisoning, as it occasi<mally occurs after the extenial appl' -"
ti(»M nf thi< dniir. I nder those ciniimstanees the urine has a trrPtni?'! r"-
lvn(>L«Mjv. — The etiidogy of |mn>xysmal ha?moglobiuuria i> as yoi -
>r\ivi\ The ehlM often ajjix^rs tc» Ix? in gixnl health. The m»ist tnM«r::
a|>|»;in'iit caii.-e is cold. Certain individuals have hsemoglobiniiria \\..- -
( \(r they an' eliille<l. or wet their fet»t, or plunge into wld water. >-•
CM-.- of iKenio^dohiiiiiria appi'ar to be due to infection, as in scarlet I'V-:
AV'iinkrrs disease, and malaria. Certain inorg^anic sulistam^^ when t;'k c
hy till' mouth, especially chlorate of jxitassium, phosphorus, and arsenic, ha^
j)nMliic*'d lijiiiinMJohinuria.
DISEAJBES OF THE KTDXEYS, BL.ADBEB, AND GENITAL OROANS. 941
Some cases of haeinoglt»biiiuria have severe symptomj? at the time of the
ttack; such as chilU, cold extrt*iiiities, and a rapid, small pulse. Neither
fiiese syraptonis nor the htenioglobinuria last verv Lnig, as a rule. At time-S
^t is iiiipo88ible to dt^termiue the cause of the bteninglubinuria. A case which
lately come under my notice shows Iiow difficult it id to determine the
iiise of this disease even when a post*mortem examination can be obtained.
A ^\r\ (Cii^e 456), four jean and eight months oM^ had far «eTeral we«ks grown pale,
llost in weight, nnd shown symptoms of indige^^tion. Latt'r the urine was ivdueed in
imoiiitt And waft dark-cohered. There was also flight iinlLmia of the e^ elids and feet. No
Kuther especial symptoms arosei aud the child went out of the house as usuaJ and seemed
"otherwise well. For three or four days before her death the palK>r and cedetna increased
narketlly, nnd the urine was ]e«i9ened in amount and became still darker in color. About
twenty*four houns later she bwanie verj^ dulL and on the following day was much Wnnched
nd almttfit unconscitius, except that when she was aroused to be examined she would resbt
rjind Mcream. The urine sht>wed the condition of hsamoglobinuria. The child died a few
|luiur« lator.
The post-mortem exami nation ^ made by Professor Councilman, showed evidences of
^profound anemia. The bone-marrow was red. There were hanuoglobinuria, fatty degener-
^stiou of the hearty liver, and kidneys, and hiemoglobiu casts in the tubules of the kidney.
Chvluria, — Chyluria is a rare disea^. Two forms are usually spoken
of, tlie tropical and tiic non-trdpiciiL
Etiology* — The tn>|ncal torm is canseil by a |mrasite, the filaria san*
gtlinis hominis, a species of round -worm. This pant^ite is found in the bliKxl,
Iand at times in the urine, especially that parsed towards nigiit The CAuct
connection between the parasite and the chyluria has not yet been determinc^l.
In the uon-tropical form the parasite has not lx?en fijunil. Cases have Ixvn
rejiortetl where the parasite apj^eared in an individual n^iding in the tri>pi<'s,
and dlsappcaiTd on his returning to a tx>ld t-limate, although tlie chyluria
contimied. The chyle is Bnp{Ki8ed to get into the urine atler it has left the
^^ kidney.
I8vMPTc3MB. — The symptoms of this disease are shown chiefly in the
urine. The urine has a railky ap|x^rance, sometimes a sour odor, and tends
to decompose rapidly. The n^actiim is slightly acid, or neutral. Micro-
aoopic examinatiou shows the fluiil to Ije fille*! with fine fat dn>ps in suspen*
Bion. The urine at times contains bhxKl-oorpnscles, and allnmiin is always
prt'sent* The attacks are apt U* in* pamxysrnal, lasting for days or weeks,
^ then ct»asing and again recnirring, A fatty diet may or may not cause an
increase in the chyluria. The individimla affected bv the disease mav have
a hcaltliy ap{iearance. Coagula may at times be formed in the bladder and
L give rise to pain and difficult micturition.
■ Pr(X3>osi8. — ^The prognosis of chyluria is doubtful. It is a difiease
■ which lasts for a long time and may cause anicmia and emaciation from
■ the loss of fat and albumin.
H TuKATMENT. — There Ls no treatment which is known to be beneficial.
■ HydronephroBis. — ETiouKiY. — Hydronephrosis may be ciingpnitaK in
■ which case it may be due to oonstriction of the ureter. Botii kidneys may
U
942 PEDIATRICS.
Ih' atlW'ttHl, hilt usually only one is involved. When ao[uin^l i: .
alln'ts hut one ki<hu'y, and niay be cau?Hxl by ol>striuni«>u t*::.* -
urim* either from alM»vi\ as by an impacted caleiihis in tht i,/. .
kidiiry or in the un'thni, (»r from lx4ow, Ijy the pressure Inm .*
iiilarptl nu*>enteri<» trlands. The effects are niechani«.'al, an<l ;;r- i
|in<<ur4* of the n'taintnl fluid on the kidney, which load? t ■ t> :
al»-<ir|»tioii of the kidney-sukstauce. These tumors ftointiim-^ .
larirr si/.i».
SvMi"n)Ms. — The main symptom of hydronephrosi-i U tht* pr^
an alMloiiiiiial tumor i-onmrtetl with the kidney. When iL-- tui
irmwu sutficii'Utly larji:i\ fluetuation can l>e usually detected, an^i ..•■ i-
jrivrs a fluid whi<*h onlinarily contains urea. Subjective MmptoOi- _
absent. If oidy one ki<lney is affected, the other performs the f-n' .
I)*>th, and the ^»neral (•ondition of the child may remain g««>d.
TK^MiXosis. — Tlie pnignosis is doubtful. Cases have i*-^j >:
u|M»n with sut'cvss both liy aspiration and by removal of tlu'tuiur.
Tkkatmkxt. — The treatment of this disease is ess€*ntially ^siirji .i
A( TTK CvsTiTLs. — Aoute cystitis is not a common aflet.ti"U i:: : :-
and childhntKl.
Ktiolociv. — It may \\q caused by a vesical calculus, by irriraiiDf.v
tur|H'ntint', and also oocjisionally by the extension of inlkiiua tb .:.
irenital tract.
SvMiTOMs. — The symptoms of acute cystitis in childreu do !: :
iVoni thosr wliirli arc met with in the adult. The chief ?vm'.t - •
• jiHiit and painful micturition. This local svmptoui is iiHiuliv .
pMiiiid l»y frv«M\ which may In? hi^h, and by jjeneral svmpt<»n>': .: - I
t'ntl'iihn— , and cryintj from vesical pain. The urine is va.^^x ::
tjuaniiiic--, anti, as a rule, is of a reddish color. The siH^/iri«/ ltj '
hi-:!!. When freshly piisscnl it is acid, but it quickly Unxmi'.^ :ili-:»-
tlien i^ a lieavy s4Kliment, and it of^ntains a trace of albumiu. Mi:r-
exaininati.Mi >Iic»ws chiefly pus in large quantities, sipianious epitliili.::.-
-«.nir 1>1.mmI. Tn istahlish the diagnosis it is nect»ssary to ohtaiu iL- :'
by I In- tatlieter. t)r, in fenudts, first to wash out the vairina tborr^'iil;
thr t pitliiliiini of the vajrina and that of the bladder are verv similir.
Pi:ni.N(,<H.— The pn>gnosis of acute cystitis is gocxl after thv >l:
ot' ihr ran>e.
ri:i:ATMKNT.— The es|K'cial cause of the attack must be Iwknlir.
n iiiov. .1 if pn--il»le. The child should be kept perfiH:*tlv quiet in 1-t ^
-hMiil.l 1m. nindf tn drink a great deal of water. The diet shonkl K-i*:-
Sdaliv. - -hniild Im» u>e<l fiHX'ly.
('iii;«»M( ('v>TiTis.—Clm)nie cystitis may be caused in childa: i*
a.liilt^. I.y a v(-ieal ealeulus, by foreign bodies in the bladder, by tin- ^
|Kii»irM.inata, and hy tiilK^mdosis. The nuclei of the calculi are genomic *
jh.^mI nt' urie arid, up<»n which phosphates are precipitated in alkaliner
aiul liii^ ilep(.>itic»n is favored by the accompanying catarrhal inflamn:s"=
DISEASES OF THE KIDNEYS, Bt^DDER, AND GENITAL ORGANS. 943
Symptoms. — Micturition is frequent and at times [minfuK Later there
ay be a conBtant dribbling of urine, giving rise to an offensive ammoniaeal
lor and cjiusing irritation al)oiit the genitals. Where there is a ealcuhis
the bladder the stream i^ ofkn suddenly interrupted during micturition
id the pain is more severe, Pnjlapse of the rectum is not uua^mmon with
ine. In addition to these local symptoms there an? j^eneml symptoms of
[isemia and loss of weight. The urine is ammoniacally alkaline, offfUHive
odor, and turbid, has a heavy ropy sediment, and wntaios a trace of
bnniin. The setJiment should be examined as soon as ]>ossible atU"r the
iiie is passed^ bet.'aust* the ammonia which is prtKluettl fnjm the urea diJ^-
iegrates the cells. The examination will show a large ijuantity of pus,
me blood, bladder-epithelium, and crystals of triple phosphate and urate
ammonium.
Prognosis. — The prognosis of chronic cystitis depends upon the cause,
pon the length of time during which the disease has [lersisted, and the
or absenc*:^ of a secondary affection of tlie kidney.
Treatment, — The urine should l>i? dilutetl l>y giving distilled water in
irge amount. It may be rendered less irritating by such drugs b» salol
nd buchu, and less alkaline by ben/Amte of 8«Hiinm, Washing out the
ladder is of use in many cases, and Ick^bI applications may be raa<le in
berculosis of the c»rgau. OptTative treatment is indicatwi w^h(*n a nilculus
jQftUsiug the disturljan<^'e.
At times it is exaixlingly difficult t*j determine by the general symjitoms
rhether a calculus is prast^nt in the bladder, 1 shall report to you a case
hieh illustmtes this difficulty,
A boy (Cue 457), seven years old, be^^Rii to have pain of a spafiinodic cbamctor in the
n of th«3 bladder durinf* mieturitioti. In coniiiociion with the pain there would Ims a
idden fltoppnge of the dow of the nhtw ntid a b<«aring-down feeling in Ihu r««tum. Tbeie
mpUtUJi^ ainiulat^d those of & vesical calculua so closely as to render a differential diai^ntj^ia
^ry difficult. The boy wani uf a nervous teinperament, and wa« rather ansmto, but other-
was well and ftrong Nothing abnormal was detected about the prepuce or the rectum
!hm pain was so annoying and caused so much tri^uble that it was deemed adrisable to
ve the bladder examined f<ir stone. An examination was made by Dr. Bradford^ and
thing abnormal was detected* At\er the bladder had been examined, a decided improve-
lent tofik placet apparently connected with the pa^^^ing of the sound, and the boy re^jovered
itirely after remaining at home from school for a few weeks aad having daily exercise in
m open air.
VtrLVO-VAOiKms. — Vulvo-vaginitis is a very oomnioii affection in
ittle girls. It arises from a variety of irritations, one of wdiieh i» the
' vermieularis* In a very lar^* numlier of eases the gonoofxx*ns of
has Ix-en found in tlic jjundeut secretion. The gonocoeeus was found
I all of six eases lately treated at the Boston Children's Hospital. Tho
isestj^ may als(j arise in childn^i who are very much debilitated, and is met
rith at times in scarlet fever and in measles* Again, it is not infrequent
d anaemic girls^ in whom it occurs witJiout any apjmrent cause.
Pathology, — The labia are reddened and am more or less swollen*
944 PEDIATRICS.
TIktc* is a thick, purulent discharge of a greenish-yellow o 1 : -
otlrn>ivc'. At times there Ls more or less excoriati<m of iLo iair-
t»t' the labia. The inguinal glauds may be .slightly enlarge! ^m: .
Tho urethra is, as a rule, involved in the irritation, and is ^w>ll-:ii.
SvMiTDMs. — There may be some fever in the early ?'ta2t>
va«:initis. Smarting and burning are usually complained of, Ut;::
thr staining <»t* the clothing first calls attention to the dLsea.-*. Ii
dren (■oiuuioidy l)eeome jMile if the disease j^ersists for some lim-. ).
riti«iii is |)aintul in some cases, and the disease is one of the iLiL -
oi' dysuria. In many cases the children api)ear to be quite \^e!l. -._:
exception of the lo(ral cnmdition.
Pkckjnosis. — The pmgnasis is good, but the disease is apt i - •
Inngrd f<»r s<'veral weeks or months. Complications may arirt ri
extension of the |»r«»eess into the urethra and the bladder, and -sf:* ;:-
ti<»nal symptoms Referable to these i>arts.
Tkkatmknt. — 1^K«1 applications to the vagina constitute t:- :
saii>iactory fl»nn of tn'atment. This is difKcult in young chiMivL.I; .
Ik* ae^Hnnjilishctl with a soft rubber catheter. Such solutions 3> hw.
4-1 < M ), n irrosive sublimate 1-5000, or creolin 1—500, may l>e ti:^;i1. I: --
M'vcre casi's l<H*al a|>plications of nitrate of silver 1 or 2 [lenvuLi^
nctv-sary. The lal)ia should be kept separated by absorl)entivtT<»:.i^::
parts kept dry and covered with some mild dustiug-jMiwJer A>
Fro. 1«2.
m.'-lTmm.m- •»
\,
.\
( iunnonrci rontuineri in pusK?eUs lh)m male. » yeaw old. Acute sitage of inflhm'-'. . ■-
<'lrMnlinc.'^s iiin>t be observed, to prevent infection of the eyes aD•^'•^■■■^'
iMT^ons. 'Hie parts should \ye protected with compresses held in pi*- -■
l»aiula'j(', wliieh shcMiId lx> Avorn all the time, and the compresses ^b*"^'- '
in .(iirntly t'lian^rtHl and burned. The towels used for the iwtient ?b:t:l''
be Irii lyinir alxuit, and should be carefully disinfected. Tonic treaty:-
DtSBASBS OF THE KIDNEYS, BLADDER, AND GENITAL ORGANS. 945
tnetiriH^ indicateci The urine should be kept dilute, in order to avoid
ritattng the iuHamcd surfaces, and any cf^mpUeatirig rystiti.s should lx»
mted. During tlie active stage of the dideoi^ the child should be kept as
liet ns p«irksible, and on a diet of milk.
Where the vulvi> vaginitis is caused by the oxyuris vermieidaris, especial
ire should \)e given to eradicating the ])arasite from the rectum. After
US has l)een done, the vagina is readily fi^ed from the parai?ite by using
n injet^tion of warm sweet oil, which is to be allowed to remain for three or
liir miniiti:?s, the vagina then lx*ing syringed out with warm water.
Gonorrhcea also may occ^ur in boys.
\
ThiA lK>y (Ctt^ie 468), eight years old, came to tbe fartspltiil yetterdmy complaining of
lln on micturitioti and on walking. The pr^^puce was found to be very much ewoUen,
id ther*? wa« a diachiitge of pua fh>m the un^thra. An examination of th** dischai^t* by
Ir. Mwllory tbciwed the pn^etiee of gonrx^X'ci in thi? pu*-cflb. Thi* Rpocimen {Fig, 180,
^^ 944 )f tnken from thi« ea^ef thows the morphology of the pftrasite aa seen by mefliit
t tk Leitz homogeneous oil immereioo i^g^ Leitz stand Oc. No. 3^ tube closed.
The gon*>cocci are ovoidal or bUcuit-«hAped, and usually ix^ur in pairs, the flat Mdci
Uufs **p\yifu^ to each other. It is characterif^tic <vf tbern that they are found within the
|iiaK!dls as well aa on their surfaces and free in the fluid.
I Orciutls, — Ort*hitis, i»r influmination of the testis proiier, may ix^enr in
ibildliotMj fmni direet injnry^ but it U a ran' dii^ea-se. When pn*sent it is
pmmoDly accompanitd by hydrocele. The orehitis which so commonly
bllows mump,s in the adult is les?? eomnitin in ehildrt^n.
Epididymitis. — Resides being due to tmiinja, twtite efmlidymitis may
B causal by any irritation of the mncous niembniDe of the urethra. In
pig disease the whole semtum h apt to Ix' hot and tender, and the child is in
neat pain. The e|ndidymis h inueh enlargetl and exfjuisitely tender, and
Migbes the testis forwartL The oord is oflen implicated, becoming eulai^:ed
^ * painfnl on pressure.
The treatment should W energetic, as, owing to the swelling of the
about the testicle^ there may lie so inneh pressun* that tlie gland will
seriously daniagfxl, althfingh the subse<jttcnt atn^phy may not declare ib^lf
pr a considerabk' time. The ifiild sliould 1m» kept ujK>n his back in l)ed,
pe bowels fix*e<l with a eatharti(% and a !=erie8 oi' hot [x^ultirt.^ ke]>t upon
pe scrotum. In all inflammations of the testis or epididymis? the scrotum
Ihould \x* pla<x-<l in such a position tliat the lower end of the testicle points
ipwar*!.
I TrBERciTLAR DISEASE OP THE Teptict.e. — Ab Compared with the fre-
pency of itj^ iMvurrenee in adults, tiilx-rcnlar disease of the tcs^ticle is rare in
Dfancy and cliildhood. When the dis^^^^s*^ is present the gland is consider-
>ly swollen and often nochdar^ but rarely very tender* As the disease
[Ogresses, adhesions may form witli the tissues of the serotnm, and the de-
Stierated material may bt* disehargtxl through a fistulous tract.
General treatment is iiidieattxl if the disease is just starting^ but if it
already destroyed the usefulness of tlie gland it is safer to operate
60
y U) PEDIATRICS.
iiniiKHliatrly aiul remove the f<K»us of infection; here, of f^«'r«f. t
Im* <rni<lr(i by tlif» (Hmditions el?H»\vluTO. I
Ti'Moiis. — III addition to tiilK^ifular cH.<C'a.so 4>f thu tertk:.'_: • }
titiiiid in iiitiuirvand early eliiklli<MKl. Tlifsi» may iM.Miin.njii:;:. •
The <oiiirrnital tiiinni> aiv very raix\ and are usually of ilu- <i.rj:
Tin- iiHwt enmninn «it* tlH» aeijuin^l tnnioi"s are sare« •niata. .\ 'i!
inaliiriKiiit. The rapid jrJ'owtli and the large .size nf tLi> v:.r .
n-ii«lt'r tin* dia;rn<»si> easy.
Phimosis. — In i-arly life there apjK^aiis to Ix^ a phy^iu]..-.-: ; . ♦
of tin- pn-pm-e Ui the «rlaus ju^nis. As the ehild irr«»w? ol.!: i..-. |
sjuii- nniiiially <li»«apjM*ar. When the adhesion bi»t\v»;vu tiit [:-; |
thr jjhms nniains |M'rn)aiient and the prejiuee is very tiirht. in :. i
jjiv(< ri^' to vari«>!is syiiiptoni.s. Thus the t.*seaj)e <if ilit- iiriu- 1
iiH-iliMirnally hiiidennl, and the urine itdleetinv? behind the -ji-.i-m- l . I
ri-r t«» irritatitin. Snie«rnia is also apt t*> iHilkvt around thfor'.!. i j
way an inlhmnnatnry condition of the i>rt*puc.v (p>sthitisi .»r -i: rv .
•halaniti-) may nvi<i\ As a result of this then* is swelliniT. ani luk:
i- |»aint'nl an<l ilini<Milt. In addition to these Icn-al symptom? !l:.l- •
ary tli-!iirl»ain'r^ arise tn»m the local reflex irritation. Aui-n-dr
lurv.Mi- phcmnnfiia t»t* irniiter or less deju^ree, such as i.vuvuW -ib. ':'-.
si- may hatl to enni*esis and masturbation.
In all caM- of jiln'mosis Icn-al treatment is in<Iie:itiMl. and u:lt .
ililatMiioii. iii«-i>ion, or rinMuneisiou. — the latter beinjr the jii«»< nil:--
prodiirinu tin- lM->t n\snlts f«)r eomplete relief fn.»m thf ni'Tlsi'l •' .
Ill all .a-r^. «vin if tin' phimosis is verv sUm^Iu. nuM-haiiii-al ::.:
-h-MiM Kr jM-r-i-trd in until absolute cleanliness eau Ih.» -iriirMJ. *
\\a\ ..Illy will mtire n-lief from the local and n-tie.x >vmi»l'mb ■- ■ ■"
Am IMA.— I have alivady siH)ken of the forms of anuria vv;,;.i: -
fiMin >M|ipns>ion of the nrine in nephriti.s. Anuria mav a!-* ' ■'
iiiliiiit- and in younir ehildi'en irres|XH.»tive of auv disetu^. T:.' .
will u..t |ia- it ^ water for iKThaps t wen ty- four hours, a]»ixinutly i:
r-p«".ial ran-!'.
Il'.t applications over the bladder and making the oliiM -ir:
iiM'i-. a-.i| amount «»f water will usually relieve this tHmditioii. It ^
«alU f..i- til.' ii.-cnf thf catheter, and s<»rious results mxil not K^.ipjT-
Km Ki>i- ilncoiitincneeof Urine). — Ennn^is is a ciinditi.-ii ii
tli'i-. i- ail invnlnntary diseharjjje of the urine. It mav Ix- c-'Miii." ■
jH 1 i.HJj.-. It may al^i 1k' diurnal, noc*turnal, or IxUh. It is..f v(?rv:^•
.M .urn ii. «• in infancy and ejirly ehildhcKKl. It is a symptom niili-"*
.li- :.- . and in m..^t ca-es is a true neunisis. During the tir-t vritr-' .:
infant ha^ n..t learned to assume cvmtn.d of the met^hanism ut lui-v ■*
luit dnrin- ilic MM-mul year this eontrol is usually attained at an '.-•"•
a lat. r jm i'i«»d aj-coiMlinM; to the individual.
i:ii.)i.M(;v.— The c:uises of enuresis may be orpiuic or functi-r..
latter in all [.n.l.ahiliiy heincr very eomnionly of a reflex natim-.
DISRASES OF THE KIDNEYS, BLADDER, AND GENITAL ORGANS. 947
The organic causes oompriae such malformations m small ureters, a
tnall bladder, exstrophy of the bladder, and hy^io^padias. Euuix'sis may
Iso be caused by central lesions of the brain and cHjrd*
The progmjsis and treatment ui' these organic castas of enuresis vary
rdiDg to the conditions which cause them, and need not be considered
ere. In a large ntinilxT of etises the children are of a highly nerv'on.s
emperament, but enuresis is als43 oiXcn present in ehildren who otherwise? do
lot show any nervous symptoms. As ha^ been «tated by Kaehford in an
tdmirable pa[ier on this subject, this crmdition may dejjend ujkui (1 ) iiri-
ible and unstable nerve-centres, {"2) anH?mia witli malnutritiuu, and (3)
sflex stimulation of certain nerve-centre?* in the lumbar cuvfL The lon-
itudinal and circular muscular tibrtna of the bladder, w^hich by tlieir am-
S'action empty the bladder, are innervated by sensfory and rai>tor nerves
from the lumbar i-egion of the eorti, ami tiie external i^tpliincter in the pi\»s-
itic jK)rtion of the urethra, w hich by its contraction prevents tlie escape of
Tine from the bladder, Ls also innervated by nens^ory and motor nerves from
the himl>ar ajixl. The i-eseai*ehes of Von Zeksl t*how the manner in which
reflex causes may act in starting or cheeking the How of tlie urint*. Thus, a
reflex caiTicil to tlie prc»()er cx^ntif in the hunbar wrd woidil, thnmgli the
Xnotor librci?. of the ei\*etor uer\'e, contract die muscailar e<jat of the blmlder,
Und thmugh the inhibitory fibres of the same nerve relax the sphincter
vesica. In this maimer the urine which is Ix-ing exi^elled by the eonti-aet--
ng bladder is alloweil to pass without hinderanec^ through the ni'Iaxed
Bphincter vesicie. It is also t*) he rememl^eretl that the act of urination is
in pait under the contnJ of the will* Admitting these anatomical and
psychical facts, it is easily tmderstood how the causes wliieh prmluce enuresis
may act in two ways: either dii^-dy on the (X^ntrts in the lumbar e*ird,
making them more UTitable or unstable, and in that way increaiiing their
pieflex excitability, or indirtMrtly thrt>ugh exaggerati^l n?flex eaus€*s that afftxt
)oth aecelemtor and inhibitor influences sent to the bladder. These influ-
may be psychic, originating in the bmin, or may Ik? the result of
external irritation originating in or near the bladder it^ielf.
There is aUo during childhood a lack of development of the oentres of
inhibitory reflex act«, and in tJiis way the muBcular fibres of the bladder,
liaving no iidiibitory restraint, ait? excited to arti<*n by even .^i slight a
l^eflex cause as a small tpiantity of urine in the blailder. For this i>as<»n
enuresis is a normal ciindititin during infancy, and c!ea.ses when tlie child's
inhibitory mechanism is more developtnl (Soltmann). The inhibitory influ-
ence of the will is in abeyance during dtx'p slumlier, and n<xlurnal inrxmti-
Hence is therefore more frcH^uent than diurnaL In any disea^'s which iint
fiocoro[>anied by ansemia and mahmtrition tlie reflex irritability of the
lumbar nerve-centr€*s is much inereaMtl, and enuresis may result. Keflex
enuresis may be caused l)y irritation in any |»ortii)ij of the gen i to- urinary
Iraet^ as by a veatcal calculus, cystitis, vulvitis, phimosis, very add urine,
nod over-filling of the bladder, as in diabetes, or by an irritati(»n of fH)me
year. The c-ciscs in which enuresis docs not disap]
always in prls.
THKATNfKNT. — Tho treatment of this fuiicti^
often viTy unsatisfactory. A(»cordiiig to my expn
of cases the iliseas** is intractable and is not al
whatever, the in<livi(lnal finally rt»c*>vering with
ean'ful examination has shown that no nialforn
lesion i-^ jn-esent, the urine rIiouM be exaniintn:!, to
inally aeith When this is found to be the canst»
cure ean 1k' (^fK^cttHl in some eai^s by siniplv diliitii
es|M-<'ially Avhcn thert* is irritation around the mea
cations an* of ^reat service, and in some oases dilal
iliiee a permanent cure. Where phimosis is prest
times olitainetl by cin'umcision. The bowels shoii
well to have tin* child |iass its water just before go
it in the niithUe of the nij^ht in onler that it may
foot of the ImhI shouhl ixj raised, in order that the i
neck (»f tlu* bladder. There is no especial drug wli
be relied u]x»n in curing enuresis. Where the chiL
bilitated, inm and nux vomica are indicated. Whc
tal)ility of the nerve-centres, belladonna and atn>p
in relieving: this condition ; but in many cases thev
results even when pven in toxic doses. Faradism
or to the base of the sacrum and to the symidiys
iMMietieinl. Then* is, however, no routine treatm
ejise should 1h' studied ch)st»ly, and in manv instiino
of the etuidition hits \xvn found the enuresis can b€
DIVISION XVL
USEASES OF THE LARYNX. TRACHEA, LUNGS, AND
PLEURA.
LECTURE XL VI 1 1.
DISEASES OP THE LARYNX AND TRACHEA.
i
LARTKaoBPAsiCus.—Nftw GnowTHs. — FoRKioif BoDftt.^CEDKMA.— Laritnoitts.
LARYNX.^ — The afiectious of the larynx which occur inf»st oommoiily
in infants and young children are neuroses, new growths, legions pro*] need
by foi*t*i^n IkmH(*h, a^lema, and laryngitis*
Lahynocksfasmu8 {LaryngisniiLs Stridulus). — The neurcms which es-
pecially affects the larynx in infancy and childhood h what I have already
dt^CTiUfl under the name of laryngossiiasmni^ when !?|jejiking of reflex irri-
tation f if the larynx in my lectnn* on Nervous Dini^asi^s (|Jage 747). I shall
thereff>re merely n^fer you to what I said at tliat time c<mcerning it.
New Giw>wth.s. — New grt>wths in the larynx in infants and children
ftre rare. They may be wngenital, but these are very uuwmimon. They
may l>e malignant, such as e|>itheliomalu and saramiata^ or bc^nign, such as
fibmrnata, myxomati, and |>apillomata. Tho^ of the former class are no
rari* that they neeii hem* only l>e referred to. Of the latter cla^ the fibro-
mata and myxomata are Uh} rare to U* more* tlian UH-ntioued* The pajiillo-
ita, on the other hand« although rare, are the most common larj^ngeal
^|rr«)Wths lu early life. They may pnidncc such sfTious results that it is
im(>oitant to rt»cognizc them at once* They may be ct»ngi*nital. Their
c^use is not known* Papilloma of the larynx in young children is usually
multiple.
The Hyni|»tnms of this growth apjx^ar at aliout the first, sec^ond, or third
year. Tlie first symptom that is noticed is hriarseness. This hoarsenefia,
instead of |)assiug off in a few days, as is common where it arises from other
attk'tiniiH (»f tIjc larynx, continues and grt»ws more marked. The next
fiyniptnm is dyspnu'a, TliLs ap|iears at iutt^-rvals of a few months, or may
not arise for some years after the first alteration of the voiee^ The dyspmea
[first api>c*ars at night, when the child is asleep. In the daytimet when the
949
1 i\v |»ii»jriit»sis 111 iiK-fH.' rasi-K is* iniu liuiu%»?? iiit; j^rt
'V\\v U^t tn>atiiieiit of multiple papillomata Ls t
n'lnovr till' ^n»wtlis thnnigli the mouth.
TIh' ililVu'ulty of n'nit>val is in some cases so grea
roiu|H'tt'nt o|M^rators have preferred to postpone the r
is oKl«T. or until the symptoms are so urgent that 1
(•:iti«>n. The eliiUl during this time must be kept i
luit Ih'i\\ applieations an* not indicated. These gi
pK'trly n innvtHl, have a tendeney to recur.
KtiKKUiX Hnnitx — FoR'ij^n l)odies rarely lodg(
ariithnt otvurs mon» c-ommonly in children than ii
a|>t to put artieli's »)f every description into their mc
Thf .--yniptoius whieh indicate the presence of
huynx an* an attack of sudden suffocation and a clu
voicr in a c-liiM wlio has previously shown no sigm
>yiupioms of huynjj:t»:d disease.
The a<'ri(lrnt is t)ne whieh is so serious that the
at once in the hands of a laryngologist. The larvi
wiili tlic larynirosi'ojH*, and the foreign body remov
li»r«r|w. (ircat can* should Ik? taken not to push tl
(r.-K-licM. a- tra«'hc«»tomv would then be necessary. I
iiia«l\isii»lc to intHHluce the finger blindlv into th
iliini: whirh may cansc a sudden inspiration.
(Khkma. — tr^dcma of the larynx is not a con
lite. It may arise from a numlx^r of causes, and is
ease « iM'where or to >omc local irritation. It occurs
in iie|)Iiiiii> and in the acute exanthemata. It m
l>r«Mlii,c,l l»y Ineal Icslous, such as uhvrations, fro
iiili;il:iil..ii- ..f hot vajiors, from the swallowin^r oi
DISEASES OP THE LAR^'l^X AND TRACHEA.
m
HSAbitngitis. — The most erjmmon inflammatory It'^^ions of the larvux
IBch occur \u early life are (1) eatarrlial (fabe enjup, croup) and (2)
^UfJfj membranous (membranous croup).
Acute Catarrhal LarynfifitiB. — The pthological condition which is
rcssent in the acute form of laryngitis m a redness or h^i^eramiia of the
iryngeal raucMius membrane, awximpaiiie^l by niort- or leas swelling and
08 ©xiidatiiin. The cause of afiite c*atarrlial krynjritift is otlen a simple
Kteosion of a mtarrhal wjudition of thij nose aiul [iharynx to tlie krjnx.
fore rarely a catarrhal coiiditirtn of the bnmchi and trachea may extend
pward and involve the larynx. At times the cuuditiou appmn^ to be die
^nlt of atmospheric changes and undue exposure to dampness and cold.
?he lumen of the larynx in infancy and in early childhood is so small that
iven a moderate swelling of the laryngeal mU€on8 membrane may pn^liK^
tufiicieiit stenosis to give rise to marked obstructive symptoms.
Symptoms, — The symptoms of acute laiyngitis ai^ a heightened ti^m-
lerature, ;l8,a^ 38.8°, 30,4'' C\ (lOP, 102", i03^ F.), and even higher,
poarseness, and enough. These symptoms, otviirriug in cfjiniection with a
■irecediug rhiuitu§ or pharyngitis, or arising from a primary inflammation
pf tfie larynx, may ixmlinue for a nnmWr of days without any more s(*riou8
Hianitestatious, ami if ttie child is kept in an e<pmble tempi^niture the attack
pay pa^ off within a week. In some ca^es, however, another set of symp-
ionis may ap[K'ar after the primary manifestations have la>tc<l for a variable
>eri*Ki Tlie child may have been as well as usual during the day* and
nay have l^een playing alxnit. Towards the latter |»art of the day its voice
bay have betxjme hoarser, but otherwise no especial symptoms may liave
iri^n* The child, aller l>eing restless for a time, suddenly awakes, and
r|)riogs up in Ijed frightened, often eintehing at its tliroat as if it hiul a s«en-
lation of suffocation. The cough, which during the day was hoarse and
lomewhat metallic, is now loud and nLS|>ing. The child has difficulty in
)rt»atJ]ing, amount lug to orthopufea, and it^^ face is aingested. These symi>-
Dras continue for a variable peri^id ; usually they last for only one or two
lours, but rarely they may continue frir many houi-s. In one very nn-
pommou cit?e wt^ieh w^as under my care the attack lasted for three or four
ireeks, during which time it otlen seemetl as thougli snffixation was immi-
lent. There was in this case no evidence of any lesion beyond a catarrhal
aryngitis, and recovery finally t^xjk plact?. These attacks are [lartly due
io (ilist ruction in the larynx from the swollen mucous membrane, but ar©
argely the result of a neurosis due to a highly sensitive ef>ndition of the
nucfius membrane. On the f*>llowing day the hoarseness may omtinue,
mt the child may seem bright and may |jlay aliout a^ usual. It is very
common for the attack to recur on the secrmd night with greater severity,
lUt in <vrtain cases one attack terminates the dlsi*ast*, and af\er a variable
rifxl of days, the voice becoming clearer each day and the tenjperature re-
ming to normal, the child recovers. diiUlren who have once hail attaoks
f this kind are liable to have a recurrence until they grow older*
Dv uiv loriiiaiioii oi u iiit'iiiuruur in iiie iui'\ iix.
'Fkkatment. — The trtiitmeiit i»f acute catarrh
tin* <*hilcl ill a riMUii of an ei[iiable tcnijX'rature o
KIS'' to 70^ F.) until its tomijerature has Ijecome no
has <lisa|»}M*anMl. I havo also ibiiud that a few <
^ivcn ill tJK' latter part of the aflern(M.>n and just i
sl«i'p, an* of iK'iM'Ht in prcventiug the 8{>asmixlic
wliirli I liavt' just (lescril)ed as occurring in the u
iMtur^ in tlie night the symptoms of sutJcKiuion c
<lnM' of fnun ten to tiftecn dro|»s of wine of i|x»car,
to nauseate >li;rhtly. An emetic will sonietiiues cut
nature, l>ut in niauy ejisi's is not necessary. An am
to iiauseat<' sliirhtly, i)ut not to cause the child to v«
tin* spasui <if the larynx that the attack will SiX^n
<ases. however, even if vomiting has i)eeu produce
and nthrr measures for ri'lief are recjuired. In atldi
erate dos<s of tiuetura opii i^mphorata mav be giv
strain usually ^iv(\s ^riMit relief to the s|>asm.
Aeutr laryujritis is a sc^lf-limit^^d disease, and one
is aininst iuvariahly ^ihkI. In children who arc» ver
the iuterf rciiee with their respiration may prove t
ea>es are rare and should l)e treateil with stimulant
nni its eonrsf. The symptoms of acute catarrhal
lyinL^ to the pan'uts that the physician is often led t
niop' -«ri(»ii-Iy than is necvssary. Many accidents 1
ini|>i-«>ju'i" mauairrnicnt of the steam, from giving s
miueral. and Ironi the exhibition of .strong drugs, the
i\n\ Tlie iicer-<ity for ojKTative measures rarelv ari
Chronic Laryngitis. — A chronic form of lar
DISEABEB OF THE J.ARYNX AND TRACHEA.
953
ersally involved, and to regulate the climatic gurroundiugs of the child*
1 ap|>U(titiou8 to the lan^nx iu these cased are seldom neoessar}'.
PBeudo-Membranous Laryng'itia. — A j>seudn membrane in the larynx
my be raust.ll by the inlialation of irritating vaiMDrs, ur by the inspiration
corrosive licjuids. These accidents are so readily recognized that there is
[o difficulty in determining the cause of the pseudo-membrane in these
Treatment for tlie relief of the stenosis should U* institnttnl at rmce.
consists in the application of ccjld and such siHtthing Inhalations a.4
!.75 cc. (1 drachm) of compound tincture of iDcnzoin in a quart of boiliug
iter. The cxvm[>Iioating retlenm which is often prt^ent in these ea^^es may
uire oj)erative interference.
The most a>mmon miise of pseudo-membranouin laryngitis* and the one
hich prolnibly in all cases produces it, is some fnrm of nn'cro-fjrganisni.
hese micro-organ is ms» as I have alrt^ady stattxl in my krture on diph-
eria, may be of sieveral varieties. Until it is proved not to bi^ so, bow-
er, pseudci' membranous laryni^itis must U: elinieally looked U|»on as in-
loiis and due to the Khjl>s Lix^fflrr liaeillus, I must again inipR^ss uix>u
Oil the fact thata sim|)le catarrhal inflammation hx^lizeil in the larynx may
pnnlucf^l by the KI(l>s-Ij«»t*tHrr IpariUus, Pseudo nienibramHis laryngitis
may then, until further investigations pn>ve the cjintrary, b_* defmetl as an
fectious inflammation of the munnis membmne of the larynx a*rirni|miiicd
ly u psendo- mem bra nous exudatiMU, whi<'h ni;iy Ix* caused by a nnnil>er of
|iiier«>orgnuu=imfl, of wbirh, acLTuxliug to our prest^nt knowledge, tlie Ivlebs-
>etHer ba^-illns U the most cummtm.
I have descritied the symptoms, diagnosis, and treatment of jvseudo-
membranous laryngitis in a previous lecture (page 824), and i?hall, there-
ore, refer you to what I tht-n said.
Some aid in the ditrerc^utial diagno*^is of fiseudo- membranous from acute
tarrfial laryngitis mn be t^btainwl fmm the tern jm^ rat u re, which in the hitt*'r
c<jnsiderably raised, while in tlie former it h mtidcrate and si»metinies
normal or subnormaL The slow course of a constitutional dis<ai?e gnulu-
lly causing oljstrnetion is signifinmt r»f this inft^-tious form of laryngitis,
TRACHEA, ^ — Fatliologiml i-onditiiins of the trat'ht^ not C!onnt*cted with
ihase of the air-passage&i above or l>t*low it are uncommon. The lesions uf
Ihe trachea may be primary or seL^uidary. In the latter they are merely an
^tension of the disease fmm the larynx or the bronchi, and do not play
ftn es[>eeially significant part in the attack. Tlie only primary disi'as*^' iif
ftlie trachea which is common in infancy and chtklhiKKl Ls an acute inflam-
fuatiDn occurring in its mucous lining. When this inflammatory HiiKtitinu
pn'Sfut, it produces an irritsiting cough wliifli can usually be ext-ited by
sntle pressm^ over the tmckca, — alK^ut the only method by which w^ can
ocate the disturbajiee.
The treatment is to pn^tc^ct the child from an atmosphere which is either
hot or too cT)ld, from high M'intls, and frnm dust. Douching tlie fn>nt
f the n(!i'k with cc»ld water several times during the day id also desirable.
LUNGS. — The disi'jtses which affect the lungs ii
(litVcr soniowhat t'roin the same dlsc^ases occurring i
of the (litlereiK'es whic'h exist in the anatoniii-al i
(hiring the early years of life, esiiecially the first fi^
have (leserilK»<l to yoii in pn»viou8 Icxjtures (pages
tohl you that the prinei|)al differences were that
relatively lar^T i>ortion of the huig in the child
ill the tl»rnier the interstitial tissue was present it
tht' eaviti(»s of the air-vesieles were smaller, and thi
tivcly thicker ; also that the epithelial c^dls linin
very numerous. Thesi* cx?lls in inilaniniatiou tend
whi<li is our of the ehanieteristics that mark the p
These anatomical ditfeivnec^s are of great signific^anc
lun^ is (liseits<'(l, and tend to make a congested lun^
im}M)rt in the youn^ child than in the adults I si
mmIIm' to you all the various |)athological conditions
i'hild's lunjrs, hut shall nstriet myself to those clini<
\N hi«h re|>rescnt the esjKM»ial diseas(*3. In order to t
tile <li>eas<' acconlinjr as the Immehi, the alveoli, or i
are inn^t affeetiNl. You nnist remember that [X)s
often >how various lesions which during life were i
definite symptoms, so that we mnnot ex|>ect the clini
entinly the pathological lesi<ms. Beginning with
w lii<h is a direct contiiuiation of the larynx and tl:
>|)eak (»f bronchitis.
JJuoNciNTis. — HroncI litis is often seoondarv to ?<
a direct ('xt<'nsion from an inflammatory condition of
In a iimiilH'i" nf ra<rs, however, the group of svnipt<i
DISEASES OF THE LTJNOS.
96S
ihial tubes — namely, the prominence of its capillaries and its comparatively
■lose cjonnection to the muscular walls — render the bronchial mucous mem-
nitine peti^iiliarly suswptible to congestion. Exposure to sudden atmt)«^])heric
kbanges, esjxiially humidity, ap|>earij to be of great etiological im|>oitance
En the prtnluction of bronchitis* Any impurity of an irritating nature in
BHiuiJpired air may in certain individnak result in an attack ol* bn»nchitis.
p. catarrhal inflammation of the np].wr air-passagc!«. Is ollcn followed by a
limilar intlammatiou of the bronchial myc<ju.s membrane. Bronclntif? is
■f frec)uent occurrence in pertussis and meaales. It Ls in children often a
prominent symptom of typhciid fever, and is a fret^nent t*onipIicatinn of pul-
konary tulxTculosis and epidemic inHnenza. There are alst^ trrtiiin disea^^cs
pf nutrition in which bronchitis frequently occurs. The niimi prominent
pf these is rhachitis, in which the complication of bronchitis is often of
■erious tmpjrt.
I Acute Bronchitis. — Pathology. — The [pathological conditions which
pre present in acute catarrhal bmnchitis ai"e, acconling to Delafield and
Prudden, a c<»ngestion and swelling of the mucous membrane, and an arrest
pf the functions of the muaius glands. Later, tixe mucous glands resume
their functions with increased activity, the congestion diminishes, there is an
Increased dt^quamation of epithelium, an increased formation of the deeper
ppithelial ct4ls, a mmlerate emigration of white blocxl-ivUs, and s«>nietimed
ihe red blood-cells also escape thn>ugh the vesw^ls. The whole process is a
bujjerticial one, and den's not prmluce any change in the walls of the broncfn
beneath the mucous membrane, unless it has juTsistetl ibr !^>me time, when
there may be a slight thickening of the walls. When the inflammation
Involves the smaller bronchi they may Ik- occluded, Tlie occlusion of the
pmaller bronchi may result in the cmj! lapse of the gn)Up of air- vesicles to
krhich they lead, and thus will be produced areas of atelet'tasis, which may
pe furtlier changed by inflammatory processes. The bronchial glands are
pequently enlargtxl, even in mild attacks of bronchitis,
I I have here the section of a lung (Fig, 133, page 956), made by Nor-
Ihnip^ taken from a child, which shows the exudative inflammation of the
bronchi which occurs in acute brrmchitis.
[ The speturaen shows hy}>erp]asia of tlie lymph-glands due to bn^nchitis.
Ellis condition is very commonly found in bn>nchitis, e8|ie<*iiJly when it
bccun«i in debilitated children. There is desrjuamation of ttie epithelium
lioing the bronchi, as well as a slight thickening of tijcir walls,
I Symptoms. — ^The onset of acute bronchitis is usually mild» but I have
■Mil in a debilitated infant a simple, uni:*oinpli('atcil Immcliitis Ix-gin with
Mcnivulsion. The symptoms are very varial>le in tlieir intensity, and are
ksually more acute and definite in a previously healthy child than in
Bcbilifiiled childn*n, in whom tliey an' oft^n subacute and of an insiflious
patun*. In infants and young children the brom^bitis is almf»st always
brw^ed by a catarrhal t^ondition of tlic iipptT iiir*|i4is8RgeB. In the mild
IftseB there is a heightening ol' the Urupi^niture, 37*7"^ to 38.3^ C. (100*^ to
9&e
PEDIATRICS.
101** F.\ cough of greater ar less severitj't and a diglit IfsKoi^ill
up|>etite. On physic-al examination the ptilmonarv resoniiwe ifciii
Ih' normal. A few sibilant and sonorous rdles are be^ widifff^'^
<jiit*ucv in the area btjtwwn the tR:a]>ula antl the vertebral <T>lunj
rtlles may also be heard. In ?ever« cases the children siu^
lesii di8<ximfort, produced pmlmhly by the thoracic ■ •
diildren the Im^aUty of the pain cannot, as a hji
oougb is hard and dry, the respirations may be i^lightlr mmi m ft l
Fig. ISa.
\Lym,GI
"' Art
Br., brtmehiis. Art.. nrWry , Lym, iil., lyiiit.h ^Util
pulse qtiiekene*!. The children may appear quite sick f*>r r^A i r
days, aiul tht^ tern|iL*ratiiiT jnay rise as higli as 118.8^ or liliM <
or 102.5° F.) ; but when thi.s hitter point is reached the onset of abm
piieumonia should 1m * cure fully watclied for, P8|MHnallv if after f'
four to (brty-cight houn? tlie teniijeratiire din:^ not fall to 37
C. (KK)^or lOr F. ,
After a few days tlie severity of the symptoms lessen8« Uie c*-
looser, the rales gradually disapfiear, ami under favorable o.
symptoms subside entirely in a week or ten davs. There U -
exjiKji^toration in children under six or seven years. In the mm <^
cases the rales are more* nuniemus than in the mild f»*rm of thi^diw
are of the same eharactcr. In the course of* some i^aees f»f hmpchiti^t*
porary localized diminution or even absence of the n'spiratiirv iood i
result from the occlusion of a bronehns. This is esptniillv^
infants, and onlinarily is not ae«^>mpanied by a ehanw in die
s^innd. This form of Ijronchitis is the one which allect^ the Itiff^
tJie mtdium-sized bn>nehi.
BtSEASEB OP THE LUNGS,
957
There is no characteristic temperature in bmnehitis. As a rule, it is
loderate» 37.2"* to 38.3** C. (99^ to 101 ° F.), but it varies greatly accord-
Ig to the individual and to the degree of nervous excitement
DiAGN08i8.^ — The diagnosis of the ordinary ca-^ics of acute bronchitis,
here only the large- and inediiim-sized briDuchi are affected, is not difficult,
le only disease fur which it is likely to be mistaken being hroncho-pncu*
lonia. In this hitter disease the greater severity of the symptoms and the
igher temj)tTature will usually show its presence, even though the physical
gns may be only tliose whicli I have deseribed as occurring in bronehitis,
II the more severe forms of bronehitis it is iii>metimes exct*edingly difficult
I make the differential diagnosis fnim broncho-pneumimia. If, however,
le temperature, after three or four days, remains high, and rises to 39.1*^
• 39.4° C (102,5*^ or 103*^ R), with markeii remissioiLs and exacerlmtions,
ie diagnosis beeomen doubtful, and in these *?ast?s we sln»uld strongly susjiect
lat a broncho-pneuraonia has arisen as a coniplieation. We must, how-
, remember that in certain easei* of hnmeho pneumonia the tem])erature
lay be as ni<»derate a^ in aeute bronchitis, and we must therefore rely on a
combination of symptoms rather than on any one symptom or sign. An
pmpjrtaut ]w»int iu tlie dittereutial diagnosis between bronchitis and broneho-
I Dneimionia is that the physical sigus in the former ai'e much mort^ fn^piently
bund in all |>arts of the thorax, while in the latter circumscrilxHl groups of
leas are often detected in ditferent parts of the lungs. The niles iu them-
Ives, however, are not distinctive, as the nili^ in lironelK>-pneumonia are
lostly those of the acc^ompanyi ug bn^nchitis. Although the physicjil signs
f dulness and bronchial respiration are conclusive evidences that the case
not one of bronchitis alone, yet an absence of these signs does not justify
Jos in excluding l>roncho-pneumonia. Where the dyspnoea, general prostra-
Ion, and restlessness are slight and the temjx»niture moderate, the case is
ikely to l)e one of bronchitis, while if thi^o symptoms are marked, and are
ombined with cyanosis, ililatatiou of the nla- niisi, and a higher temjjera-
nre, at least a provisional diagnosis of broncho- pneumonia should be made«
some ceases the differential diagncrsis will als«> have to Ix* made from the
«iflet of a pleuritis or of a loljar pneumonia, but the mmlenite tem]>erature
|1k1 respirations, the normal |>t?ri'Ussion-sounds, and the diffuse bihitenil rAl«
|i bronchitis usually make the diagnosis from tliese diseases quite evident*
PaociNosis. — The prognosis, when* no rompli«ation arises and the child
B previously healthy, is good. In debilitati'd children, and esjuvially where
lim^hitis is prtf^ent, even a mild form of bronchitis may prove to be serious,
aetHumt of thedanger of a eomplif^iting bmncho-pneumonia, and in these
IS the |irf»gnosis is much more unfavorable.
Treatment. — The treatment of acute brtmchitls is essentially hygienic<-
T'hc child sliould lie (*onfined to a warru» welb ventilated room which has a
anny ex|H>sure, and which is heatccj by an opni fire to a temperature of about
0** to 21. P C. (G8** to 70*^ F.). A few drops of wine of i\wimr shotild be
^ven if the oough is unusually diyj and to thiss a few drops of tinctura opii
i>l til'- -rii:ill« r iiPHH-lii. lif'f '/" (tn/iitifi/ oh€j<. I li
til-*-, riur-f. tV«»m tluir rliniitil hiirtorA', :?eeni t«:
rliiii- ratlur tliaii <•!' Iinni<-li«»-|»ni.*niii*»nia. I ^jK-ak
-Miilit'iiM- ilitli-r snin»'\vliai fmni tlio-^* of an oi
l-.i-m ..i" lipnicliiti- lia- no i-oiiiuftion with what
.•:«ll..l rapillarv lironcliilU, l»iit which i.- uow \v
i.ulv -\iv^*- nf iir«»inlio-|»iieninniiia. Thi< f«»rm <
li:i- ti.iniMMiilv iM'<'uiT<'<l in infants in the first r
liav m«t with it as late iL- the third yc'ar. Tl
:t-i . riaiii'-<l. wa- tli«' sum- as in an onlinarv bronc
-.1 iIh- iip|MT air-}»a.*-air«**i usually pi\it<Hiig the
.li-in-i- \va- rapi«l, an<l tlir symptrmiri sc>»n Ix-t-an
iM ratlin- ua-. a- a rule, nnKKTat<»ly rairH-cl, :17.7^
1'.'. 'ill*- ciMiuli wa-i <-<»ntiinious, and fly.spnrea, v
i;i|.i«llv il vil'»}M«l. An examination showed non
A li.il." tli'Tax, ami ihw moist rales. The res^pinit
WM- .jiiiik, and all tlu* symptoms were of a violei
IIh- inliint- \v<-n' much <li>tressiKl, and were uu
Vih-r IPUM twj-nty-funr to lorty-eight hours the s
iii. tiMiiM ratlin- lM-<amc normal or was only slij
iii..i«t vi-.l- wi'i-f n-placiil l»y t-^tarse moist n'lles ami
I. si. « .1 ail «'nliiiary l)n»nrliiti.s of tlie hir^T and
hi the «:uly limirs and days of the disea-sc\ w
tii'Ir li«i-lit, and it' the infant is weak and del
l.:i<l. 1 r. hnw.vrr. till' first ii-w days are passed
ih\ .iii.iliK" tak«-» pla<-«'.
'1 III- rMi-iii nf hnmchitis is to be diflerentiated
i I t. iiiiM iMiJiii'. iii<t«ad ol* n'niaininj]: hijLrh and 1
DI8EAS£S OF THE LUNGS.
969
auBtion is lial»le to occur at any moment. The extreme oongeition of
blood-ve8sels of the smaller bronchi may in some case8 occlude the air-
ancl areas of atelectasis may result* 1 lie indications for treatment
I oxygenate the blorjd, to support the i$treiigtb until tlie di.'^ea.'^ has run
958 PEDIATRICS.
(iiinpliorata may he added if the jiatient is excessively nervous. The^ reme-
dit^s are all that will usually be needed in an attack of acute bronchitis.
Where a rhachitic child or one who is much debilitated is attacked by the
dis<'jisc, esjKvial care must be taken to support its strength by stimulant?
aiul (iHiil.
Besides the acute bronchitis which I have just described, I have md
with a class of ca.s<.\s which are extremely rare, but which, apparently, are iii-
Htanecs of an exaetTbation of an ordinary bronchitis through the invulvemeut
of the smaller bn)uehi, not the terminal ones, I have seen only six of tlioi'
eas<s. These, ln)m tlieir clinical history, seem to have been cases of bron-
chitis rather than of broneho-pneumonia. I speak of tliem 6ei>arately, as the
symptoms ditler somewhat from tliose of an ordinary bronchitis. Thb
f<>rm of bronchitis has no connection with what was formerly erroneously
csiIKkI capillary broncliitis, but which is now well known to be only an
early stag<» of broncho-pneumonia. This form of bronchitis in my ea>€!>
has c»onimonly occurred in infants in the first two years of life, though I
have uwt with it as late as the third year. The cause, so far as could be
aswrtained, was the same as in an ordinary bronchitis, a catarrhal condition
of th(» upjKT air-passii^es usually preceding the attack. The onset of the
(liseast^ was rapid, and the symptoms soon became very severe. The tera-
]KTature was, as a rule, mcxlerately raised, 37.7° to 38.3° C. (100° to l^H'
F.). Th(» cou^h was continuous, and dyspnoea, witli more or less cya^^^^i^.
rapidly developfnl. An examination showed normal resonance through ilie
whole thorax, and fine moist niles. The respirations were rapid, the ]ailso
was (juirk, and all the symptoms were of a violent and suftlx'ative n;itiin\
'J'lie intimts were nincli distress^xl, and were unwilling to lx» laid dewn.
After from tw<'iity-t'our to forty-eight hours the sympt(.)ms grew less sivcrv.
the teniiK»ratiire luH'ame normal or was only slightly raised, and the liue
moist rales were replaced by coarse moist rAles and the sibilant and souonjii?
rAles ot' an ordinary bronchitis of the larger and the medium-sized broiirhi.
In the early hours and days of the disease, when the symptoms an* at
their hei«::ht, and if the infant is weak and debilitated, the prognosis b
bad. If, however, the lii-st fvw days are passed in safety, recovery almost
invariably takes pla<'e.
This form of bronchitis is to be diiferentiated from broncho-pneumouia.
The temperature, instead of remaining high and having the remLssious of a
bronrhcKpneiunoiiia, soon lalls so as to corrcsjwnd to that of an onlinary
bronehitis. Fhe physieal signs are those of bronchitis rather than of |)nrii-
nionia, and the rapid r(H*overy of the infant with the common svmptom.sot*
an ordinary hrcMiehitis, rather than with the prolonged and characteri^nV
.synipt(ans (►f a l)n)ncho-pneumonia, verifies the diagnosis of an inflamma-
tion of the smaller bronchi.
1'hes(» eases may be complicated with broncho-pneumonia, as are the
ordinary eases of l)ronehitis.
1'he treatment ol" this class of cases is very important, as death fwm
DISEASES OF THE LUNGS,
959
exhaustiou is liable to occur at any moment. The extreme congestion of
the blood-vessels of the smaller broDcIii may io scjine cases occlude the air-
iU', ;i tiHiuUii) oM,
s, and areas of atelectasis may result. The imiications for treatment
are to oxygenate the blood, to fluj>|)i»rt the strength until the disease ha& run
960
PEDIATRIGB.
its course, and to prevent the in&nt from falling into a oomatose oond
The treatment, therefore, is the administration of oxygen, the use of s
lants, oonsisting of aromatic spirit of ammonia alternating with brand;
change of the position of the infant from time to time.
Here is an infant (Case 459, page 959), three months old, who has for the pc
days had an attack of acute bronchitis, characterized by a paroxysmal, dry cough, 8
accelerated respirations and pulse, and a moderate temperature varying from 87.7^ t
C. (100«> to lOIo F.).
The percussion of the chest has been normal, and there have been some sonoro
sibilant r&les, with a few coarse moist r&les heard on both sides of the chest. £ax
morning the infant was attacked with excessive dyspnoea and cyanosis. Its pulse rof
120 to 180, its respirations from 80 to 70, and its temperature from 87.7<' C. to 81
(100^ F. to 102.5** F.). An examination of the chest showed normal resonance ai
moist r&les throughout both lungs. It has been very restless, refiises to take its foe
evidently wishes not to be laid down in its bed, but to be carried about. It is being
with alternate doses of aromatic spirit of ammonia and brandy every half-hour,
physical signs are those of a diflUse bronchitis of the smaller bronchi, which you see
indicated by small black spots painted on the front and back of the chest.
(Subsequent history.) After twenty-four hours the temperature fell to 88® C. (
F.), the pulse to 150, and the respirations to 44. The fine rales were replaced
ordinary coarse r&les of a bronchitis, and the infant rapidly recovered.
The symptoms and course of all these cases are very similar, so 1
shall speak only of one other child, whom I saw in consultation witi
Horace Marion, of Brighton.
CHART 82.
Da^B of Disease^
j
t
2
3
4
6
e
7
S
C.
1'
aot'
106'
g
105
lod^i
102'
101^
It Cm HAL
9/
96
95"
sTe
liE
Hi:
MV,
UE
ME
ME
a £
41.1-
40.5*
40.0'
39.4' .
38 S°
38.3"
37.7*
37.2*
37.0' 1
36.6*
36.1'
35.5'
35.0'
/
f
"^
Lr:
^
—
^
S^
Acute bronchitis— exacerbation. Male, 7 months old.
A male (Case 460), seven months old, and previously healthy, for two days had a
cough, with a few sonorous r&les in the chest and a temperature varying from 86.6® t<
C. (98® to 99° F.). On the third day of the attack he was suddenly seized with in(
cough, dyspnoea, cyanosis, respirations of 70, a pulse of 160, and a temperature of Si
(101® F.). An examination of the chest showed normal resonance and fine mois
DISEASES OP THE I.UKG8.
961
111 both lungs. The infant wus treated with nromatic spiiii of &mmonia nnd bruiidy
I aUeitiate do8e«. On the following day the tempK-rature fell tu S7^ C- (98. 6** F )♦ and the
fine riklea were replnced by coarse hile^ and eonoruus rale-s. Tbij broncbitig tnfited for a few
dap, and the infant then recovered entirely.
Here is the chart (Chart 82, page 960) which ahowB the sudden ns4j of temperature.
I
I
I
I
Chronio Bronchitis. — Chronic brooch itis may result from a r^eries of
attm^ks of a«.'att} bronchitk, or from a nuiwber of otber causes. Among these
may be mentioned various affections of the Iitngs, such diseases ct^nnected
with malnutrition as rbachitis, and prolon^^ed attat*ks of |M*rtussis.
The pathological conditions occurring in chrooic bronchitis vary greatly
in degree, and the lesions found at the post-mortem examination are often
slight in oc»mparison with the severity of the symptoms during life. In
cases there Ls a considerable production of mucus, pus, and serum. In
which have lasted for a long time, in addition to the inflammatory
products aflecting the walls of the bronchi there may be dilatation of one
or more bmnchi, and tlie muscular coat may be thickened or thinned.
Emphysema may also result.
The symptoms of chronic bronchitis are very much the same as those
of acute bronchi tLs, except that the temjx^rature is not so apt to be
heightened, while the general symptoms of malaise, anorexia, and loss of
weight are more prominent. In severe and prolonged cases whei-e emphy-
eema is presentj the thorax may assume the jwsitioo of full inspiration, the
ribs being permanently raised and the anterr>-f>osteri«»r diameter of the chest
inerea^ied. The physical signs art* the same as in acute broncbitis, so far as
tlie r^les are concerned. The resonanoe ts usually normal except where the
chronic process has produ<\J empli^sema, in which case there will be areas
of hyper-resonanoe olleu ass<>ciat(^l with a tympanitic t*>nc. Occasionally
atelectasis of considerable areas of the lungs may take place, with a resulting
lessening of the rt^piratory sound. This o<H*urrcncc may in some cases
prove to be serious, but in others the accompanying symptoms are mild, and
the alveoli may again return to their normal degree of inflation.
The diffcn>ntial diagnosis is to be made from chronic aflt'ctions of the
lungs in which tfic thickening of the interstitial tissue has taken place with
a resulting lessc^ning of resonance, and fpjm tlie c*judition in which the
bronchi are dilate*!. In the latter case there are accorapanying symptoms
of a profuse exudation of purulent matter.
There is one form oi' bronthitis which from its duration may be called
chronic, and yet which from the very slight degree of constitutional symji-
toma that aotsompany it c^irres|irmds rather to a subacute affection. In these
casGAy which usually occur in infancy and in early childho«xl, the child often
ippearB quite well, but for long perir»ds of weeJcs, or wheoever it is exposed
to a damp atmosphere, a loud wheezing will be heard in the chest Auscul-
tation will a'veal Uie prt*senc« of sonorous rdles everywhere, and in this
variety^ as well as in other forms of chronic bronchitis^ a roughened senjsa-
tioD may sometimes be felt on patpaticui during n^>inition,
61
962 PEDIATRICS.
The prognosis of chronic bronchitis varies according to the cau
Where it is secondary to disease of some other organ, it depends entire
upon the prognosis of that disease. In rhachitic children the prognosis
unfavorable, and in them a broncho-pneumonia is especially liable
develop, with a fatal issue. Cases of chronic bronchitis are also liable to
invaded by the bacillus tuberculosis. In cases which are the result of aci
bronchitis in individuals otherwise healthy, the prognosis is favorable, pi
vided the proper treatment can be carried out. As emphysema in chror
bronchitis is rare in children in comparison with adults, the chances f
recovery in the former are correspondingly good.
The treatment of chronic bronchitis is essentially climatic. The ch]
dren should be kept in a warm dry climate for some months after the bro:
chitis has entirely disappeared. Especial care should be taken that tl
child is suitably protected by flannel undergarments. Where other trea
ment is required, as a rule, tonics will prove of more benefit than the dru|
which are usually administered for their direct effect upon the bronchi
mucous membrane.
Fibrinous Bronchitis. — During the course of what may appear to 1
an ordinary bronchitis, in rare instances a fibrinous form of bronchitis hi
been met with. In this variety masses of fibrin in the bronchi form cas
of various extent according to the number of the bronchi which are affected
The disease may run a short course of days or weeks, but is usuall
chronic and may last for years. The paroxysms may also be periodic.
The diagnosis can be made only when portions of the casts have bee
ex{Xictordted.
The treatment is chiefly by the inhalation of steam or of atomized lim
water, and by supporting the strength with proper nourishment and stimu
lants until the disease has run its course.
Broncho-Pneumonia. — Broncho-pneumonia is an affection of the lunj
characterised by an inflammation of the walls of the terminal bronchi an(
of the alveoli. The disease may be acute or chronic. It may occur at anj
age, but is the most common and fatal form of inflammation of the lun^
during the first five years of life, and is much more fatal than lobar pneu-
monia at this period. During this early period, and especially during th(
first two or three years of life, the lung, from its embryonic type, is mort
frequently subject to the form of inflammation occurring in broncho-pneu-
monia than at a later and more developed period. The disease is usually
secondary to bronchitis, and commonly occurs in connection with measles^
scarlet fever, pertussis, and diphtheria. Broncho-pneumonia is also a very
imj)ortant disease, not only as grave in itself, but also because it is so fre-
quently followed by tuberculosis.
Etiology. — A prominent predisposing cause of broncho-pneumonia is
age, and where pneumonia occurs in a child under five years of age it is
usually in the form of broncho-pneumonia. This is due principally, as I
have already stated, to the anatomical conditions met with in early life.
DISEASES OF THE LITNQS.
963
I
Childrea who are weak or debUitnted by previous diseases show a predb-
podition to broncho-pneumoDia, and it therefore frequently arises in the
«our^ of tuberculosis, chronic gastro-enteric disease^ii, and rhaehiti.s. Those
geasotis of the year which are marked by ec»Id, moii^tui"e, and variationi* i>f
tem{>erature especially predisjK)se to the development of broncho-pneumonia.
AH these conditions, however, in all probability merely pi-epare the way for
the entrance of certain germs which produce the disea.se. What these micro-
organisms are is still uncertain, as it is known that a number of different
organisois can produce the disease. The origin of broncho-pneumouia from
intestinal infection must also be eonsidered, (Sevesti-e.)
I
Aeqte brc^cliCk-piietiniODia inTotvlng dlffereat Ai«a« of the Iuim;. A* ct^n^tlidiited li)Dj?-ti«sur ; B. dlUted
bniudhim (Winmi Muaettm, UuvArd Uiilvenlty^ )
PathoIjOOV.^ — In broncho-pneumonia the inflammatory pnK?c«8 affects
the walls of the smaller and terminal bmnehi, which become thickened and
markedly infiltrated with cells. The inHommatory process then extends
through the walls of the bronchi to the surrounding air-vesicles m well aa
to the terminal ones. In this way centres of consolidation are formed in
964
PEDIATRICS*
diflerent parts of tie lung. The course of this inflammation varies in
f rapidity, at times attacking only a small {R>rtion of the lung, and agi
being more difTuse in it8 oni^i and gradually invading large areas. T
le^ionri arc irregular iu their distributi^ui, and usually occur in both lun;
Tliey are at timers so extensive as to involve a whole lobe, but, as ha.*^ Ik
statal by Northr!ii>, whatever the extent of hepatization, whatever the tL
o<'t'upifxl iii its wurst*, and whatever the jx>st-mortem appearances, the esse
tial le.>^ion is an inflammation of the walls of the terminal bronchi and
the adjaaixt alvfH>li.
Tiiis lung (Fig. 134, p^e 963), taken fn>m a young child, presently
macrosoopie lesions of bnmcbo-pneiimonia. ■
You will notict* that tlie arenas of cou?«ilidation surround the bronc
and tliat thin bronchus (B) is inarki'clly dilato<L
This s<^tion of a lung (Fig. I'i5}, made by Northrup, was taken frt
an infant sixtetni months old, in whom the broucho-pneuraonia was a C50i
pliaition of measles. It shows the early pathological legions of broncl
pneumonia,
Fm. 135.
Brtmcbo-pneumonla compUcating measles. Early et«ge. C L, T. , ivmfoli dated long Uanifi ; Br.» bron-
chiole : Ij.T,, emphyaematoiis lung Ussue,
You will notice that in oue of the lobules there are two bronehioleg
(Br,) with infiltmted walls and pus within them. They are also filled u4th
exudation, and the lumen of each is almost eutii-ely occluded. A portion
DISEASES OF THE LUNGB.
965
cf a neighboring lobule is conmlidaied (C. L. T.}. A considerable {x>rtion
of the lung tissue (L. T.) in the section is, as you see, normal or emphv-
Mmatous*
Here is another section (Fig. 18fJ), made bv Northrop, ill iistra ting the
broucho-pneumonia which follows a diphtheria desoendiug fn>m th*^ upjier
air*pai»age8| and which may occur in any acute infectious disease* It shows
the typical lesion of broncho-]>neunionia.
FieL i;:c-
BroDcbO'pneiimcHila secoadiuT to flipl)tb<*rlii.
Tn the bronchuSj which you see enlarges in the middle of the section, the
lining muoous membranw is hanging in shreds into it^ lumen. The walls
of tlje bronchus ai-e densi.^ly iufiltraU*d, aud the contiguous alvHili are fillc-d
with exudation to a gi*eater or less extent and are e<jnH4_ilidated by it. This
section was taken from the lung of a child three years old who during an
alUiek of scarlet fever developeil diphtheria of tlie larynx, Thediphthcriti**
process descended later into the bronchi.
Here is another section (Fig. 137, page 966) taken from the lung of the
same child, but showing the tissue relatively ks** affecteil.
Many of the otjnsfjlidatt^ alve<)li contiiin tree* blood-cells. The bron-
chial wall (Br.) is infiltrated and almost entirely denuded of its lining
membrane.
These smaller bnmchi are surrounded by zones of intense congestion
and tntiltration. When the iuHammation is intense and is arcom|ianied by
abundant seeretirm tht^se brfjuilii fretjuently become diIat*Hl. This dila-
tation is ttSf*<Knal»Hl with a weakencnl ciindition of the bmuchial walls and
with an abundant secretion. These dilatations [irobably, according Uy the
BroQcho-pneumotiia eeoondary to diphtheriiL. Br., bmnfiihiiis ; C L.T., conMollilatod luag-tissue ;
K. L. T., lun^'tlaBUi* nearly iionuaJ i AtL, artery,
red blocKl-eorpuscles in varying pr(*[K)rtioii and amount* Filiriii whe
present is only in small quantities, and often is absent altogether. Th
capillaries in the walls of tlie vesicles are ooMgest<Ml and promiuent. Th
jK>rti<iiis of lung whieli arc not liepatizt^d are tx>ngested ami (t^dematom
The cavities of the air-vesicles are diminished by the enlarged capillarie
and the swollen vt^sieular epithelium.
In aiklitiun to tlie other lesions which I have just described^ areas oi
atelectasis are frequeotly found in broncho-pneumonia. This atelectasis i
usually piWut^tl by raechaniea! clauses, such as obstruetion by pns or tena
cious mucus. It may also arise as a result of enfeebled respiratory jwwei
The blood-vessels Ijecome dilate<l, tlie walls of the alveoli paitially enl)a|i9a
the residual air is absorbeil, and an exudation of serum with proliferative
DISEASES OF THE LUNGS.
967
I
I
bUs and leucocytes takes its place. The atelectasis m commonly Bvm met-
rical, affecting the posterior margin of botli lower lobes of the lung, but it
may also appear in irregular scattered ai'eas in the jx^sterior portions of
the upper lobes (Northrup). It may occur cither during the acute stage of
the inilammation or later when the pneumonia has become chn^oic. There
are no distinct stages in tlje pathology of bronclu>pneum(juia which cr»rro-
S{)oud to tha^ of lobar pneumonia. According to Northrop, bronchi ^pneu-
monia develops by the irivgular invasion of successive portions of the
lungs, and the process resolves m like manner. The different consolidated
areas in the same lung may often sho>v all the stages. The mottled a|>
pearance which is so often notit*ed maerosctipieally in these Iui»gs may l>e
caused by the presence of lobules of gray and red hepatization lying side by
ride. Of these inflammatory products the fibrin dLsiutegRitc'^ quickly, and is
therefore absorbed more rapidly than the cellular elements, which do not dis-
integrate 80 readily. In lobar pneumonia, therefore, absorption takes place
fioooer tbau it does in broncho-} Kueoraonia, where the proilucts of inflamma-
tion are mostly cellular and resolotion and absorption are naturally slow.
Instead of the gradual disappearance of the various pathologiail lesions
the pneumonia may |.>ersist. This persistent form of the disease may,
according to Delatield aud Prndden, fi>llow a single attack of acute l»roucho-
pnctumonia, or there may be several iK'nt*^ attiicks b'fon? the chmrnc condi-
tion fattjomcs evideut, and the course of the disease may thus vary in dilTcrent
ca»e8. When this persistent bnjucho- pneumonia »xx'urs, the pTOlifi*rative
cjells take part in the formation of new itjunective tissue, aud in this way
pmstent thickcoing is causett The alveolar walls of wrtain portions may
become similarly thickeued. The walls of the brouf^hi and their surround-
ing tissue are es|>eeiaUy subje^i't to a fK*rsistcnt thickening and a formation
of new csonnective tissue amstituting chronic broncho-pneumouia and |K?ri-
bronchitis. The brout'hi already dilated Ix'cnme still m<»n^ enlarged by rhe
oontraction of tlie cicatricial tissue surrounding tliem. Tlie iiTi*'\t'Ti fitntmc-
tion of this new tissue, together with the pressure within the tuU- II rilitated
by a weakened condition of the walls, allnw^ of saccular as well m of fusi-
form dilatation of the bronchi. The epithelial cm'IIs of the dilatfxl brctucht
pndiferate, and, tailing from the bronehial walls, mix witli the bronehial
seCTetion. The remaining epithelium is swollen and loose. The lesions of
cbronic bronchr>pneumouia ai*e fnYpiently associated with tubcTinlnsis of
the broncliial glands and with other ttibei*cular leaiona.
In connection with tlie i)athological lesions occurring in chronic broncho-
pneumonia a condition ealled fihroid pfUhms has in very rare casea been
noticeiJ in children. The k^si^ns which represent iibn»id phtlilsis are mani«
fitted in the presence of conneidive tissue in the lung, with a corresponding
dcstnicticm of the true pan'nehyma. These changes are usually unilateral,
and should not be considtred as represt^ntiug a disease, since tliey merely
^MXHir in the c!Ourse of various chronic pulmonary affectionj^^ among which
are tuberculosis and chronic bronch«>pneuraonia.
<\ L. T., coDfiolid&ted limg-tisstic ;
You will notice the areas of ainj^olidatiHl limi? (C* L, T., jx?ribn>nehitis
around the bronclii, which are dihitaJ (bmuehiect-asis). You will also ^
serve that there are areas of normal lung-tissue (N. L, T.). ^
Under this second mieroscojx* (Fig. 139) h a seetiou, also made by I>r,
Jfortiirup, taken fn)m a lung with chronic broneho-pucumonia in which tlie
proeeBs ha;^ advanced ntill further than in the other*
In the middle of the spetniucn you will see a dilated bronchus with a
section of a blood-vessel just l3t^low it. There is e^ULsiderable connective-
tissue formation about lx)th. Here you see that the j)roccss of a j>eribix>Q-
chitic pneumonia has gone further than in the other 8f>c*cimen (Fig. 138),
and that there is, in addition to the dilated bronchi with the surrounding
cellular iutiltration, a teudencj to the formation of connective tissue in the
interlobular septa. This is the form of chronic broncho-pneumonia which
is sometimes called intci^titial pneumonia, and is usually characterised by
a long w>ui*se and delayed itMLnivery,
A fre^pient lesion which occurs in the course of broncho-pneumonia is
mtphi/seina. According to Northrup, it is usually vesicular and situated in
DISEASES OP TH£ LUNOS.
969
^
h
^
the anterior portion of the upper lobes. It is due to the diminished amount
of air-capacity, tc^ther with the violent introduction of air into the cbe^t
cauaed by dyspna?a and eoughiug. This distention of the air-vesieles i&
supposed usually to dlsapi>ear with the subsidence of the lesion which is
causing the emphysema. Emphysema, both of the vesicular and of the
interstitial variety, most commonly cjc^curs in the pneumonia which follows
pertustus.
Fio. 139.
CSiraiilc braocho^imetmifivilii. Br dl.. ma^' ! . imia ; Th. U T., tblcketied I
The intei-stitial variety may exist in the form of su{>erfKMal sjics formed
by the rupture of air-veaicles l)eneath lifting the pleura, or it may ext»/iid
between the lobules in V-shaped tracts fmm the anterior edge of the upper
lobe even to the root of the limg,
SvMPTCiMs* — The symptiaiis of broncho-pneumonia vary greatly, owing
to the many different lesions which ci>mmonly occur in the disease and which
by their greater or less severity make its course exceedingly irn^lar. In
no many instances is the bronelio-pncumonia secondary in some otiier disease
that tlie symptoms are neoessarily modifif<l by tliosc of the initial afleirtion.
Thiui^ where bn:>ncho-pncumr»nia arises in the course of diphtheria, the
j^v ^ 1^ are often obscuitd by the severity of the general symptoms of
tJ. ^ koria, WheiT hn)ncho-pneumonia is s«^condary to mc^asles and tn
pertuflBta, although at times ita onset is difficult to detect, yet, as a rule, the
970 PEDIATRIOB.
quick respirations, the marked and continuous rise of temperature, and 1
evident exacerbation in the severity of the pulmonary symptoms, usua
permit a diagnosis to be made even before the physical signs have becoi
prominent Its onset, however, in measles is, as a rule, rapid, while
pertussis it is slow and insidious.
The group of symptoms which characterizes a broncho-pneumonia arisl
during the course of bronchitis is somewhat more definite. In place of t
moderate temperature and the absence of signs of serious disease which a
usually met with in the course of an ordinary bronchitis, when bronch
pneumonia supervenes the temperature rises, the pulse and respirations a
quickened, the alse nasi dilate, there is more or less cyanosis, the cou{
becomes more frequent and painful, and the general aspect of the patient
that of one suffering from an affection of a severe type.
The temperature in broncho-pneumonia varies greatly, according to tl
extent and severity of the lesions. Corresponding to the intensity of tl
pneumonic onset, or to the especial disease which it complicates, the tempe
ature rises rapidly or slowly and insidiously. The most common course :
mild cases with gradual onset and terminating in recovery is for the ten
perature to rise gradually to 39.4° or 40° C. (103° or 104° F.), then i
have a morning remission of three or four degrees for a number of days, an
then to fall irregularly by lysis. A crisis is very rare in broncho-pnei
monia, but sometimes occurs. Although the remissions in the temperatui
during the active stage of the disease are often quite marked, yet, as a rul
the temperature does not at this time fall to the normal. This is of servic
in differentiating certain cases of broncho-pneumonia, as well as lobar pneii
monia, from malaria. Occasionally the temperature is reversed, the highes
point being reached in the morning. This is rare, and is of no especial sig
nifieance. Where the temperature instead of remitting remains high am
steadily rises, the disease, as a rule, soon terminates fatally. Instead of th
continued high temperature which occurs so often in fatal cases, a low tem
perature of only a few degrees above normal is sometimes met with, usuall;
where the vitality is low and the power of reaction slight. The duration of
the heightened temperature is very variable in broncho-pneumonia, and maj
last for a number of days or for weeks without the necessary result of th(
grave lesions of a more chronic process.
The pulse and respiration, though quickened, vary according to the
severity of the disease and also according to the degree of nervous excite-
ment. This latter is a very important element to be considered in deter-
mining the gravity of their rate. The pulse is at times very rapid, 160-180,
and even higher ; it usually varies from 130 to 150 or 160 ; though regular
and full at first, it l)ecoraes weak and sometimes irregular as the disease
progresses, and is very apt to remain rapid even after the temperature has
declined and convalescence has been established. The respirations may be
quickened by an unusually high temperature, but depend mostly on the
extent of the involvement of the alveoli. They vary from 50 to 80, but
DISEASES OP THE LTTNOS.
971
^
I
they maj be even higher, and are accomjianied by dilatation of the alfe nasL
The respiration often shows a pause after iospimtioa instead of after expi-
ration^ as occurs in normal respiration^ and is usually acoompanied by an
expiratory moan.
This sign, however, is not characteristic of broncho-pneumonia^ a*^ it may
occur in lobar pneunioDia and in various affections where the circulation ia
interfered with and where respiration is painful. lu like manner the dilata-
tion of the alae nasi may occur in any disease accompanied by a heightened
temi>erature and nervous excitement. Temporary exacerbations and changes
in the rhythm of respiration are quite common in broncho-pneumonia, and
in some cases a Cheyne-Sttjkcs tyjK^ of respiration has Ikh'u notic<xl. This
sign is usually one of grave import., Rec^ession of the epigastrium and of
the intercostal spaces c?ommouly oceurs iu bronclio-pneumonia, and varies
aooording to the severity of the puliuoiiary lesions. In infants painful
respiration is shown by a frowo rather than by crying, while in young
children it is shown by their wliiinpriug and suppressed cries.
The physii'al signs of bri>ncho-pneumonia are almost entirely those
of the accompanying bnmcliitis, but in typical cases they oorresi>ond to the
various pathological hisions which I have just described. ActNjrding bb
laiger or smaller areas of the lung are involved, corresjx>nding areas of
dulnead on percussion may be found, pmvided these areas are sufficiently
^tensive not Uj be tuaskt^d by other resonant portions of the lungs. They
can, as a rule, Ik? deti^'ted Wst by very light percussion. Tht^e areas of
dulness are usually liilateral and of somewhat vai'ied extent, though, as I
haTe already stated, an entire lobe may in rare iustanoes be sufliciently
involved by the broneho-pueunionic process to prmluw very exteu.^ive areas
of dulness. Over the area of duluess bronchial respiration, and in some
caaes increased vocal resonance and fremitus, may be found. On ausculta-
tion moist rAlea of all sizes may be heard all over the lungs, or, as is more
usual, in circumscribed areas.
A sympti^m which occ^urs quite cc»mmonly in broncho-pneumonia is
iosis. This may not only arise from the interference with the oxygena-
of the blood from the Icsiiins involviug the air- vesicles, but may also be
uced by a temp miry atelectasis of certain {>ortions of the lungs. The
is is oftien at^companittl by attacks of dyspnoea When these 8ym[j-
ims result from atelectasis, the temperature, as a rule, does not rise, but may
even be somewhat reduced, and areas of duluess may lje detecU'd on jji^rcua-
sbu. During these paroxysms the skin is oilen cold and moist When the
cause of the atelectiisis, whether it l>e ol>struetion by plugs of mucus or pus
or temporarj' exhaustion of the contractile powers of certain portions of the
lungs, has been removed, the cyanosis and dyspncea pass away and tlie
general symptoms improve. These symptoms may arise at various periods
during the course of bnmcho-pueumonia, and unless tlie atelectasis
ofi' within a few days a fatal issue is very apt to results
Well-marked physical signs, especially dulness on percussion, are u
972 PEDIATRICS.
found at the bases of both lungs behind, and also between the scapulae anc
the vertebral column. The earliest changes, however, in percussion anc
auscultation are often first detected in the highest part of the axilla. Thes<
signs of consolidation are rarely found in the early days of the disease
when the bronchitic signs are usually all that can be detected. The physical
signs are markedly modified when atelectasis or emphysema is present.
In cases which recover, resolution takes place slowly and the lung
gradually returns to the normal condition. Great weakness and prostration
oft:en last for a long time. Relapses are quite common.
Complications. — Pleurisy of a light grade is not an uncommon com-
plication of broncho-pneumonia. Abscess and gangrene sometimes, though
very rarely, arise. A case of the latter occurred at the Boston Children's
Hospital in the service of Dr. Morrill.
A very frequent and important complication of broncho-pneumonia is
tuberculosis.
In certain cases of the fulminant type of broncho-pneumonia the post-
mortem examinations show extensive deposits of miliary tubercle, which in
these cases is the cause of the accompanying acute inflammation. This con-
dition is called tubercular broncho-pneumonia.
A frequent, short, hacking, and painful cough is a constant symptom
from the beginning of the disease, and even after resolution has taken
place this may continue for a long period. Infants and young children,
even up to the age of seven or eight years, have often not learned to ex-
pectorate, so that we cannot, as in adults, judge of the character of the
sputum. When the sputum is seen it corresponds to the pathological exu-
dation which I have just described when speaking of the pathology of the
disease. Vomiting is at times met with, and diarrhoea is not uncommon.
In certain cases disturbance of the gastro-enteric tract is present from the
very beginning, and the intestinal disease is apparently as important a
feature of the attack as the pulmonary part. As the attack progresses
the child loses much in weight, the face often looks pinched, and at times
during the height of the disease there is a certain amount of delirium,
which in combination with other grave symptoms, such as uncontrollable
diarrhoea and a depressed temperature, is a serious symptom.
Diagnosis. — The diagnosis of broncho-pneumonia should first be made
from the bronchitis which ordinarily accompanies it. This has already
been sufficiently referred to in speaking of the diagnosis of bronchitis.
The differential diagnosis between the non-tubercular and the tubercular
fornLs of broncho-pneumonia is important, but can rarely be made in the
early stages of the disease, as the lesions are the same, and a bacteriological
examination of the sputum in these cases can seldom be obtained.
The disease which should be especially considered in making the diag-
nosis of broncho-pneumonia is lobar pneumonia. The two diseases are per-
fectly distinct, in onset, course, duration, and termination, and can best be
described when I si)eak of the diagnosis of lobar pneumonia (page 985).
DISEASES OF THE LUNGS.
973
P Phognosis. — Age is a very important factor in the prognosis of bron-
ch*>-pneumonia. As Morril! Iiajs shown by a carefully prepareil tabic, a
large majority of the fatal ciistis of bronoho-pneumoiiia oc4:'urs in the first
two years of life. The progn^jsis varies aeeortling to the disease in tlie
course of which it occurs. It is most grave when it occurs in ]x?rtussis,
e8)RH>rally in infants, and the younger the child the more fatal the disease.
■^ext to jH^rtUft-^is, the gravity of the pntgnosis is greatest in measles and
diphtheria* When it oocurs in saeh diseases as rhachitls and tuberculosis,
^r where the individual has not been well cared for, the j>ro^nosis is also
l^cn* unfavorable. I have already i-eferred to the tempcratui-e as a prog-
noetic sign in broncho-pneiuaiouia. Act^rding to Holt's observations^ the
kliighest mortality cn^urs among the cases of shortest dumtion, and the
' dlmtise is universally fatal wheu its duration is shoiier than four days.
After this early i:)ericKl of daug<3r is jiassetl the prognosis lieeomes much
mure favorable, the lo^vest death-rate in Holt's caaes being met with in
|Ca$cs terminating in from eight to fnurtecn days. When the disease lasts
f for more than two wec*ks the chances of recovery ai'e lessened eyery day
that the temi>erature remains rabed. The cases in which there b a very
ihigh temperature, 4 LP C\ (H>6^ F,)» are usually fatal. Where the disease
I is protracted, dcatli generally (lecurs from exhaustion.
I Treatment. — The treatment of bronch*vpneuraonia is that of tlie
spivial disiuse to which it ls secondary. The strength should Iw* carefully
supported from the time tliat the disease is fiD^t det<^ ted until cf>nvaleswnL^
lias been completely establbbed. TIxe patient should lie cani^fully mu^setl, as
tl»e nursing Is the mr»st impjrtant part of the treatmeut f»f bri>urho-pneu-
monia and rcfjuirt^s much judgment and intA^ligenee. The atmos{>here of die
i\-K>m should be equable, tlie temiKTature fi\)ni 20° U) 21.1° C. (SS'' to 70°
F.), and espc»cial attention should l>e paid t4> the ventilation. The heat and
ventilation obtained from an oj^en wtw:»d fii-e are espeiially vahmble. As
few drugs as pt>ssible should l>e given, since there is no drug which will cut
lihort the disease, and most of the drugs oommonly used in the treatment
of pulmonary affections are, as a rule, of more harm than Iteuefit in liron-
chi>-pneumouia. The vitality of infants and young children is fi<» easily
lle^^ned by a disease so severe as broncho-pneumonia that the i^espiratory
pi>wer is likewise fpiiekly diminished, and we should avoid, except where
they are especially needed, such drugs as opium. IjM>cac in minute dos*ift
seems to ikoilitate tlie removal of the mucus. During severe paroxysms
lui atmosphere of steam or the admiuistraticm of oxygen is indicated, jiceord-
^Ing as the symptoms secern to l>e prrtducetl by a tenacious exudate or by
iinai(*rated lung-tissue. lu east*s where cyanosis and dyspnoea are urgent, if
the^ de[>end upon mechaniail obstruction with its resulting atek^isi^fi, an
^anetie is oceasionally demandtHl. In s<jme cases, also, where much exhaiis^
flion arises from inccssiuit tYjughiug, small dosc« of tinctura opii campliorata '
may be used with caution, and discontinued as soon as passible. When the
tu^eut symptoms are caused by the heightened temperature, mudi relief
976
PEDIATRICS.
89.4® C. (108*> F.) in the morning and 40o C. (104*> I
siclc, had considerable cough, but no expectoration ; t
she was somewhat cyanotic. On examining the ches
nant, but throughout both lungs there were moist H
on examining the heart and abdomen. She was treat
On the following day she was in about the same
and temperature were as on entering the hospital. Ii
backs slight dulness was detected on percussion, with
areas.
On the third day the pulse had fallen to 186, th<
ture to 88.8« C. (101<» P.).
To-day, the ninth day of the disease, the pulse ii
very much improved. The dyspnoea has disappeared
and she is more comfortable. On examining the fr
resonance on percussion is normal, and I find no ab
examining the back you will find certain circumscr
which I have marked in black. One of these areai
and the vertebral column, another is at the right base
another is at the left base just below the angle of the
bronchial respiration is heard. Just outside of the ar
areas moist r&les of various siaes, which I have indie
that the physical signs in this case of broncho-pneumc
lesions of this disease are usually detected on physical
(Subsequent history.) Five days later the child
During the following ten days the abnormal signs in
respirations, and temperature did not become permar
child, after remaining weak and debilitated for some y
hospital in good condition. The chart of this case is i
This case apparently arose in the course (
in a rhachitic child. I have told you that 1
monia in rhachitis is usually unfavorable, but
sufficient vitality not to succumb to the disea
In connection with this case, and with
gravity of the prognosis of broncho-pneumo
tion with rhachitis, I shall recall to your i
showed you in the wards of the City Hospifc
The child (Case 462) was two years and one mont
tuberculosis. It hud bronchitis when it was one yei
three months. One week before entering the hospital
and began to lose in weight and to have diarrhoea. A
wtis a case of marked rhachitis. The breathing was r
able cyanosis, and the child was dull and somnolent
various parts of the lungs, with moist rAles of difFerer
to 150, the respirations from 80 to 90, and the temp<
104° F.). The symptoms increased in severity, the ch
day after it entered the hospital it died suddenly.
When broncho-pneumonia attacks a child
was shown in this case, a fatal issue almost a)
Here is a chart (Chart 34, page 977) shov
t
P DISEASES OF THE LUNQfi. 977
>f ED infant (Ca^ 463) eight months old, from tlie nineteenth day of an
ittaek of broncho-pneumonia until con vu licence was established.
CHABT S4.
^^1
Daya of Disease.
y.
19
20
21
22
23
24
25
2e
27
28
29
30
31
32
33
34
35
36
37
38
ao
C-
107'
105
10^
MS
ME
ME
MS
ME
M E
MB
MS
ME
Mt
Me
ME
HE
MX
ME
MS
ME
ME
ME
ME
Ml
41 6
41.1
40.0'
40.0'
39.4'
38,8*
38.3*
37.7*
37.3*
37.0^
I03
102*
1 i
]/
J
y
1/
/
/
101
0
06
150
140
130
4fiO
1
/
/
/
/
>
y1
7
/
^
J
1/
/
f
/^
/
/
/;
/
V
/
/
/
\
^
/
1
r
"'"
^
^
'^
36.8
36.1-
35,5*
^
^
^
^
/
^
A
^
/
/
^
/
/
^
1 P H
\
I
110
^
•
1
T
ID tb<
lidoG
«fpin
MX VI
rberp
\m 111
randt.
ome c
T
\\
mouiti
i fa
t be]
UioE
me<
wer
jimi
but
tUv
od <
h«i ft
T
onti
nor:
bcc
'b#»i
Mi
■
Acute broDcho-poeatDOElaM Infftnt, 8 months oM Rc^coverv In thlrtv-^ix dayit
nffiDt, a male, bad always been »tmriff iind welL The parenta were healtby, but
ther's sid© a number of brothers and sisters bad died of pulmonary tubereul45eU,
ing nursed by ite mother, who wat strong and woU. On December 16 the infant
am well, and on the following day, after having pasied a re«tle«a nigbl, bronebla]
I and rales were detected at the base of the riKbt lung. The tempt-^nitur** on that
I from »8,8° C. (101*' F.) in the roomini? to Sg.!** C. (108« P.) in th© evening.
« no symptoms except ft flight oough, and the respirations were acetunpanied by
ofy moAn. Until Deoember 2S it took about a quart of milk in the lwenly*four
on the 24th it refUsed to take any food, and the temperature, whirh had been
coming down so as to reach almost 88.8** €, (lOP F.) in the evening, began to
Sulnett and fine rales were detected in the left lawer back. Tbe puUe at tbii
to 180, but wa* regular and strong ; the respiration* Taried from 00 Ut 70. The
bow«d more active dilatation, and there was slight twitching of the amis and
%e cough became more frequent, and there was slight diarrhoea. Those symp-
nued for several week;^, when they lessened in severity and tbe tempemture fell
ue WM treated with brandy and digitalis, and finally recovered entirely.
1 thi« child wa« eight year; old he was attacked with purpufs ThegmaUca^
m a month by nephritis, and one month later by a flever«» attack of broiM)bo-
%,t which involved extensive areas in both lungs and was aeootnpaiiied by comtant
62
^^^H
978
PEDIATRICS.
diarrhoaa, delirium, oyanoBis, and dyspnoea, resulting in death from exhaustion ii
second week of the disease.
This next case, a girl, two yean old (Case 464), had up to the present attack heen s
CHART
85.
Day» of Disease.
IT,
1
2
3
4
6
6
7
e
0
lO
11
12
41.6'
41,1*
40.51
40.0'
3S a""
107°
loa-
106°
Mt
MI
tllE
VI
liK
Mt
MI
us
M«
Ml
Ml
Ml
MX
Ml
m
Mt
1
fro*
*<M
»fffir
twi
[
104^
103'
^
1
k
1
\
l\
fe
s
1
\
} J
38.3'^
137,7*^
!37,2''
37.0'
iOO
67'
oe'
1
/
/
y
\
i
/
^
/
/
/
^
\/
/
N
.
^
/
r
y
/
.X
36, 6
30 1-
35.5'
36,0*
*
95
150
1
7
~
'
140
ISO
/
/
/
/
/
/
120
1 iio
iOO
QO
60
70
60
/
,-^
/
/
/
X
^
V
/
/|
\
/
^
1
—
^
50
45
40
35
25
r
'v"
1
\
;
T
/
J
/
/
\
r
•
1
/
/
/
/
y
20
15 I
iO
^
^
^__^
^^^
Broncho-pneumonia followinjr crisis of measles. Child, 2 years old.
and well. There is no tuberculous history in the family. She entered the hospital six
ago, and was placed in the isolating ward, as she was found to have measles. On ent
DISEASES OF THE LUNGS.
979
her tempemture wai S9,B'* C. (IOS.7^ V,), the pulse wtu 120, and the respirations were 412.
An eiann'rwitum of the chest showed the heart to he tiorniaL The poreuiMion showed
normiil re^juance and hanh put^rile respiration, with numerous fine and coarse taoist riles
throughout both lungs. Nothing else itbnormal was detected.
Fiire days ago the temperature fell to 38.1^ C. (100.7° F,), four days ago to 87.3*» C,
(99.2° F.), and day before yesterday was just above normal. During these da^^ the efflo-
Tesoence rapidly faded, and she seemed better, though she occasionally had a harsh cough.
Yesterday she liad a slight rise of temperature, but there were no marked symptoms until
to-day^ when the temperature rose to 40*= C* (104'' F.), the pulse to 160» and the r>!Spira-
tiona to 50. She is, as you see, very rei^tle^, and has considerable dyspncea. She is pallid
and sometimes slightly cyanotic. On physical examination there is found diminis^hed reso^
nance over an area in the lower part uf tiie left back. Over this area the breathing U bron-
chial, and there is also a number uf moist rales. On the ri^ht side 4^»f the thorax, e»p«K:iaIly
at the base of the lung^ there are numerous coarse moist rales and harsh respiration, but
no dulneas.
This case lUustratefl the rapid development of a broncho- pneumonia during an attack
of measled, occurring after the temperature produced by the measles had fallen to the nor-
mal and while the effiorescence was disappearing. The physical signs show the presence
of small areas of consolidation in the left lung, and the uiiiual diffuse bronchitis throughout
the right lung and parts of the left lung.
(Subsequent history.) This chart (Chart 85) shows the course of the temperature,
pulse, and respiration during the next twelve days. The pulse continued to be mpid and
the respirations to be somewhat ntbed for some days after the temperature became normal.
The abnormal signs in the chest disappeared, and the child made a rapid recovei7.
Chronic Broncho-Poeunionia. — I have already described the patho-
logical lesions which tyccur in chronic broticbopneumonta. In a certain
number of cases, after a child has had an attack of acute hnmcho^pneumonia
lie physical ^igns of consul idatioa may i^ersist, although apparent recovery
his occurred so far as the general symptoms are concerned* When this
occurs the fever may return after a variable [x^rif»d, and the child, after
having become still more emaciated, may die after a numixT of months of
exhaustioD. Instead of this fatal issue, the child, as has been shown by
DeJafield^ may be left with a chronic form of the disease, which may last
tor many years and be accompanied by symptoms of cough, dyjipncea, and
times periods of fever. The most common termination of these city's is
in acute general miliary tnljerculosis. In certain cases, however, where
only a small portion of the lung has been aHectcJ, the child may recover
as it gprows older, Broncho-pucumouia of a subacute or a chronic type is so
apt to develop in the limgs of young children during the course of any
diBiease of a prolonged nature, that frequent examinations of the lunga
should be made, in order that the insidious development of these pulmonary
Inona may not be overlooked.
The treatment of these chronic cases of broncho-pneumonia is e«s*?ritially
ciimatic. The child should be taken to a warm dry climate of high alti-
liide, where it can live in the open air, and where it will not be subjected to
frequect atmospheric changes.
Atelbctasls. — Atelectasis is a collapsed and unaerated condition of the
air-vcfiicles. It may be congenital or acquired.
Cbngemiai atd&^wns arises because the infant has not sufficient general
980 PEDIATBIGB.
vitality and respiratoiy power at birth to inflate fully all parts of its lun
There may be an obstruction by mucus. There are in these cases an
of uninflated pulmonary vesicles of varying extent. These vesicles at i
post-mortem examination can easily be artificially distended, and then cs
not be distinguished &om those which have been normally inflated.
The symptoms of congenital atelectasis are cyanosis, dyspnoea, rap
respiration, rapid, feeble, and often intermittent pulse, a temperature usual
lowered, and dulness on percussion with lessened respiration over the atele
tatic area. These are the typical physical signs of atelectasis, but in mai
cases some or all of these signs are absent and the areas of atelectasis a
detected only at the post-mortem examination.
The prognosis in these cases varies according to the extent of the pu
monary tissue involved and the vitality of the infant. As a rule, tl
prognosis is very unfavorable.
The treatment of atelectasis is to stimulate the infimt, and to endeavc
to raise its temperature by means of a warm pack. In a number of cases
have found the administration of small quantities of oxygen to be of bene
fit. Artificial inflation of the air-vesicles has not proved to be an especiall
valuable form of treatment.
Acquired oteledaMs is a symptom of some other disease, and I hav
already spoken of it sufficiently in connection with what I have said con
cerning broncho-pneumonia. Acquired atelectasis undetected during life i
frequently found at the post-mortem examination of in&nts and younj
children dying of almost any disease.
Lobar Pneumonia. — Lobar pneumonia is an acute self-limited disease
of the lung, running a definite course and caused by the diplococcuf
pneumonise.
Fio. 140.
^ I
^
(5)
Diplococciu ppenmontei.
Etiology. — Although lobar pneumonia may occur at any age, it is not
met with so commonly in infancy and in early life as broncho-pneumonia.
Ex|)osure to cold, and especially to sudden atmospheric changes, apparently
renders the individual more susceptible to the invasion of the micro-
organism which causes this disease. Here is a specimen (Fig. 140) of this
organism, taken from the sputum of a case of lobar pneumonia. It shows
the morphology.
DISEASES OP THE LUNGS.
981
According to Delafield and Prudden, tliese germs during their develop-
ment are dLstinetly sphemidal, but in their mature condition tliey often
become slightly elongated and a little broader at one end than at the
other, which gives them a lanceolate form. They are very apt Uy occur in
pairSj and are frecinently ^een in short c!iaini5, but rarely in lung chains.
Very frequently when growing in the living animal the pneumoooocu.H is
Burroundetl by a distinct homogeneous cafisnle of varying thickness. The
oooeus iteelf Is readily stiined ; the capsule is stained witli diflicuhy.
Pathology.^ — The pathological condition which occurs in acute lobar
pneumonia is an acute exudative inflammation which involves pr^jgressively
the whole of one lobe, or the larger part of one lung, or portions of both lungs.
There is no especial distinction between the lesions of lobar pneumonia as
they occur in children and those which are met with in adults, exa*{>t so far
as the anatomical conditions differ according to the ag<? of the individual.
The stages of congejitioo, red hej>atixation, gray hepatization, and resolution
take place in succession in the pneumonia of the child as in that of tiie adult
In the stage of congestion the lung is hyjjera?mic and (Klenmtous and tiie air-
vesicles oi»ntain fibrin^ pu8, granular matter, re<l bloiKl-iM.41s, and t^pitliolial
cells. The epithelium of the air-vesicles is swollen, and there B.re large num-
Viers of white blew k1 -cells in the cat>illarie8. The large broncla are c<:»ngested.
The small hronclti txmtain the saoie intlainmatory products as do die air-vesi-
cl^. This stage lasts only a few hours, aa a rule, but may be protracted for
several dny^. When the exudation of the ioflammat4>ry pn»diicts has rwiched
it^ full develnpmeut the presence of these pnKiucts within the air-vesiek's aud
bronciii causes the lung to be slightly enlarged, and at this time it is said to
be in the ccm*litiuu of re<l hefmtization* After the air-ve^^ieles have become
completely filled with exudation thei-e follows a jieritxl during which the
exudation first Ijecomes decolorized and then dogeneratHh This Is the
period of gray hepatization. This happens at a variable time, wliich is
usually shorter in children than in adults. The et»lcir finally l.>ecomes gray.
The exudate then undergot\H still further degeneration and s«_>rtening, and is
removed by the lymphatics. This is the stage of resolution. Res<>lutif)n
Q|boald begin immediately after delerveseeuce and l>e completed wilhin a few
flh^^'s, but it may not begin until a numixT of days after defervescence, and
may be unusually protracted.
The bronchi are almost always affected in lolmr pneumonia. Tlic pneu-
monic pnijcess may occur in small patches, but usually involvt?s an entire
lobe. The lower lobes are the one?^ which are most frequently affcf*tcd in
early life, but the hxsality of tlie pneumonia is of pathological rather than
of clinical im|x»rtance, as the disease may attack any part of the lungs. It
t)» generally a unilateral di.scase, but in some ca^es it may be bilaterah
Symptoms, — The onset of acute lobar pneumonia is^ as a rule, sudden,
and in the infant or young child is frequently acoompanied by vomiting and
uomctimes by convulsions ; the latter, however, is uncommon as an initial
s}*mptom afler the period of ini'ancy. An initial rigor is nooommou. I^un
982 PEDIATBIOB.
is probably present, but cannot usually be located by the child with tl
same precision as by the adult, young children often referring the pain i
the abdomen. Cough is a common symptom, not only in the beginnin
of the disease but also during its whole course, and often seems to 1
painftil. It may, however, be absent for several days in the beginning o
the attack. There is rarely any expectoration before the seventh or eight
year. In some cases during the height of the disease there is delirium. I
the milder cases the delirium may be merely a slight wandering, but in tl
more severe cases the children may become much excited, and the deliriui
may be accompanied by contracted or dilated pupils, and even involuntar
passages of urine and of fsBces, with continual movement of the head, mus
ciilar twitchings, and other symptoms which may simulate closely those o
cerebro-spinal meningitis. In place of the delirium and the excited coudi
tion there may be a condition of stupor which sometimes simulates th
stupor of tubercular meningitis. In another set of cases the nervous symp
toms markedly simulate those of the non-tubercular form of meningitis
Meningitis in any form, however, rarely occurs in the course of pneumonia
Violence of the symptoms is not common. Marked cerebral symptom
seem to depend more on the height of the temperature and the extent oi
the lung involved than on any especial part of the lung being affected, sucl
as the apices. In infancy and in the early years of childhood, in place oi
these cerebral symptoms there may be simply an apathetic condition during
the height of the disease, and the infant, although somewhat somnolen
and restless, often shows no other nervous excitement. The course of the
disease is usually shorter in young than in older children.
The rate of both the pulse and the respiration is increased, but tlu
greatest increase is shown in the rate of the respiration. This is much
higher proportionately to that of the pulse than is usually the case in other
affections which would be likely to simulate lobar pneumonia. There is
commonly dilatation of the alae nasi, and it is seldom that this symptom is
absent in pneumonia. The pulse varies from many causes, among which is
the nerv^oiis condition of the especial child. It may be 120 to 150.
The temperature is a very important symptom in acute lobar pneumonia,
and is almost diagnostic of the disease. In the initial stage it rises at once
to 39.4° or 40° C. (103° or 104° F.) ; it remains high, with slight remis-
sions of about two degrees in the morning, for a number of days, and then
in a large number of cases falls to the normal within twenty-four hours by
crisis. The time when the temperature falls and the crisis takes place varies.
It may occur as early as the third or fourth day, but is usually between the
fifth and the eighth day. It may, however, be delayed until the ninth or
tenth day, and in rare cases still longer. When the temperature falls at the
crisis of the disease it is very apt to be subnormal, and to remain so for a
number of days. Sometimes after the temperature has fallen to the normal
it may rise again, but, as a rule, another rise of temperature points towards
the involvement of some fresh area of the lung or to some complication,
DI8EASEB OF THE LUNOa.
983
SQcb as plearmy. The fall of temperature at the time of the crisb is oft^u
aooompaLiic^l by symptoms of great prostration and even collapse, and it
18 therefore importaat in young children to watch carefully for the crisis
and to be prepared to combat these symptoms. The normal height of the
tem|)erature in acute lobar pneumonia, according to the extensive observar
tions c»f Holt, is from 40^ to 40.5^ C. (104^ tc* 105^ F.). In children
over three years of age the temperature curve resembles the adult type in
being regular and falling by crisis, while under three years of age the pro-
portion of t\^ical cases is much less, and there Is moi'e irregularity in the
Oijurse of the temjK^rature, which may fall by lysis. The younger the indi-
vidual the more likehhfXKi there is to be a wide fluctuation in the range
of the temjierature, which has a tendency to be of the remittent type even
in uncomplicated ceases.
The physical signs of lobar pneumr>uia are the same bb oc3cur in adults*
There is duhiess on percussion over the affected area of the lung where con-
8f»lidation has taken plaec\ with bronchial respiration, increased voml fi-emi-
tus, and increased vocal resonance. In tlie initial stage of tlie disease fine
riles are heard at times, but not so oomraonly in children as in adults. When
resolution is taking pla<:^, moist n\les of all sizes are heaixi These are the
typical signs of lobar pneumonia. In some cases the physical signs are
entirely absent for a numljer of days, and the diagnosis has to rest upon tlie
heightened temjM^rature, tJie incrt^ased respirations and pulse, aud tlic dila-
tation of the uhe nasi. In the c^rly days of the disease the ci>ugh may be
absent ; this rendorti tlie diagnosis still more difficult. The cough may con-
tinue and the physical signs remain unchanged for a numbt^r of flays atler
the temperature has fallen* The physical signs in some ca^s immediately
diasppear when the temiieniture IxHomes normal. Fine dry r^les are not
beard so frec[uently in tlie lobar pneumonia of young childj*eu as in that of
In certain eases, wheiv hejmtization of the lung has taken plaoe in the
usital way aud the crisis has ct>me with a fall of tem|jerature, resolution Mill
fail to take place and the lung will remain solidifi(xl sometimes fiir a long
period. Although an infivtioii by the bacillus tul)ercuh»sLs may be sus-
pected in many of tlu^e ciists, fnmi their protracted course and fmm the
prostration which usually act^i>tnpauit^ them, yet such infection does not
na^c^fsarily take place, and rcsc*lution uilou finally occurs. In these erases the
lung is left appai'ently in the same normal c<jndition as if tliia variation in
the resolution had not taken place.
Aj an illti£trat)on of delayed re^lution in lobar pncumoiua I fihall report Uy ycm th*
ai«e of a little girl (Case 466), four years old, who, when she was i>erf<?c'tly w«ll and ttrvng,
«raf suddonlj attacked with vomitJUK, pain in the right side, and wugh accom(utnit*d, ac*
CKmling to her mother, by a rt'ddtsh-brown sputum. Fhyieical ezAiiiirmtit'n on the fdluw*
log dfty revealed nothing abnormal except a few fine moist raleo at thu ba£c of the rij^ht lung
behind. Tlie pulft« wa* 170, the respiration* m, and the tempc^nitupe SU 4** C. (ia3<» F.)* On
ib* fullowing day the teiupemture still remained rttiAml^ Hnd thvre wa* dulneM« im pi*reuMton
I lower right lobe behind, with bruncbial ruapimtion. On th« fuUowing djij the dal-
984 PEDIATBIC8.
nes8 had extended over the whole of the right lung in front and hehind. The temperat
varied from 88.80 to 89.4° C. (102« to lOa® P.), the puUe from 150 to 160, and the respi
tions from 50 to 60. These symptoms continued until the eighth day fW>m the onset of ^
attack, when the temperature was found to be 88.4® C. (101.2® F.), the respirations
and the pulse 160. During the next nine days the temperature, pulse, and respirati(
remained the same, and there was no change in the physical signs of the lung, exc<
that in addition to the dulness and bronchial respiration a number of fine moist rales wi
heard in the back and in the axillary regions. The child was seen at this time by me
consultation with Dr. Calvin Ellis, and the physical signs were verified. During t
next week no change took place in the temperature, pulse, respiration, or physical sigi
Some days later the temperature fell to the normal, the respirations to 86, the pulse to 13
the dulness began to disappear, and the numerous coarse and fine moist r&les of resoluti<
appeared. Resolution took place rapidly, and a week later, thirty days from the onset of tJ
attack, the lung appeared to be in a perfectly normal condition. From that time the chi
gained rapidly in strength and weight and recovered completely.
In some cases the child may show the rational signs of pneumonia, quic
respirations, rapid pulse, dilatation of the alsB nasi, apathy, delirium, an
perhaps vomiting and convulsions, for many days before the physical sign
appear in the lung. In order to illustrate this delay in the appearance o
the physical signs of lobar pneumonia I shall report to you briefly two case
which I saw in consultation with Dr. Chase, of Dedham. The whol
course of the disease and the physical signs were so similar in both instance
that one description will suffice for both.
They were two boys (Coses 466 and 467), brothers, the older boy being three years ok
and the younger sixteen months old. The older boy was attacked on November 19, anc
the younger one on November 20, with continuous vomiting, which lasted without much
intermission until November 26. In addition to the vomiting the temperature rose in the
first twenty-four hours to 40.5° C. (106° F.), and until November 26 varied fnnn 40° to
40,5° C. (104° to 105° F.). The respirations varied from 40 to 50, and the pulse from 150
to 160. Both children soon became unconscious, were very restless, rolled their heads con-
tinuously, and had contracted pupils. On November 26 the temperature fell to 39.4® 0.
(108° F.), and during the next two days varied from 39.4° to 40° C. (103° to 104° F.).
On November 27 a small area of absolute dulness with bronchial respiration was detected
in the older boy over the left upper lobe in front, and on the following day in the younger
boy over the left lower lobe behind. After the first few days there was slight cough in
both cases, with movement of the ulae nasi. On November 30 the temperature in both
children rose to 40.5° C. (105° F.), and until December 2 it varied from 40° to 40.5° C. (104°
to 106° F.). On the evening of December 2 the temperature in the older boy suddenly
fell from 40.5° C. (105° F.) to 35.5° C. (96° F.). The child became cold, the pulse became
feeble, and the respiration could scarcely be detected. The application of the hot pack and
an enema of hot brandy-and-water rapidly revived the child. The same fall of tempera-
ture occurred in the other boy on the following morning. In both children signs of resolu-
tion were detected before the temperature fell, the lungs in both cases rapidly became nor-
mal, and after a short convalescence the children recovered completely.
Ill some cases lobar pneumonia may attack both lungs. Again, after the
disease has run its course and the temperature has fallen to the normal, a
fresh portion of the lung may be attacked and the temperature may rise
again. In rare instance in otherwise typical cases of lobar pneumonia I
have been unable to detect any r^les over the area of solidification through-
out the whole course of the disease.
DISEASiS OF THE LUNGS.
98S
I
I
»
Diagnosis. — The diagnosis of lobar pneumonia, when the typical tem-
perature and the characterif?tie physical signs are present, is not difficult, but
there are a number of atypiod cases in which a doubt might easily arise for
a number of days after the invasion of the disease. An early diagno8id
from a pleuritic elfusion and from other pulmonary affections is at times
impOi8BiIde,
The differential diagnosis between lobar pneumonia and a pleuritic effu-
sioti may be quite difficult in the early stages before the characteristic areas
of dulness have been established. In bc^th diseases dulness over a limited
area, and bronchial respiration without any especial difference in the vocal
fremitus and vocal resonance, and without evidence of a friction-rub or of
r^es, may make the two diseases simulate each other closely and compel
OS to wait for further developments before determining which disease is
present.
From tubercular disease of the lung the diflTerential diagnosis is usually
not difficult, except in young infants, in whom the tubercular process with
its corresponding symptoms may in rare t^ses simulate lolmr pneumonia.
The disease from which a differential diagnosis should especially be made
B broncho*pneumonia. Lobar pneumonia and broncho-pneumonia are so
distinct, however, in their previous history, initial stage, coui-se, and dura-
tion that^ if care be taken to note closely all these stages of the two diseast^
and to arrive at a <Hagnosis from the evidence given by all the stages and
not by any one stage, the diagnasis can, except in the very early days of the
diaeaee, usually be determined. Lobar pneumonia, in <?*>ntra«listinction from
broncho-pneumonia, is a primary disease, characterized by a sudden onset
and a regular temjierature, the rise iK^ing sudden. This is aiHianpanied by
a corresponding rapidity of the jnil^*.^ and respimtions, dulness on jiercus-
fibn usually involving and limited to one lobe or one lung, with increased
voeal fremitus and resonant^, and bronchial respiration over the doll area.
This is followed by a fall of temperatui-e and by a rapid resolution. The
duration is short and definite* Broncho-pneumonia, on the other hand, is
usually secondary to a preceding bronchitis, occurring either alone or in the
coarse of some otlicr disease. It is characterized by a slow and insidious
QjMsei, except when occurring in the ojjurse of measles ; it has an irregular
temperature, the rise usually not being my sudden or so high as in lotiar
pneumonia, and the respirations and pulse slowly rising \vith the tcmjx'ra-
ture. There is often an al)st*nw of change in percussion, the dulness if
present showing itself in small ^katcJies and commonly in both lungs. There
is also often an alxsenc*? of marked vocal fr»?mitus or vocal resonance, and
of broncJiial respiration, except where the patches of dulne^ are pnmounced.
Moist rAles of all siztN may Ix* Uvsinl iu circurascrilMfl areas throughout lioth
lungs. The tcmjKTaturc is usually of a remittent type, and this condition
lasts for weeks rather than days. The resc»hition is slow* The tluration is
\ of the two
ate bonie in mind,
often prolonged. If tliese pictures <
m error in the differential diagnosis will seldom be made. In tlie doubt-
986 PEDIATRICS.
fill cases, where the characteristic course of either disease is absent, it wi
usually be found that we are dealing with a case of broncho-pneumoni
which LB an exceedingly variable disease, rather than with lobar pneumoni
in which some of the characteristic features of the disease are almost invi
riably present.
In making the diagnosis between pneumonia and meningitis it is o
much aid to remember that the alow intermittent pulse, slow irregular resp
ration, and moderate temperature of meningitis are uncommon in lobs
pneumonia, where in most cases the pulse is quick and regular, the respira
tions rapid, and the temperature high. It is not uncommon, however, t
find irregularities and intermissions in the rapid pulse of pneumonia. Th
younger the individual, as I have already stated in my lecture on menio
gitis (page 612), the more likely are the symptoms of tubercular menin
gitis to be replaced by those of the non-tubercular form of the disease, whicl
may often simulate closely the symptoms of pneumonia. The convulsion
wliich occur in pneumonia do not differ from those which occur in menin
gitis or, in fact, in any other acute disease. A careful physical examina
tion should be made at every visit, once or twice a day if possible, as ii
this way the masked symptoms of a pneumonia may at times be detectec
w^here they would be overlooked if only an occasional examination wen
made.
After the first four or five days, as a rule, the difierential diagnosis be-
tween cerebral disease and pneumonia is not difficult
C'oMPLiCATiONS. — The complications of acute lobar pneumonia are
not very numerous. At times a ])ericarditis may occur, with its resulting
effusion, but these eases are rare. The most common com]>licatiou is a
pleuritic effusion, which, especially in young infants, is apt to he purulent.
In many cases the onset of the disease and its initial symptoms are ap-
parently characteristic of pneumonia, and yet a few days later it becomes
evident that a purulent pleuritic effusion has either complicated the pneu-
monia or was the orijLrinal disease, simulating in its symptoms the early
sta^(^ of lobar pneumonia. Lobar pneumonia is at times a serious com-
plication of other diseases, and adds materially to their gravity.
Gangrene. — One of the rare complications of lobar pneumonia is gan-
grene of the lung. This lesion is never found as a primary disea.se, and is
rare in children. It is usually met with in weak, debilitated children whose
circulation is impaired.
Progncxsis. — The j)rognosis of lobar pneumonia is very favorable. In
young; infants, or in those who are weak and debilitated, it is often fatal,
but in comparison with broncho-pneumonia the percentage of recovery is
very high. When the tem|x?rature rises to 41.1° C. (106° F.) the prognosis
Ls usually grave. The convulsions which occur in the initial stage of the
disease in infants are commonly not of grave import. Occurring late in the
disease they make the prognosis very unfavorable. When delirium occurs,
although it may be severe, it does not render the prognosis especially un-
DISEASES OP THE lAJKOS.
987
N
»
^
%mrable. The fulminant type of the disease which sometimes ijceurs h a
very fatal form.
Treatment. — As lobar pueumonia is a Belf-Umited disease of abort
duration, the children are not so apt to die of exhaustion, and as a rule
only an exjiectant treatment i^s trailed for* Where the di.si-afe*^ ixx^un* in very
young infants it is safer to administer Bti mutants from the beginning. In
childi^n, however, it is often not necessary to use any drug whatever, and
it is safer to wait until there are indications that the ditsea^se will not run
a benign course before using drugs. Such indications are especially given
by the temperature. Although at times a high temperature doe^s not neces-
sarily indicate danger, since a temjierature of from 40*^ to 40.5° C, (104®
to 105° F.) is part of the regular course of the disease, yet if the tempera-
tare rises above this point it is \vl41 to reduce it by means of bathing and to
give stimulants in the form of brandy. The child should be plaeed in a
ii>om of an equable temperature of 20° or 21.1° C. (68° or 70° F.), and
should be given milk every two hours. There is no necessity for making
any ejcternal applit-ations to the chest. The use of poultices is to be depre-
cated, and in my experience in usually without benefit except in certain
instances for the relief of pain. The nursing is of especial imix>rtauce|
and close watchful uei^s, especially at the time when the crisis is expected
to take place. At tliis time the temperature in infauts and young chil-
dren may fall with such rapidity to several degrees l»eIow the normal
point that collapse often takes place, the skin is cold and moist, and some-
times the child becNjmes unconHjious. Under these circumstances the pulse
is feeble and intermittent, and io some cases death may occur unless active
measures are taken for establishing reaction. The nurse should therefore
be warned as the time for tlie exjK^ted crisis approaches to Match the
child both night and day, and to have remedies ready to be used in case
serious symptoms should arise. These remedies should be the external
Application of heat by means of the hot pack, and tlie administration of
brandy by the mouth if the ehiM can swallow, otherwise by rectal injeetiou.
I have known of a case (Case 468) whciY^ n child died in the coJlajise folio w-
iog the crisis of a lobar pncaraonia, Ihu'ing the convalescence from pneu-
monia the child should be protected from atmospheric changes, cold, and
dampness for some time.
Lobar pneumonia may occur in the earliest days of life. I have met
with a case (Case 469) which on the diii'd day of its life developed a lobar
pneumonia and died in twenty-four houi^s. The auti^psy was made by Dr.
W, Fp Whitney, and the characteristic hepatization was fouud.
Here ii a boy (Oaeo 470), eight years old, who entered the bospit*] on the fourth dny of
•n «ti»ck of lobar pQeurnonia. The uttack bou^aii with vdmitingr i^^)d cougcb* but no pain,
ttpeetontion, or chiU. An tizaminatJon showed the right lung ^3 be* anrmal. On the hit
tide ot the cheat an area corresponding to the loiser lobe in tlic \mck wat found to »how
ftliioliite dulne^ on percu«fiion, brcmchial r«$pi ration, and many drif mniit rilea, Notbinf;
#lit Abnormal was dt<tect«iL Tht5 child wae very rvitl*^, but un the following day^ the fifth
988
PEDIATRICS.
from the onset of the disease, the temperature fell by crisis to the normal point Thif
(Chart 86) shows the typical temperature, pulse, and respiration of a case of lobar pneui
CHART 86.
(Cask 470.)
Days of Dmase.
1
F.
4
5
6
7
S
9
10
11
i2
13
e.
107*
ioe'
103'
loa
101-
loo"
■so'
HI
US
ME
^iti
VK
ME
,ME
MI
HE
u%
41.6-
4ir
40.5'
40.0'
3BA*
J
^
/
36 s'
38 3'
37.7*^
37.2"
37,0'
36.6"
35 5"
^
97"
05
\
^
_\
S^
.-_^
^
\~~
^^^
36,0'
150
140
ISO
120
110
100
90
90
70
60
s.
\
k
N^
^
^
L^
50
4&
40
35
30
25
20
15
.0
1 '
1
A
r
■|
^
-^
'
1
Lobar pneumonia Male. 8 years old. Crisis on fifth day of disease.
(Subsequent history.) After the crisis the child improved rapidly, and the physical
disappeared in ten days.
DISEASES OF THE LUNGS,
989
ThU little girl (Case 471), two and a half yean old, entered the hospital on the thitd
d^ of an attack of lobar pneumonia. Ti>dAy is the tenth day from the onuet of the db-
•isef and thU chart (Chart 37) shows one of the vjihutiona in the criflb which ih quite fr^
quently met with in young children.
CHART S7.
Days of Diseti$e,
F*.
3
4
5
6
7
8
e
10
c.
107
lOG*
105"
i04"
urn
ME
ME
M E
ME
M E
HE
ME
4i.6'
41.1'
40.5"
40.0"
39.4'
38.S*
38.3*
37 7*
^
^-H
/
103*
n
r—
_^
102*
X
/
lOi'
lOo'
/
/
90*
37 2^
r^^
V
l"" 0^
"m*
^— ,
07*
36,1"
.IK A* 1
-
9^1
'^ 1
!36.0'
Lobar paeiUBonla. Irrk^ul&r crisis on etgfatli day. Female, 2>^ jeasa old.
In Ihlt case the consolidated portion of the lung was the lt.*ft lower loK\ The resolution
i» rapid and conTnlescence norm&l.
Thifi little girl (Case 472), eight year» old^ had pertussis when she was fourteen tnontha
Cask 472.
tiihqim
Lobar poeanum la. Ft vcd by the pngmnoolc fnww
bf blaek tines* ainJ the aiva of dimmixnt^i rvHfUWJce Rii'i ih^^ One itlei are tuarkvd by Naek
990
PEDIATRICS.
old, scarlet fever when she was five years old, and measles when she was six years
Five days ago she lost her appetite, was very feverish, and was attacked with acute
CHART
88.
(Cabi 472.)
1
Dai/a of Disease.
104"
100*
m
^7
90
95*
a
4
5
6
7
8
9
10
11
12
13
14
c.
Ml
MM
HS
HE
MB
MC
ME
MS
Ml
ME
ME
U E
41.6'
41.1-
40,0°
38.0*
3S 3°
^
J
^
/
/
/
/
37 7^
37.2"
\
^ ^
^
r1/
H
r-1
0 /.u
.
30.6
36. r
35.6*
35.0*
i50
140
130
120
110
100
90
ao
70
1
A
/
/^
^
/
V
i
\
A
A
^
M
,^
—
50
45
40
35
30
1
*
y
M
y
/
/
^
/
r ■*
_^
20
' is
10
.—
i
Lobar pneumonia. Female, 8 years old. Irregular crisis on sixth day.
referred to the left side of the epigastrium and the lower part of the left axillary h
She has since had a hacking paroxysmal cough, with no expectoratioD. For the pas
days she has been delirious. She vomited twice yesterday, and is very weak. Her to
DISEASES OF THE LUHOe.
991
I
m yoa e4»e, ii honvity coated^ the aim nadi are workingt her face is deeply fituhed^ and tbe
haf dyepncea to such an extent that «ihe has to W pnjpped up on piUows.
Hirr respirHtinns are 45, diiBcult and painful, her puUe 120, and her temperature 39.5**
C* (108,2*" P. )» A physical exttmintttion deteclis nothing abnormal in the fn:)nt of the chest
or in the right hiick. There is absolute duloess in the lef\ back, beginning at the fifth rib
and extending to the base of the lung and into the axillary region. Over this area of dul"
neu there La increased vix-al fremltw^ and bronchial re$ptmtton. In thia area, nlm^ there
m a few moist rilea Just above the upper border of the area of absolute duine^ there
arp diminished reeonanee and a number of tine rBles. Thi* is the fitih day of the diaijAAe.
AJthoui^b the general conditiuu of the child ^eems to show no especial chnnge^ yet the
phyaioal ligna ahow that resolution has begun and that we may at any time expect the
criiU in occur.
(Subse^iuent hifitttnr^) On the following day the temperature fell to 87.7** C (UKP F.)
in the morning, but rose again in the evening to 39* 1=* C. (102.6® F,), Un the following
d»ij^ the seventh day from the beginning of the attack, the temperature fell lo 37.2* C
(90° F.), and then varied from 87.7^ C. (KMT P.) to S7.2« C. (99^ F,) until the eleventh
4tLjn when it became normal. The chart (Chart 88) shows the pul^i^ and respiration up to
the fourteenth day from the beginning of the attack.
This case i^ one which illustrates the fact that the physical signs of resolutioxi mtkj
netliiiei appear before the tempemture falls and the crisis cornea; aUo that at the time
' the criib the temperature may fall, then riiie again fur twelve to twenty-four h<^ur»T and
then fall to the normal, as in ibis case. The child recovered completely-
This boy (Case 473), six years old, was taken sick four days belbre entering the
hciipitAl.
CvLSK 473.
I uirin jiiu Th tve in Vf&Alc4i *.
On entering the hospital bis pulse was 128, his reapirationi^ 00^ and his tempomtum
89.8^ €L (1Q8.8* F.). A pby«$ical examination showed that there was abiolute dulneit
ovfr IIm entire upper lobe of the right lung. Over this area of dulooti tbefv were bron-
cirin) respiration and incfeued rocal nwonance. There wai also an oocaaional bigb-pitched
992
PEDIATRICS.
rile. The left lung was normal. I have marked the lower border of the dulneas prodi
by the consolidated upper lobe by a black line extending from the sternum just above
CHABT 89.
(Cabb
478
0
v.
5
a
7
B
9
iO ii
12
13
14
15
16
17
c.
107
loe
106
104-
loa"
toa°
lot"
100
99'
HE
HE
MS
MS
m
MiMl
Ml
ME
ME
HE
MK
MB
41. e'
4i.r
40 5*"
J
Jl
40.0"
30 4°
^
/
A
Y
/
/
\
f
L
3S S°
/
\
/^
\
^B 3"
'
\
>
37.7°
37.0^
36,6^
^^
*^^
07
1 96
^
Ir
^
jj.L^
35,0°
ido
140
130
120
110
100
90
SO
70
eo
A
^
/
^
/
/
k
'^
r
/
\
\
1/
A^
V"
1
1
^^
60
45
40
35
30
25
20
1 15
10
v^
7-
t^
"S
1
^
^
^/1
/
/I
___^
_
Lobar pneumonia. Male, 6 years old.
ricrht mamma and around into the axillary region. On the morning of the sixth day :
the beginning of the attack the temperature fell to 37.7° C. (100** F.), but rose agai
the evening to 40.6° C. (105° F.), and a physical examination then showed that the mi
DISEASES OF THE LUNGS.
993
koW of the right lung wa^ involved in front, u I hjive indiciited by thli «6cond bliick
lioe Mow the one which T have just described. The lernperutiire during the next two
days runmined between 39.4° and 40<* C. (lOS*' to 104° F.). but on the fnllowing day, the
ninth from the onset of the dbeaae, the temperature suddenly fell U» 37.0® C. (1»1*,7^ F.)
in the eveninife!^, but rose the next morning to 39.3" C. (^10'2.8° F.), and in ihu evenin^j roM
to 89.9* C* (103.8** F.), A pliysical examinution then showed that the whole of the lower
loho was involved, a* I have indicated by the third black line. On tlje following day the
upper lobe began to show evidence of resolution, and the tenji>er»ture felt to 88,3® C,
{\ii\^ F.). Two days later the tempeniture began to fall by lysis, the physical sign* of the
upper and middio lobes entirely disappeared^ and the temperature reacbfd the nornml |>oint
on the fourteenth day fmro the time of the onflRt. On the seventeenth diiy fn^m the dme
Mf the oriM't I lie lower lobe was aLso found to be in a normal ctmdition, and fr».tm that time
convalescence woa uninterrupted.
Here ia the chart (Chart 39), which shows the temperature, pulse, and respirations in
Ibb em» ^om the Hl'th to the seventeenth day of the dbease.
In aome rare cases the iufeetiou in lobar pneumonia is so inteiL^^ tbat a
ni|ii«lly fatal issue may occur.
I have seen a little girl (Case 474), nineteen months old, who had been having so mild
Ml attack of diarrhoea that she was playing about out of doors, suddenly attacked in the
afUrnoon with convulsions and a temperature of 40.5'^ C (105° F.). The convulsions con-
tinued dunng the night, and t^he soon became comatose. On the following diiy the tern*
perature still remained at 40.5** C. (106* F.), the respirations were much acceleratedt and
the pul*e was about 120, An area of absolute dulnes» over the left lower lobe behind, with
brtmchial re«pirtttion and inrr^ased vocal resonance and fremitus, rapidly developed. The
child did not respond to treatment, and died in the evening.
Tuberculosis of the Lung. — Tuberculosis of the lung is an affection
in which certain lesions are pnxluced in ihe lung by the bacillus tuberculoBis.
Although this tulKTcnlar atlectiou may attack any organ or any }wirt of the
body, yet whenever it «x*curs eLsewliere it is almost invariably found in the
Iiiog. It is well, tlierefort^ to si>e^k of this especial manifestatiou of tuber^
culosis in connotation with diseases of the lung.
Etioixkjy. — The cause of tuberculosis, as I have just stated, is an
organism, the bacillus tuberculosis. Here is a specdnien (Fig. 141, page
994) which shows the morphiilogy of this urganism.
The^se organisms are, according to Dt'latield and Pruddcn, &lcnder,
lilamentous bacteria varying in length from one*quarter to one-balf the
diameter of a red bhj<xl-t^4L They are frequently curved and bent, and
may form short chains. This bacillus nmy retain its vitality for raanv
weeks in a drit^d coudition, but is kille<l l>v an exposure of lirteen minuter
to a temperature of 100^ C. (212*^ F.). In most cases it finds its way to
the tissues by inspinttion, although it may also gain access to the body by
being swallowed.
Pathol(3GV. — The pathological c^onditions which result from infection
by the liacillus tnbcnndosis are very numerous. The lesions in ihc child
do not differ fmm those which occur in later life^ and I shall thcR^for*' not
d«»j»crilx' them in detail.
The ordinary chronic tubercular lesions met with in adults are seldom
63
DISEASBS OF THE LUNGS.
095
I
I
t, may be a terminal prrx-es* in casefl id which local tubeiTular
exktB in other parts, mch as the skin, bones, lymph-glands, or the
nn>genital tract*
As in the other tarms of bmnclio-pufjiunonia, the initial lesion is a bron-
chitis and pcTibninchitis^ the dLstingui^hing tubercular features being casea-
tion and neen>9is of the consolidation with the presence of tlie tubercle-
bacilli. The aceomjjauying phenom*/na of atelectasis and emphysema <3ecur
m tiiey do in non-tobercular broncho-pneumonia* In some eases tlie non-
tul)ercular broncho-pneumonia precetles the tnlxMTular diseaisie, this occurring
particnlarly after measles, sttarlet fever, (l!|Vlithcria, and f)ertussi8. Acooni-
ing to Mosny, where the tubercular 1 iron cho- pneumonia tJ>llows the non-
tubercular form, in addition to the lesions of the latter disease, tliere are
found true tubercular processes, such as ptTibronchial nmlula^, tuliercnilar
infiltration, and I'aseous areas. Where tlie [latient is tlie subject of a latent
tul^ereulosis, such as may follow one of the intetlious diseases, a non-tuber-
cmlar broncho- pneumonia may also develop. In th(*He instanc<^s, atx-ording
to Mosny, the lesions may Iw* seen surrounding the tubercular iM-ribmneljitic
nodtdcs, or foci of non-tuliercnlar or iulM?rcular bn>neho-|)neumonia ai*e
Ibund scattered through the apices of tlie lung.
SvMPTOMS.^ — The symptoms of a«;ute tuf>en"ylar bronchi* pneumonia are
very similar to those of non-tubercular broneho-|JUcym*mia. A<xM>rding to
Osier, in most cases the onset of the disease simulates that of the onliuary
non-tubc*reular broneho-pneumouia so closely that a differential diagnosis
between the two diseases cannot be made until al\er death, aud ev< n then
the post-mortem apfiearances may not be those distinctive of tuben/ular dis-
ease, and the pathol<»gi*»aI diai:nosis t^n be dctermlntMl rmly by finding the
bacillus tuberculosis. The children may be attacked with cough, a height-
ened temperature, and the physical signs of bmncho -pneumonia. The
physical signs, as wr^uld naturally be exfict^ted, are usually found in tlie back
and lower portion t>f the lung rather than at the apices, as in adults, on
account of the usual nidus of the tul>erciilar lesions, — namely, the bmnchial
lymph-glands. In some cases thi^ onset of the disease is not s«» acute, and
itfi course not so rapid. The chihl emmMates and has only a moderate fever,
hut later the de\xdi*pmcnt of such symptoms as sweatings chills, and hectic,
together with the signs of softening and breaking down of the lung-tissue,
leads us to susj>e<'t that we are dealing with tuljerculosis of the lung.
Diagnosis. — The diagnosis, as a nik% is to lie made by taking into con-
iiideration the family history' of the child, as the tissues of children whose
(>arents are tubercular show an es|>ecial liability to infection by the bacilhis
tuberculosis. The diagnosis can lie made positively only in those cases
where a specimen of the sputum can be obtained and examined for the
\mci 1 1 us tu bercu los is.
PiiOGNoeis, — The pn^gnosis is invariably unfavorable,
Tbeatment. — The treatment of tubercular broncho-pneumonia is the
that of the non-tubercular form.
^^^ PEDIATRICS.
Chronic Tuberoulosis of the Lungs. — Chronic tuberculosis of th
lungs as it is oixiinarily met with in adults is rarely seen in young children
During the first three months of life tubercular disease of any form is ver
rare, but in the latter part of the first year it becomes very conmion. Th
tubercular lesions which are found in the lungs in later life also occur ii
early life. Although cavities are not so commonly found in young ehildrei
as in adults, it is not so much that they do not exist as that, their localit}
being more at the root and central portions of the lung, they are more diffi-
cult to detect on physical examination. It has been noticed that large cavi-
ties at the apex of the lung are rare in early life, but become more common
as the child grows older. Tubercular disease of the lung Is verj' irregular
in the extension of its lesions in young children. Much more advanced
lesions are asually found at the post-mortem examination than are detected
during life. As I have already stated, the primary lesion of chronic tuber-
culosis of the lungs is commonly a tubercular broncho-pneumonia.
Symptoms. — ^The symptoms of chronic tuberculosis of the lungs differ
but little in the child from those seen in the adult, and are marked by the
same irregularities in their course. This is due to the varied forms of the
lesions. In young infants the symptoms are so often obscure and the
physical signs of the serious pathological conditions which exist in the lungs
are so frequently masked that the diagnosis is apt to be very doubtful.
There is often a history of tuberculosis in the parents. The more common
symptoms of chronic tuberculosis of the lungs are gradual loss in weight,
strength, and appetite, irregular and moderate fever, hectic, and sweating.
The physical signs are slowly increasing dulness in certain areas of the
lung, esjwcially in the back, accompanied by rales and other evidences of
solidification. Later in the disease the characteristic signs of cavities may
develop. Cough is usually present, though it is sometimes so slight in the
beginning as not to be especially noticed by the parents. Hsemoptysis is
rare in infants and in yoimg children, but may be present in older children
as they approach the age of puberty. As the disease progresses there is
dyspnoea, usually of a moderate grade, with cyanosis, but in some cases con-
sidemble destruction may have taken place in the lung-tissue without the
presence of any esjiecial dyspnoea.
The course of chronic tuberculosis of the lungs is rather more rapid in
children than in adults, and it is seldom that the long-protracted course of
the disease so frei|uent in adults is met with in children. Sometimes, how-
ever, the child improves in its general health and may live for many years.
In these cases the terminal phalanges of the fingers may become clubbed,
and there is usually dyspnoea on exertion.
Diagnosis. — The diagnosis is to be made from chronic empyema and
from chronic non-tubercular broncho-pneumonia. The former disease can
be readily eliminated by making an exploratory aspiration, but the latter
can often be distinguished only by means of a bacteriological examination.
In older children, where a specimen of the sputum can be obtained, the
BlifilliM'OF THE LUXQ8,
M7
diftgnoeiB is readily made by the detection of the baeillas tuberculosis. In
younger children, in whom exj^ectoration does uot take place^ the diag-
nosis i^ much more difficult, but if the cbildivn are carefully watched it ia
orteu iwjssiblc to obtain a sptvijueti of the i^puttim if the child hapjK^ns to
vomit, in which vslaq panicles of sputoni may be coughed up with the
vomitus and can be ^'[larati^ from it and exaniiue<l.
Prognosis* — Ttu* prognfMi.-^ of chmnic tul»ereiil(KsLs of the hnigs wliciv
the symptoms are at all advuncal i.s very ontavonible, but the (lost-moiicni
examinatioQ.s of so many iodividnals who have died of non-tulx^rcular dis-
allow the prcseiu^ of old tnlxTcular lesions which have a]>paix;'ntly
a??ed to be of grave iiiiport, that we imnt aeknowlcd)^* that it is |KjsHible
for many cases to isurvive the inva*fiion of the bacillus tuberculosis.
Treatment. — The tivatniout of chnmic tiilx*niilnftis of the lungs Is
etiiscntially climatic* and the eliildivn should Ix^ reoKiVfxl at omv, if |x>ssiljlL%
from a climate where the altitude is low and the atmosphert* damp anfl sub-
ject to great varintrous. Too hit^h ahitudcs are also to be avoidtd. Where
the child trannut b** rt^uovtM:! t^v a more favorable climate, striet attcntifm
to its general hygiene and t<^ its fiwxl will iu some eases be <bl lowed by an
apparent arri'st <d' the tubtTcular pn^ess.
Cask 475.
Chronic tuberculnidfi of the Iiuifr. Ffemalc^ 8 je*n^ o1«K
little ^ifl (Cti^ ^'^'^)i tn^ht yenn uld, has n, bUiory of tuberculosig iii h^t fmmily.
mn atliiok **f pcrtuwie when ebe whs fix years old, and fltime months igo nn fltUck
\lis^ Following the tttuck of miMlfli «he begun Ui bftTe hf^fldfu^bi!, cough, snd «&-
DISKASES OP TItE LUXGS.
d99
the diseaee is often eodeiiiie. Pertussis seems to have some esijeeial rela-
tiou to measlegy as children witii the latter disease are liable to coDtraet per-
tti^is, and in like manner tliose witli jjeiitirtsis are liable to eontratrt measles.
Fertii>>*k may occur at any age, and the disease ha*? even ham known to be
contracted in utero. One attack nsually protects from a second. Debilitated
children with catarrli oi' the respiratory tract are more subject than others to
the contagium of [XTtnssis.
Pathology, — -There ai^e no pathological lesions distinctive of imcxim-
plicateil pertiiSBis. The condition which characterizes the |>aroxysmal at-
tack*? is exti*eme con^stion of the ditfei*ent organs, such as the meningi^,
the lungs, the heart, and the kidneys. In grave or fatal ea^es the legions
are those which arise either from mechanical aecidents, as emphysema or
hemorrhage in varions parts, as the eye or the meninges, or from such oom-
jihcating disc»ases as brcmelio-pneumonia witli it*^ actYmijjanying bronchitis
and atelectasis. The bronchial glands are often found to be enlarged.
Symptoms, — The jMTiod of inenlmtion of }>ertnssis is variable, but 18
itsually less than two wet^ks. The symptoms in the Ix'ginning, and often
ibr several weeks, are simply those of a bronchial eatarrh with a slight rise *
of temiMTTature and a cough whiel*, thfingh sometimes s|)asmixlic, is often i
itidistinguishable ih>m that of an ordinary bronchitis. After a jw-riod vary-
ing from a few chiys to tw<« or tluTe weeks, tlie eongh becomes more severe
and of a more decidedly s|»usniodie cliaracter, and the [xxniliar whi»op wliich
characterizes the dis<^ase appeal's. The cause of thcKC pamxysms s*xuns to
he a spasm of the larynx. This is actMimpunic*:! by a tWling of suffocation.
The jmroxysm begins with a nundxT o4* short, s|iasmridic, expiratory coughs,
«iieceethKl by a long-ijrawn inspinition and by the jKN^'uliar who*>p. During
Ibc panixysm, es|Mx»ially in scvei^e (ust»s, the faiv and mucous membranes
beoome cyanotic, the eyes protrude, the cx^njunc^Uva! are congested, and the
child looks as thotigh it won hi die of a^^phyxia. After a few st'conds th«*
child, with a cunvnlsivc n»iigh, expels Hjme tenacious mucus, and is then
relieved, or tlie attack Returns again, and again sul)sideS| and the symptoms
of asphyxia pass away. Tht^si' paroxysms are o!\en followed by vomiting.
They may occair only four or five times in tlie tw€*nty-four hours, or again
much oftener, — at limes thirty, forty, or fifty times. At the onset of the
attack the I'hildren are usually very much frightened, and either run to the
mother or nui'si* for aid, ur go to some part oi* tlie room where they can lie
undisturLieil during the attack. In certain children, after the severe jmmx-
v^UM have lasted for some time, a small ulcer is formed on the frtennm of
the tnuguc. This is Ix'cause tlie fnenum is driv^en against the lower edge
of the teeth during tlie [jaroxysms. During the otmrsc* of tlie (lartixysmal
9tag<* of pertussis it is quite conmion to have subcMjnjunctival hemorrhages ;
bm^y deeper-seated hemorrhages take place in ttie meninges and in tlie
^oiirptT parts of the eye. In protracted c^ast* jx^tecliia? sometimes aj»|Kiar in
the skin. Rpistaxis may also occur.
Examinations of the chest during the attack have shown that Llie pul-
1000 PBDIATBIC8.
monary resonanoe is lessened during the expiratory stage and is dear durin}
the prolonged inspiration. The auscaltation usually shows diminutioi
or absence of the respiratory murmur. Bronchial r&les are heard occa
sionally.
Koplik has noticed an increase in the area of the relative cardiac dul
ness during the paroxysmal stage of pertussis, which is often accompaniec
by a slight blowing murmur limited to the apex of the heart This ma^
well occur from the engorged condition of the right side of the heart, whicl
subjects the heart to a great strain and may thus result in dilatation. The
heart-sounds are apt to be insular during the paroxysm, and in protracted
cases during the intervals the pulse is often irregular and quickened, while
the respirations are not especially increased unless some complication has
arisen. In severe cases of pertussis the kidneys are sometimes congested,
as shown by the appearance in the urine of albumin, casts, and blood-cells.
Sugar has also been found quite frequently.
After the disease has lasted for some weeks tliere is usually a certain
amount of oedema of the face, especially under the eyes. The paroxysms
are precipitated by nervous excitement or by an irritation in the throat or
the respiratory tract, such as may result either from swallowing or from
the inhalation of dust. The stage which is accompanied by the whoop and
the more exaggerated paroxysms commonly lasts for three or four weeks, <»r
even longer. The paroxysms then become less severe, and, although the
cough wntinues, the whoop gradually becomes less frequent, and after three
or four weeks more ceases entirely. When unc^omplicated, the duration of
the disease is usually three or four months. Slight changes in the atmos-
phere or exjx)sure will give rise to a relapse. The ivlapses, however, are
not, as a rule, of a severe ty[)e, and in these cast\s the cough seems to arise
from renewed irritation of the sensitive mucous membrane of the respira-
tory tract rather than from a fresh infection by the specific germ. A per-
sistent cough following an attack of pertussis may sometimes, according to
Delafield, 1k» caused by au insidious form of broncho-[meumonia.
The period of infection is supposed to last for a certain time after the
whoo[) has ceascxl, and if the cough continues it is well to allow for a period
of infection of three weeks after this cessation. It is jxjssible, however, that
the whcKjp may occasional ly occur for long {)eriods after the child has ceai?eil
to be a source of infection to other individuals.
CoMPi.K ATioxs. — The complications which arise in pertussis arc usu-
ally of a gmve nature. The dangers from hemorrhages, unless in the
form where they occur in the meninges, are not great. The complication of
broncho-pneumonia is very serious, and often fatal. Severe and even fatal
emphysema may occur in [)ertussis.
Convulsions may arise not infrequently in infants and may end fatally,
in these cases usually being caused by general reflex disturbance, by cere-
bral congestion, or by some cerebral lesion. Spasm of the glottis may
also very rarely cause death in greatly debilitated children. Excessive and
DISBASKS OF THE LtTNOS.
IIXU
I
obstinate vomiting at times be<x)mea a serious csomplication, and may reduce
the child's gtrength U) a point which oftfu gives rise to a doubt as U) it*?
recovery. It h an especially grave com plication in infant*^ who are already
much debilitatecL
DlAGN'0618. — The diitgtiosis of pertussis cannot, m a rule, be made until
the child whm)pfl. Sometimes^ however, when* another child in the family
has undoubted pertussin a spa8mi>dic cough may allow tlje diagn<jsig U* be
made before the whtK)p ha.s develo|>ed. It is probable tliat a cliild may
Jttive pertussis without at any time developing the who<*p.
In some children a simple catarrhal laryngitis will itsiniiilate |K'rtus,Hij?>
quite chisely ; but^ altti(»ugli in these cjisi^s there ai*e paroxysms (jfgpismfKlic
tt)Ughing, a pronoimt^ ** whoop*' does not occur, and the symptouLs do not
progressively increase and last fi>r a lirng [>erirKL The diagnosis of [lertassii*
iUn iL»^ually tie made by the swulleu asptrt of the faw, the panjxyt^rnal tvnigh
followed by the expulsion of tough mucus and vomiting, and the long dura-
tion oi* the attack.
Prognosis, — Pertussis is a very serious atfection tn young infants, and
also in older children who are debilitated or poorly cared for. Where it is
oomplicatetl it is one of the most fatal disea'^es which (Kvnr in curly life,
W^hen it oc-curs in older children the prognosis is favombU% provided that
they have previously iK'cn well and strong, that they are well canxl for, and
that no complications arise.
In some crises young infants, if their vitality is unusually g«»<-Hl, and it
they are carefully nursed and made to taki^ a suflicient amount of IIkkI,
ftbow remarkable [xjwers of resistant during attacks of jiertussis.
A OMe of thk kind that cunie utider my cun- w^us thnt of un infuat (Cjue476|, Hvii
monilu old. In March she ^ulT»'red from an at tuck of epidemic iriflucuza^ which lasted
mbaiti twelve days, and fmrn whk-h she finally recovered. She wns then attucked with
niMfcleft, and alter the tempemture bud fmllen to the tmruml point she wiid attacked with
prrciissi*. After two or three daye the cough increased in i^everity, and afVr two w«dka
tbe infant began U> whoop, The attack laated for two months ^ and ihc flnaUy nxH>irervd.
During tho whole course of the diseaM; she took over 600 c.c. (20 Muntx'^) of modified
milk in the twenty-four hnun^, and for a »hort time »mall dosea of brandy wert« ^iven. No
drug! wen? ndmiui»tere<l Here is a chart (Chart 41^ page 1002) which ;»how^ the aveni^^o
f%np* of tem]>erature for lw<i weeks whou thtf dif^ease wa^ at it* heiirht.
Treatment. — In the treatnicnt of pcrtut**?!.** we nuist take iut<i i>tri-
Mderation the age of tin* imlividual, the 8ta^* of the disease, and the |»i^*^-
enoe or abacucc of complicatious* In the early months* of life, after th
diaeaae has lai^twl for a wt»ek or ten davs and has lKH^»nie nmn* H4'Vere,
the infant will uRually sliow symptoms of general cin-ulatory dUturimmv.
The great strain thrown upon the heart during tlie paroxysnift quickly
affix^ts the general gtrength of the infant, a niarketl interference^ with it**
nutrition soon appears, it loses in weight, and often it n»fu3cs it.«^ f^^iod. At
iimt^ it will iK^ernne *w»mcw^hat cyanotic even betwt^en the paroxy^nw, and
there b danger not only from the severity of the jiar»»xysin» Init also from
DU8KAS£8 OP THE LUNGS.
looa
I
I
extent that util€88 this amount cau be increasKl a fatal issue is likely to
regalt.
StinuihintH, in tht? furni of brandy or wbiBkey, ishoiild be ^iveu early in
the attaek. Where the cyanoj^ii^ is a promioeut feature and the puke i:*
irregular aud inter mitting, small doses of digitalij!* should be given. In
thc*^* cases, alj*<j, the admin lustration of oxygen is a valuable iidjunct to the
treatment. At the height of the attack, when the paroxysms are severe
and espeeially trequent at niglit, the burning of cresoline iu the room at
night is in some cases beneticiah In the milder ca^^^'s not acet.mipanied by
the more severe symptoms which I have just enumerated, Ijelladonna or
atropine oflen proves vahiable. There Is no drug, however, whieh is a
specific for pertussis at any age.
For older children whose healtli has previously been good, there is
no especial ti'eatmeiit, ex(^-ept that they should have as much fresh air, free
fn*m dust, as possible, and that food should be given them after they have
vomitefl.
Where nmiplieations arist*, the treatment is tliat of the complicating
disease.
In cases \vliich aiv protracted, a change of air, either to the eountry or
to the sea-shore at suitable seasons, is often followed by an apparent shorten-
bg of the duration of the attack.
pROPHYLAXLS. — Pertussis Ls so highly contagious a dis<*ase, and may be
so serious an atJetrtion in certain children, that a rigid pmphylaxLs should
ha enforced. It is the dut> <»f thiKs*.* who take airt* of ehildi-en with pertussis
to see that they are isolated during the whole course of the dise^ise.
I hav*' lu'iv a wixi'imeu (Fig. 142), made by Xorthrup, of a lung taken
fn>m an infant
(Cat
attack of j>ertus8i8.
0
age,
luring
KllljJlSi^'tt.iit fuli.MV ^uc t^TLiS'-i*. lJL*tt*lHlt'1
The section shows extensive vesicular cmphyaemai with great disteotioo
of the walls of. the alveolL
I bftve htfre a little girl (Ctse 478), four yean old^ who ia in the fifth woek of jui Attack
<ff prrtuisb.
Th^ Intervftli) b«iweeii the p«foxjfaiB uv osiitttly one qt twu h^jun^ She has Jtatt
h9pm lo ooughi and you will hAye lui opportumty of feeing her in ont of thv pAfosytniA.
I
The j>c>«^itioii of the oliild i*^ very characteristic, as is alsi> the
and oon^ested eondition of her face. When tliis picture is onoe t
yon have heanl tlie t-haraeteristie whoop, you will have oo diflE
making the diagnosis of pertussis.
Ill S4jme eiiyes^ even in older children and where no iK)niplica
pres*-^nt, the attack of pertussis may be so severe as to prove sei
saw a case of this kind in oonsultatioo with Dr, Howe, of Cohass<
A boy (Case 479), six years old, biM3 bud pijrtusaU for five weeks. For
previous to my g«eiiig bim thu cuugh bad be«ii so frequent and so constant
panied by votniijng that tbt? cliild had been utiftble to relaiti any food. He was
emaciati^d, and was i^u weak Ibitt be could not 6tand. This condition lasted fof
t«n days : he then begau to improve^ and flnally recovered entirely. ^^^^H
Asthma. — Asthma is an affe^^tion of the hin^ characterized
modic attacks of dyspno?a. The disease is rare in in fancy, but is
common in childhooti
ETiDLfKiY. — The cause of astiima has not been satiafactoril
mined. There h a strong neurotic element in the disease, and
eases this eh?ment is appan:^utly heiwlitarv. In individuals wh(
tendency to tlie disease it may I^e incited by various causes, such a
atmospheric changes or the inhalation of irritants.
DISlilASKS OF THE LUIffOS.
um
Pathology. — There are no knowTj pathologit'al lesioas which character-
the disease. In cases of long duration the le^sions of chronic bronchitU
often found.
Symptoms. — The symptoms of bronchial asthma ai*e tfie sijime in the
ild as in the adnlt. The onset is usually sudden, and generally occum
niglit. A catarrhal condition of the respiratory tract, es)Hx^ially of
brr»nchi, inmimonly iirf<:'t^^los the attack for some days. The child h
with distR^ng dyspmca, mainly expiratory, the I'espiraticm lieing
Kxmiptinted by a wheezing sound. The face is anxious, and if tlie attack
ntinucs for siinie time it iKHLNimes slightly cyanotic. The RS|>imtions are
ot es|Mx*ially increased in frequency. Tlic pidse is rapid, and when the
y!5pna?a is very intense it Ls weak. The temjK'rature is not raised by the
hnia. and where the pamxysm is prolonged it may lx^*onie subnormal .
V* physical signs are mostly ditfiise, sibilant, and sonorous mles. The
Itack may last for a nnmlier of hours, or even for days. The paroxysms
their severity, and, a^ a rule, ai\* ilillowetl by considerable exhaus-
The fre<|uency of tlic attacks varit^s ; they may occur often or only
inter\'als of niontlis.
PeoGNOSis. — The pn^gnosis of asthma \^'ith regard to the espet*ial attack
good. Where tlic diseast^ is not lieretlitary the children very common ly
ecover from it as they ajiproach the agt^ of pulx^rty. In many cases the
ttacks seem to defiend ufxin some local affection of the air-paasageSp and
cure of these local lesions will often be followed by recoverj' from tlic
tacks of asthma.
Treatment. — In the tit^^tment of asthma, the nose and diroat shotild
c-art*fully examine*! fiir local diseases, as the attacks may lie «:tiufte<l by the
il!erent forms of rfiiiiitis, adenrjid growths, or enlarged tonsils. The cJiil-
ren should be pnitei'ttxl fmm unfavorable atmospheric inttuences, a high,
r, inland air usually txing Iw^tter suited to thi-ni than siia air. In some
i, especially of a mihl form, die fumt^ of tiiti-e |mper will give ct>nsider-
»k relief. In very sc»vere attacks hydrate of chloral may lie given, either
the mouth or by enemata. Antis|iasmo4lit^, such as U'lladonna and
>belia, can also be used. There is no oue drug which will relieve the |>ar-
ysras of asthma exceju morphirK% which should Ix* ust>d with grc*al i^ntiou.
Ddide of potassium in gradually increasing doses is in some i-ases beneficial.
j)ecial attention should be paid to the general hygiene and to the diet of
le ciiild.
Periodic Catahrh (Autumnal Catarrh; Hay Fever; Rose Cold). —
*Fely allied to asthma is an aH'ection of the respiratory tract <»ccurring
lodically and characterizwl l>y grc^at irritation of the muc^>ns mem-
of tlie eyes, nose, thmat, and bmnchi. The same causes tlmt have
n supposed to prtKlucc* asthma seem to be of etiohigitral iin[»ortan<x* in
'riodic catarrh. These attacks usually occur in the summer nioutlis, but
generally most severe in August and September.
Tbe onset of the attack, in contradistinction to the ]mroxysDiiS of a^imai
1006 PEDIATRICS.
is generally at some definite time of the year. The especial attack h
for five or six weeks, or even longer. It is characterized by a severe ac
catarrhal inflammation of the nose, eyes, throat, and bronchi. The corj
and lachrymation are in many cases excessive. As the disease progresses, i
cough becomes very distressing, and ihe respirations are so impeded by 1
congested and swollen mucous membranes that sleep is interfered with, a
the child's general nutrition is soon affected. There is no general reme
which controls the disease, and benefit usually can be obtained only by i
moving the child to a locality which is free from the causes that produ
the disease.
The prognosis in children is good. The local treatment of the upp
air-passages is the most likely means of obtaining a cure. If it is lefl ui
treated the disease occurs every year, so that just before the yearly attac
begins it is well to have the children taken to the especial locality where
has been found that they do not suffer from the disease. In this way th
impairment of their general health will be prevented, and it is possible iin
they will eventually cease to be affected by the disease.
Where the child cannot be removed from an irritating locality, tem^x)
rary relief can be obtained from sprays of cocaine. As recommended b;
Wyman, the windows of the sleeping-room should be closed early in th
evening and kept closed during the night In tliis way the dust in the ai
is allowed to settle, and there is less danger that the irritating material
whatever it may be, will produce its effect when the child is asleep. As i
nile, it is advisable to give the child quinine in tonic doses, beginning just
before the date of tlie onset of the disease and continuing with it until the
attack ha.s almost run its coui-se.
DISEASES OF THE PLEUBA.
1007
LECTURE L.
»
I
DISEASES OF THE PLEURA.
PLEUBISY. — luHanimation of tlie pleiira may be acute or cIironic» and
may be acconii>anied by an effusion, which may be serous, sero-piirulont^ or
pimilont
Acute j>leuriti8, either with a simple exudation of fibrin or aixMmiparnitl
by fluid, is quite frecpient in children. The effusion ba« a greater tendency
to lie punilent in children than in adults*. It scema to follow exposure of
various kiuth and to be produced by a numl^er of organisms. As a sec-
ondary affection it occurs es{>ei'ially after lobar pneumonia and pulnionarv
tubercuh>4is, als^i in the course of tlie acute exauthcmata and in such dis-
eases as rheumatism.
lo reganl to the micro-t>i^nb^niH wliich are supposed to produce pleuri-
tis there k an evident diffcreaot? in the intensity of the inflammation \vhit*h
follows their invasion. In the serous exudations the jmcunuMMXYnis ha^
lieen fountl must fVcH|ucntly, and seisms to be most commonly pn*s<'iit in the
benign forms of the disease. Next to the pneam(x?occus the staphylococcos
has been found to be pn^^^nt in the lea*^t virulent forms. The Ixicterium
which has been tbund in the pleuritic effusions of tlie s<n^en'st cases is the
fltreptococcus. In thcfse effusions which arise fn>m tnlierculosis tlie bacillus
taberculosis htis hinm found.
PATHOLOCiv. — Plc^uritis is usually a unilateral disease, but may iu I'ai'e
»%§ bilateral The pathological conditions found m the pleurisy of
children do not diffrr fnmi those whiclj fx'eur in later life. Altliough
localized areas chanictcrizc«l by the pr*>(luction of fibrin (dry pleurisy) are
qaite frequently found at the post-mortem examination, tJie diagnosis of
this form of disea*^- in infants and in y«iung childmn is not often made
daring life. Where, however, large areas of die lung are involved in
bronrhi>pneuraonia, diy pleurisy quite fre<piently «jc€urs, and small ciixnuu-
scribed areas are cx)mraonly met with in connection with lobar pia'umonin.
In the common form of pleurisy, whejv thei'e is a pnKluction of fibrin and
serum (pleurisy witli effusion), a greater jiart of the pleura of one side of
the chest is usually involvtd. According to iVlatield and Prudden, m Idle
the inflammation is in |m egress the surface of tht^ affi^ted jdenm is maUil
nith fibrin, Imnds of fibrin stretch btnwt*en the parietal and pulmonary
layers of pleura, and in the pleural cavity tliere is serum in variable ipianti-
tics, Thk serum is sometimes clear, sometimes Is turbid from tlie presence
of pust-cells and flcx'culi of fibrin. Botli tlieae forms of pleurisy, althfiitgh
differing in their clinical history, are anatomioally essentially tlie same. In
both we find, firsrt, the exudation of fibrin aud a few pud-<}€Jls eitJier with or
0I6EASBS OF THE PtfUBA.
1009
I
»
creased v*xal resonance and fremitus, which are commonly met with in the
pleunsj of adults, are not, as a rule, suffieieotty marked in iuiancv and
early ehildhtK)d to be of much vahie for diagiiosk. Great difficulty may
arise in auscultation from the tiiier sounds being oljseured by the child's
crying, but in the intervals when the child takes a breath and its cry must
neoefisarily cease for a moment, valuable information can be obtained by the
quick use of the stethoscope.
Where the effusion in suificiently large to displace other organs, such as
the liver and the spleen, the presence of the etfusiou is so evident from the
usual signs that these displawments are not of especial value except so far as
they show that the etfusiou is in large amount. After thc«e large effusions
have lasted for some time, and especially when they are purulent, I have
met witli decided bulging of the afftH:?tijd side.
DlAONOSis,~The diagnosis of pleurisy with serous effusion is to be
made from lobar pneumonia and from empyema* The physical signs whicb
in the adult are most useful in diflereutiating pneumonia from a pleuritic
effusion are often rair^lcading or absent in the young child. Thus, alisolute
dulness may occur in other condititms as well as in a pleuritic effusion, while
bionchial respiration^ such as is heard over a coustilidatcd lung, may also
be heard over a large effusion. The vnc^l fiTUiitus may l>e abseut in a
pneumonic cousolidatiou^ and sometimes, though rarely, well marked over
SD efitision. Moist rdles have been heard in children over an eflij^ion, and
fluid has bemi aspirated at a |>4>int where a friction-rub was heard. It is
well known, also, that aspimtion is not a oniclusive mexius of diagnosis, fur
punctures have often bc^en made where an effusion was prc^nit and yet no
fluid was obtained. Tlie chau«,fe lo tlie level of the effusion on change in
position is of some value in diagnostieatiag a pleuritic effusion fnjni pneu-
monia, but is often difficult, and at times imjKissible, to determine in yoimg
children. The most reliable means of diagnosis in intiiucy and in early
childhotid is jx^rcussion. The area ol* dulness which occurs in lobar [)ueu-
monia is quite different from that which Is found in cases of effusion un-
complicated by pn^vious adhesions. If adiiesions are present, these typical
dianges are so interferetl with that the [»ercussiou becomes as unreliable a
sign as the others which 1 have Just meutiouiHl. The younger the indi-
vklual, however, the less likely are extensive adhesions to be present, and
valuable, therefore, Ls the evidence of an effusion given by |ier-
As has been shown by Whitney, when the etfusiun is small tliere
is absolute dulness (flatness) at the base of the thorax. A fri<-rtion-eound
may be heard over the dull ar-ea, and respiration may l^e quite distinct,
aud srmietimes accompanied by rdlc^* Under tbcse circumstances the diag-
nosis of the condition as one of effusion must dei>cnd upon the outline of
tile area of dulness. In determining these small areas of dulness the
lower border of the two sides of the thorax must first be carefully oom-
|iared by percussion^ bearing in mind that the lower border of the pulmo-
nary rfsonanoe in early life corresponds to the poeition of the ninth dorsml
1010 PEDIATRIOB.
vertebra on the right side and to that of the tenth dorsal vertebra on
left, as I have already explained to you in my lecture on developm
(page 122).
You must always remember that the percussion of an infant's oi
young child's chest should be very light, as heavy percussion, owing to
delicacy of the thoracic walls in early life, is unreliable.
Palpatory percussion, for the same reason, gives more information wl
the child is crying than can usually be obtained by the sound, but, as I hs
said in describing the auscultation in these cases, quick percussion in t
intervals of respiration is also a valuable aid to diagnosis.
Extended observations have been made on the line of percussion-dulni
found in medium effusions by Ellis and Grarland, and lately in small efi
sions by Whitney, of Denver. These investigators have shown that as i
effusion increases in quantity its upper border undergoes a gradual seri
of changes, provided there are no adhesions.
Where the efiusion is small in amount it can usually first be detected i
the back. In these small effusions the upper border of absolute dulne
begins at the vertebral colunm, extends outward horizontally for a distani
which varies according to the size of the eflusion, and drops in the neigl
borhood of the posterior axillary line by a' curve more or less abrupt to th
base of the thorax. As the efiusion increases in size the line of dulnes
drops more anteriorly. Where the efiusion is moderate, as where the lowe
half of the pleura is filled, in some cases, but not usually, a slight dis^
placement of the heart may be noticed, and the percussion over the slightl}
compressed lung may give tympanitic resonance. The upper border of the
area of dulncss in these medium effusions is found to extend at first outward
and then upward over the angle of the scapula, reaching its highest point
in the axillary region. The line may then drop abruptly from the upper
axilla U) the base of the thorax near the apex of the heart This line,
which has been called the " letter 8" curve, is characterized by having its
highest point in the axillary line. When the quantity of fiuid is still larger
and exc^jeds a certain amount, the " letter S" curve is obliterated, and the
resonance over the compressed lung becomes less marked. The displace-
ment of the heart in this latter case is a most valuable sign of effusion in
young children, and with careful, light percussion the gradual increase and
decrease of the effusion where it is of any great extent can be determined by
cardiac percussion.
You must always bear in mind the physiological dulness of the heart
which I have already described as occurring in early childhood (page 123)
under the lower third of the sternum. This dulness, however, is relative,
and becomes much more marked and absolute where it is caused by a
displaced heart.
The differential diagnosis from lobar pneumonia is greatly aided by
understanding these areas of percussion-dulness which I have just described.
Thus, where the diagnosis is to be made between pneumonia of a lower lobe
^
I
I
DISEASES OP THE PI.EUBA, 1011
and a small or mediam pleiintie effusion, where an effusioa is present the
diilne^s will be iu the lower jmrt of the thomx, with normal or tympanitic
resonance above it ; where piieiunonia is pn?seut the ani^a uf tliilness will
often correspcmd to the bomidaries of the lower lolx* only. In like manner
tlie area of dulness of the effusion will differ in tlie axillary regions and in
the front of tlie thorax from the areas of dulness pi'oduoed by the consolida-
tion of the different lobes of the lung.
The diagnosis from empyema is very difficult, as the younger the indi-
vidual the more likely are the effusion to be purulent and the early symp-
toms to be similar to those of the seroiLs form of exudation. After the iirst
week or ten days of the disease, however^ where the etitusion is purulent,
the usual signs of absorption which so conmionly occur in a serous effu-
sion are ordinarily not found, and a^spiration of the pleural cavity will then
determine whieh form of the disease is present.
Where no bacteria are found in the fluid, where there is no history of a
preceding acute pneumonia or a neoplasm of any kind, or where there is
little tendency^ to absoriJtion of the exudate, and where the exudate is found
to contain blood, the failui^ to find bacteria in the exudate may be r^arded
as pointing strongly t«:>ward8 a tubercular origin.
PRfKJNOBiH, — The prognosis of a serous effusion, as a rule, is very favor-
able in infants and in young childi-en unless one of the more virulent forms
of the pyogenic cocci is present, or unless the disease is secondary to tuber-
Guloeas elsewhere and is caused liy the bacillus tuberculosis. If the serous
eSiiiioii tends to bec*>me purulent, the prognosis is not so good, but still,
provided appropriate treatment is carried out, it is tavorable. If, as in
fare Gases, the pleuritic effusion occurs on both sides, tlie prognosis becomes
gn^e. The possibility of the presence of tubercle should be considered in
tboe latter cases.
I buire bad in my «enrice at the City Hospital a boy (Cbao 4S0)» thirteen jeais old,
who waa attacked with plfuntift and a serouB etfusion of the left side with diiplacement of
the b«art to the right After one a.^ pi ration the fluid was quickly abeorbed, but three
weeks later he was attacked with pkumy on th^ right gide, followed by an effusion and
dbplaoement of the heart to the left. Tbh eftusion wa« absorbed witliout ajipinitionf and
llii< boy was discharged ^m the hospital well and strongs with both lungt appftreotly in n
i coadidcn.
I
Where the eflFusion is very large and the heart is much displaced, there
in always the danger of a fatal issue from asphyxia, and the projrno^tis rle-
peods upon whether the effusion can l^e controlled by lispi ration and tlie
heurt thus be kept in normal position. A ca*« which illuBtratcB tlie danp^^r
of these large effusions accompanied by displacement of the heart came
ly care at the Children's Hospital :
boy (Case 461)| four or five years old, entered the hoflpital with a larj^ elTiuion in
cheet. The he^rt waa displaced to the ri^ht, and upward a» fur a^ the teo^^nd
to the right of the sternum. lie waa cyanotic and gasping. On aepirmting the
DISEASES OF THE PLEURA,
1013
The point of aspiration should usually be in the fourth or fifth inter-
space in the axillar)^ line, or a little farther back.
Purulent Pleuritis (Empyema). — Empyema h a purulent effusion into
the pleural cavity. In the first three or four years of life it is much more
oommoD than a serous effusion.
The cause of these purulent effusions is the same, so far as we know,
as that of serous effusions* The same orgaaisms are present in the two
ibrms, and they are also fre(|iiently present when purulent pleurisy is
secondary to a number of diseases, the most prominent of which is lobar
pneumonia.
Usually the whole pleura is involved, encysted empyemas in infants and
young children being rare.
The disease when primary may lye acute in its ouset, and may simulate
closely the initial stage of lobar pneumonia, In other instances it is sb.nv
and somewhat insidious ui its development. The pulse and respirations
^ may be quiekeueil, but after the early days of the disease they are often
" very little raised. There m nothing characteristic in the temj^erature of an
empyema, and the diagnosis usually can be made only from the knowledge
that the youngtT the individual the more likely is pus to Ix* present. This,
however, can \ye determined definitively only by means of the aspirator.
1^ The physical signs are the same as in a serous effusion. The abs^irption
^fc of a purulent exudate without surgical interference is very rare. I have
^ftmsasionally met ^vith cases where one aspiration was all that was necessary,
^H9u where, seemingly, coiuplete absoqition took place.
H Where cases of empyema are left untreated, a spontaneous o|>ening
Qsnally takes plarje through some p>rtif>n of the thoracic walls, but the
exudate may also find its exit through the lungs by opening into one of the
bronchi or perforating in other directions. I have met with cases where the
diaphragm was jwrfonited and tlie |K}iut of exit of the pus was in the region
of the umbilicus. Where jierforation does not occur, the pus is partially
I absorbed, adht^ions ai^e formed, and sometimes grt^at deformity of the chest
t fellows, which may result in a marked degree of lateral curvature of the
ipine as well as in great oontraetiou of tlie ehest. ,
After the first ai^piratiou, unless absorption occurs within a week, and
cepecjally if one of the more virulfut forms of bacteria is fouud in the
exudate, a radical oj^eration is the ln.*^t mettiod of treatment. Where this is
(performed early in tlie disease, the pn>ginjsis is very goixl in infancy and
early childhood, unless the empyema is of a virulent form or ts seoondary
to fiome incurable disease, such cOs is <:*ans<>d by the bacillus tuberculosis.
The pleural cavity should be thu roughly draine<l by means of drainagi?-tubefl.
In many cases, especially in childrt^n over two or three years of age, reseo-
tion of one or two ribs gives tlie best results. Although in some cases a
mpid cure in two or three weeks follows the operation, yet the recovery is
often prolonged fi>r many mouths, even where strict antisepdo precautions
have been taken at the time of the operation.
1014
PEDIATRICS,
As the treatmeot of empyema is essentially surgicaly I shall
into it^ details.
I
Thii little girl (Gii«e 482), eleven years old, was attacked six weeks i^ <
followed by vomiting. She then had a thort, dry cough. For the past few day
complained of pain in the lower part of the right chest. She hat been feverish, hat loi
weight and in appetiter and her respiratione have been painful. She liea moat conifortt
on her back and on her left iide. A pleuritic friction-mb has been heard in the 4
axillary reg;ion. Her lips and cheeks are slightly cyanotic.
Cask 4^2.
Acute pleurisy with serous tifl^ion. F^uuik. ii . . f the upper border of thai
the area of cardiac dnkiew, and tJie lanqpn.^ of ttu' Tiiy» are uuLrked In black.
Her tongue ii aomewhat coated. The ultE nnai any working, and, as you see^ the dys-
pnoea is BO marked thai she haa to sit almost uprigbi in bed. The percUMion and ausculta-
tion of the leflt lung fihow nothing abnornaal. The resonance U fair over the upper part of
the right front and back. Th«^re is absolute dulness from about the flflh dorsal vertebra in
the rfgbt back t<> the base of the lung. This dulnoaa extendi into the axillary region, where
it reaches its highett point, and then grudunlly descenda to the right parasternal line on s
level with the fourth costal cMirtilage. Over thu area of dulness respiration \» markedlT
dimiiiished. No friction-rub h heard. The V(jcal and the tactile fremitus are diminished.
The impulse of the heart is found in the fourth interapaee, 1 em. (f inch) to the left of the
mammary line. The heart-sound* are normal. There does not appear to be any di«plaoe>
ment of the liver. An examination of the urine shows it to be acid, to have a specific
gravity of 1022, to be of normal color, and to eonttiin no albumin. The chlorides are nor-
maL The phydcal signs are those of a pleuritic effus^>n of the right side with diaplacement
of the heart to the left.
(Subsequent history.) During the fljllowing week the area of absolute duhiess gradu-
ally decreased, and an exploratory aspiration showed the fluid bo he aerous. Three weeks ^
d
^^P DISEASES OF THE PLEURA. 1015 ^^^|
^m the time when ibe entered the hoepitAl, and nine weeka from the begin nin|c of the ^^^|
mMck, the dulneas on percussiun gruduHlly disappeared, ntucultatiun showed the refpimtion ^^H
CHART 42. (Case 482.) ^^H
Days of Disease.
1
y.l
j
41.6
41 i
_
US
n.*
M E
WE
M E
M £
M E
M E
U E
K E
U E
U E
M E
M E
M m
M IJM K
HE
u e,
U E
It c
P
10!?
loi
An A
40 0
/
/
39 4
^H
i02
3d 8
^H
^
3B3
^
S|
^
^
37.7
37.2
37.d
36.6
«
o(S
/I
/
^
^
■ ^
^
^
/
97-
35 5
95
35.d
2
4K£%
4AA
I4v
t20
4f Q
y
iOC)
/
/
/]
.
^
y^
/
J
J
K
li
M
/
.^^-1
/I
/
^f^
■
■ I Mtf%
^'— 1
^H
■ ■ *U^
!i
1
■J Ai%
/
/
40
35
/
/
/
7
/
k
/
k
:
/
J
J
25
^
\
/
/
/
/I
20|
16
10
^
/^
^\
^
Acute plouris}' Mriih »eracu eJAiaioD. FeniAle, 11 yeAn old.
> bt normal^ ^d the heMt reitiined iU nonnal potitian. Thi« chtit (ChArt 42) «hawt lh<
ngMMlire, ptiUe, and respirallan while ah« wm in the boipitftL
^^^1
1016
PEDIATBIOB.
This chart (Chart 48) shows the temperature for twenty-one dayt in a case (Case 4
of serous effusion in the pleura, where in the banning 165 c.c. (5^ ounces) of fluid n
withdrawn from the chest.
CHART 48. (Cabs 488.)
^^
Days of IHsecLse.
y.
r
c.
107
ME
ME
MX
Ml
M E
M t
MC
M E
ME
ME
ME
ME
ME
ME
ME
ME
ME
ME
ME^
M E
ME
41 a
44 4*
105
40 5'
iCM
40 0*
102
101^
too
304'
39 8*
/
y
/
as 3°
/
y
>
y
/
J
\
377'
ntmuM
r-^
y
/
/
^
/
/^
/I
/
/
/
/
/
37 2'
r
37 0*
98
'^e^
66 1^
35 5°
95-
35-0° i
Acute pleurisy with serous efitision. Male, 4 yean old.
The fluid reaccumulated, so that absolute dulness was found over the whole right side
of the chest in front and behind, but aspiration did not have to be resorted to again, and
complete absorption took place thirty days from the beginning of the attack.
A numl^er of cases have been reported in which a purulent effusion has
been trcatod by aspiration and has seemingly disappeared entirely without a
radical oj)eration. These cases should be borne in mind when treating
purulent pleuritic effusions. An infant (Case 484), seven weeks old, with
empyema, at the Boston City Hospital, in the service of Dr. Doe, recovered
entirely after one aspiration.
The initial stage of empyema often closely simulates pneumonia.
A case illustrating this fact has come under my observation, where a boy (Case 486),
three years old, and previously well, was attacked with pain in the left side, with a chill and
with dyspna'H. A physical examination made on the third day of the attack showed the
right lung to be normal. On the left side of the chest there were absolute dulness, dimin-
ished respiration, and increased vocal resonance, and fine r&les were heard from the fifth rib
to the base of the lung, both in front and behind. Two days later an exploratory aspiration
showed that the physical signs were caused by an empyema.
Another case which illustrates the difficulty in diagnosticating a puru-
lent effusion in the pleura in the early days of the disease is the following :
A girl (Case 486), four years old, was suddenly attacked with cough, and pain in the
right side. The temperature was 40.6° C. (105° F.). The respirations were quickened, and
the pulse was rapid. Nothing abnormal was detected on physical examination. On the
following day the general symptoms disappeared, and the temperature fell to 88.8° O.
(102° F.). In another day the temperature fell to 87° C. (98.6° P.), and the child seemed
I
m
1
iiU.iLii
DISEASES OF THE PLEURA.
1017
bright nod well. On the fallowing d»y, however, the temperature roeo to iO* 0. (104^ F.),
«b«<>lute dulness wafi detected in the right tixillary region, and an exploratrtry aspiration
showed the presence of pus,
Her^ is a little girt (Co&e 4S7)i three years old, who two yeais ago bad an attack of some
pulmonary diseaee accompanied by f«ver. Since then she haa been delicate and baa coughed
a great deaL Her cough h&n incToaiied in tht3 last few weeks, but sbe ho£ not lost in weigbt
nor had any other abnormal gy mptoms. She is pale, iind the cervical^ axillary , and inguinal
glAnda ore enlarged* Her fingers are markedly clubbed. She shows a peculiar lat«*rtil
corvaturc of the spine, which cannot be made to disappear by traction. The light aide
of the thorax expands normally, the left Me scarcely at alL There are hyperre«onano6
over the right lung, no rale«, aod compensatory rei^piration. The left lung U apparently
atelectatic^ and shows dulness everywhere except in a small triangular urea at the inferior
angle of the scapula. This deformity of the thorax h probably the result of an empyema
which occurred two years ago and was not pn>perly treated.
Hcfe if an infant {Cwse 4BB)^ une and a half years old, who centered the hospital with
ny of an acute attack, charactertKed by fever, cough, and dyspnoja. Physical exam-
ination showed nothing abnormal on the left side of the chest, but on the right ?ide there was
absolute dulness, with bronchial rvspiration. No r&le« were beard anywhere in the lung.
The upper bordi^r of the areu of dulnesij I have marked with ii bltick curved line, and
yoti see how, beginning at aK^ut the ft^tirtb dorsiil vertebra, it gradually rises as it af)prfmcb4*s
the ftxiilary line and then falls as it appnmche^ the right parasternal Line. The child's
Eacofvwx ftom empytmn. Mali-, uj vi pii^ oM, '•hi tv\ luj^ Kitr cii^iit ymrv after opentlflo.
right arm has been turned upward and forward, in order that the ribs shall bo snfflcientlj
ieparmted for the intntductlun i»f the tn>car pre^iarxtory t«» an opiTation for the radical cure
of the empyema. An cxplomt'^ry aspiration ha? already shown the presence of a purulent
efluiinn in the pleura.
(Subsequent history.) The child was operated upon by Dr. Burrell, an incidon being
in the mid-axillary line on the right side, ftnd about Li cm. () iDch) of the sevi^nth
DIVISION XYII
DISEASES OF THE HEART AND PERICARDIUM.
LECTURE LI.
I
DISEASES OF THE HEART.
Cardiac disease in infancy and early childhood may be divided into
ooogenital or acquired, developnietital or inflaramatorVj functional or organic,
fboale or chronic. In this early period of life cardiac disease has certain
'AiffBcteristics in which it differs essentially from thoE?e which are met with
in later life. One of these characteristics is that there is a more decided
tendency to rec*)vcry than at a later j>eri<!»d» Another k that, owing Uy the
undeveloped coDditioii of the infant and young child, interference with the
growth of other organs and parts of tlie body may more easily result from
diseases C(3nn€*t*ted with the circulation tlian Is jK>si^ible in tlie case of the
fully-develoj)€*d adult. ThuH, there are certain anatomical facts connected
with the ossification of the Hternura which beciime of great importanoe in
connection with eartliac disease. Deformitiej^ of the thorax may result from
the continued pressure of tlie enlarged heart on the soft and pliant bternum
and costal cartilages of the young subjwt. These deformities do not ariise
merely where the individual is rhachitic, but may also depend Ufion the
stage of development at which the cardiac disease begins. The deformity b
more or less pronounced io inverse ratio U:* the a^ and in direct ratio tij the
time during which the cardiac disease has existe<l. The shape and extent
of the deformity are also dependent on the decree of ossifif^ation which hm
taken place in the sternum. In young infanta, where the entire sternum, as
I have described in a previous lecture (page 71), is in a cartilaginous condi-
tion, the intra -thoracic pressure from an enlarged heart may cause a bulging
of the whole front of the thiirax. This may occur during the first year,
and even up to the tliird year. As the child grows older, the manubrium
and the second piece of the sternum become ossifie<l and offer more resist*
ance, while the thinl piew (»f thr sternum, still remaining in a seminmrtila-
ginons condition, may be tilted. This may occur in children in whom the
cardiac disease has not developed until the fourth, fifth, or sixth year. I
have had under my care a child seven years old who at the age of five yean
1019*
1020 PEDIATRICS.
had articular rheumatism with resulting cardiac hypertrophy, and wh<
presented this displacement of the third piece of the sternum. No othe:
signs of rhachitis were detected. The middle period of childhood is als(
a peculiarly unfortunate one for the occurrence of cardiac disease, because
the heart grows so rapidly at this period that it requires a proportionatelj
greater amount of intra-thoracic space for the normal performance of its
function than it does later.
In addition to the injury which may be done to the thoracic walls by an
enlarged heart, we must consider the interference with the normal uniform
expansion so necessary for the growing pulmonary tissue, and the consequent
loss of the elasticity which plays so prominent a part in the establishment
of the equipoise which should exist in a perfected respiratory apparatus.
The occurrence of diseases of the blood-vessels is rare in in&ncy and early
childhood in comparison with later life. Aneurism is rare. A narrowing
of the isthmus aortw is more common, and is one of the most marked of
the congenital defects of the blood-vessels. Sometimes there is an absence
of the isthmiis aortse during foetal life. The compensation for this defect
takes place by an increased action of the left ventricle and the establishment
of a collateral circulation between the subclavian artery and the thoracic
and the abdominal aorta. These malformations exert in varying d^rees
an influence on the heart, as the infant grows older, from increased blood-
pressure.
CONGENITAL DISEASES OP THE HEART. — Congenital diseases
of the heart are somewhat obscure in their etiology, but usually they result
either from an interference with the normal development of the organ or
from endocarditis, or from a combination of lx)th. In order to understand
these congenital lesions you must remember the chief points in the mechan-
ism of the foetal circulation, which I explained to you in a previous lecture
(page 19). I then told you that the parts of the foetal circulation at birth
which were of most importance in reference to diseased conditions of the
heart and great blo(xi-vessels later were the foramen ovale and the ductus
arteriosus. I also told you at what period after birth they disappeared.
Where these remains of the foetal circulation, which are normal during
intra-uterine life and for a short period afterwards, continue as the infant
gn)ws older, they become abnormal and interfere with the equilibrium of
the circulation.
Where the development of the heart has been interfered with in intra-
uterine life, there results another set of malformations, the chief of which
are an oj^en ventricular septum, a transposition of the great vessels con-
nected with the heart, and various malformations of the valves of the heart.
Where, again, an inflammatory condition has taken place in intra-uterine
life (foetal endocarditis), various other morbid conditions result, the most
common of which are connected with the pulmonary artery, causing stenosis
or atresia, a narrowing of the conns arteriosus, and various malformations
of the tricuspid valve and other orifices of the heart.
DIBEABiS OF THE HEART.
1021
I
i
The form of mflammation of the endocardium which occurs in intra-
uterine life is the chronic or sclerotic variety. Verruoose endocarditis is
rare?. (Osier,)
A deficient filling of the left side of the heart in early life^ such aa
occurs in caaes of atelectasis, fcetal pneumoDia^ or foetal endocarditisi espe-
cially where steoosis of the piilroormry artery has requital, may delay the
closure of the foramen ovale and of the ductus arteriosus, which under these
circumstances act as safety-valves. This is true also of die delay in the
dosing of the iotra- ventricular septum^ which is often of giieat aid in pre-
eerving the equilibrium of the cinjulatiou. In congenital cardiac dkease it
<fc usually the right side of the heart that is affected. The most common
oongeuital cardiac lesions are an aflfection of the pidmonaiy artery, an open
foramen ovale, an open vcutrieohir septum, and au oi>cn ductus arteriosus.
The lesiuns most (L-ommoiily found in conuectiou with the puhnonary
artery are stenosis of the pulmouary orifice, atresia of the orifice and of
the artery, and stenosis of the oouus arteriosus, Sten<:»sis of the pulmouary
urifice usually results from fietal endocarditis, though it is possible that it
may be the result of faulty development. The complete obliteration of the
crifice of the beginning of the pulmonary artery L^ t*ommon, though not so
frequent as stenosis of tJie orifice, aud is probably of deva^lopmeiital origin.
I have here a s|>ecimen (Fig. 143j which was taken from a child (Case
490) with congenitul iiinliac disf^ase under the care of Dr. Northrup. It
illustrates this maUbrmation of the pulmonary orifice,
Flo. 14a.
OoDsentUl cardUc dlwue. Male, A}^ jetn old. Rl^t and lefl rcntridw UM r^wn by two cutoL
Aetuais of pulmatiary oiilloe. IniMmiplefte BepCam vcnitiiculoniin. 1 «&<! l\ sefitiim ?eutrloiiU»miu etit
KTom; % aortic valvt^a ; 3, probe pai^tig thrtniKh namjwed pulmonaiy orUloe; 4, beat pnitw pMslof
thfonsti rlgbt ventricle to left tlirougti openlnsr In Mptum veDtriculonim.
The specimen waa taken fn>m a boy four and a half years old, who daring
life bad shown cyanosis, clubbed Hilars, and at times severe dyspnoea. The
physical signs in connection with the heart were a fine wave jierceptible to
the eye at the left third interspace, a soft, purring thrill over the base of the
heart, cardiac pulsation 1,4 cm. (J inch) outside of the left mammary Hne^
and cardiac dulness from the right stemaJ margin to the left mammary lioe^
1022 PEDIATRICS.
with no dulness to the right of the sternum. A loud, harsh systolic mur-
mur was heard over the left margin of the sternum, most marked at the
second left interspace and third rib, and not transmitted to the left or along
the aorta.
The pulmonary artery was abnormally small, the aorta was abnormally
large, the conus arteriosus was practically obliterated at the pulmonary
orifice, and the ventricular side formed a ring of white cicatricial tissue ^
cm. (^ inch) in diameter.
Here is a specimen (Fig. 144) of the same heart with the apex cut away
so as to show the relative thickness of the ventricular walls and the greatly
thickened septum ventriculorum.
FiQ. 144. (Cask 490.)
Transvene section of heart near apez.~l, right ventricle ; 2, left ventricle.
The right ventricle is markedly hypertrophied. The left ventricle is
normal. The ventricular septum is greatly hypertrophied. In this case the
ductus arteriosus was impervious and the foramen ovale practically closed.
A fcetal endocarditis had taken place before the septum ventriculorum had
closed. The endocarditis caused contraction of the conus, and the blood
l)eing forced from the right ventricle through the imperfect septum pre-
vented the latter from closing. This provided a safety-valve, which, as
usually happens in this form of malformation, allowed the child to live
longer than is common in other congenital cardiac malformations. The
aorta, receiving a direct stream from both ventricles, was distended ; the
pulmonary artery, receiving but little, remained small. It is interesting
to note in this case that the child passed through an attack of pertussis
and measles without serious results. It died ultimately of abscess of the
brain.
There may also be dilatation of the pulmonary artery, as in a case
reported by King, where the pulmonary veins united to form a trunk of the
same size as the artery and emptied into the right auricle. In this case
cyanosis and cough were present at times, and there was cedema of the face,
hands, and feet. There was also icterus, apparently arising from cirrhosis
of the liver, which was present.
Premature closure of the foramen ovale has been met with, but is ex-
DISEASES OP THE HEART,
1023
tremelv rare* I have already shown you this specimen (Fig. 6, page 42) of
an infant's heart with an open foramen ovale.
Here is another s[>eoimen (Fig, 145), which shows a small opening in
the ventricular septum.
Fio. 146.
a UDcloaed Tentiiculw septum, Ptemale. 10 months old, Warren Muieum, Hairvd UntTcndty.
Id tliis case there was almi iiii open foi*amen ovale, hot no otiier malfor-
mation. The infant, after showing the iiisual pmgressive signs of congenital
cardiac disease, died suddenly. There was no history of cyanosis.
Tlie fourth cf»mmon amgenital cartliac irajx'rfeetion, an open ductas
arteriosus, which I have just referred to, is shown in this sjiecimen (Figt
146» page 1024).
ThU heart, which ha£ been left ntUched to the lungt wm taken from an mtuit (CaM
491), sixteen daya old, who waa apparently healthy at birth and prteented no ijiiiptaiiai
of cardiac disease.
When the infant was five days old it was noticed that it would somelimea beooioc
iliichtly cyanotic. At this time it$ temperature rose to 39.4^ C. (108° F.J. A phyiacal
ezamtnation showed nothing abnorrual, and nothing abnormal waa »een on intpectJoD.
The aiiea of cardiac dulness was normal, and no munnun were detected. A day or two
liler the temperature became nomiat ; the cyanosis increased aomcwhatf but waj Ititrr-
tnittcnt and of a very slight d«•lrr^'<^ At time* the skin would become cofil, A few day*
later there waa flight intpfitinal difiturbuncc. Whf>n siiteen days old, without any othf^r
fymptotna having develupcH), the inJIkiit Ji^d suddenly. The pist-mortviti examination
made by I>r. Cutler showed tbiii widely open duotu^ arti-'notu^. The fommcn ovale i» alio
open. There are no other le«i**n*, such as stenos*!* of the pulmonary artery, open ventricu-
lar Mspttim, or leuoas of the valvi?** The hi^rl h of nonnal sSxe* A* you icc, thepB aiw no
ii|^ of the ohlitemtive endocarditis uju^iy found at this ag^ in the ductus artarioilii.
PEDIATRICB.
The ductus arteriosus, as I have explained to you in a previous lectui
(page 21), should gradually tx* t>bliterated within the first two weeks al
-uterine life Interferenci* with thiw normal involution is not vei]
jommon, mrely tKX'urs alout^^ and is usually found in connection will
legions of tlie pulmonary artery or narrowing of tlie isthmus aortee. Son
times the process of obliterative endaiteritis, which has been shown by
Fig. im.
B, open dnctui arterloKUiL Mnli?. 16 dasiis old. Warren MuMmm, Unnorrl T^nSverilty,
J. C. WaiTt»u to lie tlic nietliod by which the closure of the lumen ol
ductus arterio?5Us is a<.'<xnujilisjnxl» extends to the aorta and <^uses stenosis
of the isthmus aortic. Again, the duct, in closing an<l ivtnic*ting, pulls the
aorta and tends to narrow that vessel, tlius increasing the arterial tension.
During ftjetal life stenosis of the isthioiis aort*e does not pnnluce much dis-
turl>ancc in iuse^ where the ductus artcri^^jsus can carry the bliXKl to tlie
dc-sct*ntling aoHa, At birth, however, in the^e cases, unless tJie ductus
arteriosus remains jKTvnous, serious symptoms arise^ and, if life be pro-
longed, hyixTtrophy of the ht\ vi-ntrielc takes \Anvt% and the arterial blood
has to be couvLycHl to the dest^^^ndiug aorta by meaus of a collateral cireula-
tiHii which is establishetl Ix^tween the branches^ of the suV>elavian arteries
and the brauches of the tbiu-tiri*- aud alidomiual arteries. Premature closure
of the ductus arteriosus during fictal life luis Ijeen met wtth^ but is a rare
condition. Very rarely the ductus arteriosus may be entirely absent.
liDjierfections of the tricuspid orifi«^ are more rare. Ijcsions of the
mitral valve are very ranj' in iutra-uteriue lile. Those of the aortic orifice
are rare in eomj>aris.on w^ith those of the pulmonary orifice, but are of the
same nature, — that is^ they may be developmental or inflammatory.
DISEASES OF THE HEART.
1025
I
Tlie duration of life where there are iiitra-uterme lesions of the aortic
orifice is not nearly so long a^ where the pulmonary artery is affected.
Tran^^jKifiitions of tlie a<irta aud ijuliimutiry art^TV are very coinmouly
met with iu ajniiection with other cougeiiital defwts, sueh as s|>ina bifida
or hydrocephalus, but may occur in mfant^s wlio are otherwise normally
developed. In these casern the duration of life is almost invariably short.
Lesions of the valves vary greatly in their extent and kind.
On tlie Ixmndary line between developmental and inflammatory condi-
tions of tlie heart is a elass of ttises in which small ha>mat^)mata an* immd
on the valvej3. These hiematomata ap[M»ar juht befonM>r just aft^^r biith,
and iu the process of disintegration through \\hieh they paijs may cause a
contraction of the valvular tissue, and thus eventually produce the same
symptoms that usually result from the nmre «mimon valvular imijerfections.
Although these variuus aliiinrmal t'oiiditions may be Juund alone, yet
they gen«*rally oeeur in e«:»mbi»ation with each other, and all kinds of tran^
positions and ma I for in at ions of tlie vt^ssels are at tinit^ met with.
There are various maUbrmatious of tlie heart which occur at an early
period of foetal tlevelopment, and which are of |>athological rather than
cliniciil interest. Of these I might mention ca^es uhen:' tliere are one
auricle and one ventricle (eor bihctdare) or one ventriole and two auricles
(cor trilocidare), as well u& a «ise whicli has come under my n<Jtice» where
the heart had a <louble apx, the riglit apex lying in the fourth interspace
to the right of the sternum, and the left ajx'X lying in the fourth iuterspace
iu tlie left of the sternum.
Symptoms. — Although in some cases the symptoms of oongenital eanliac
disease are ver^' indefinite, and the disease may he masked fi>r a mimber
of montlis, yet iu a large numl»er of eiuses they s<:)on ljec<»me evident, llie
typical symptoms of congenital cardiac disease are cyanosis and attacks of
dyspnoea amounting at times to soffbeation and atrophy. As the disease
progresses, the tinge rs often l)ecome eUib-shaixih the nails blue, and the skin
cool. In connet^tion with tliese rational signs there is usually an evident
pulsaticiu in the rardiac region, with bulging of the prax?ordia. Where the
obstruction caused Ivy the lesions is sufficient to prixlur-c hypcrtr*jphy and
dilatation of the heart, an iuerease in the area of wirdiae dulness is fijutuL
Uifl\ise f^rdiac murmurs an* beard often over the whole chest, but usually
have their maximum intensity towards the upjxM* jiart of the sternum, and
are commonly systolic in time.
The most common symptom is cyanosis. Rememl^er that cyanosis may
iirisi* from innunplete oxygenation of the blcKxl, and not men-ly from the
mixtun* f»f the venous and arterial currents. Wheix* cyanosis Ls [jresent to
any extent thei^ is usually sfime malformation of tlie pulmonary artery or
it8 valves* Well-raarke<l cong*^nitat malformations may b*^ present with no
symptoms whatever. There may Ik» an entirt* absence id' cyanosis ; there
may be no incrtmst^l area of dulness an*l no murmurs ; and I have met with
instances where tiie infanta seemed to be thriving, and showed neittier lal)on«d
66
DISEASES OF THE HEART.
1027
rpecial lesions^ Ave can sometimes arrive at an approximately correct
agnosia ; but no reliance can Ik* j^lai^id upon the locality or 8otm<l of
le cardiac murmurs, a^^ such murmurs may be pnxlueed by very trivial
fBions, and may be absent ^vherc the lesions are most proooanced.
Prognosis. — ^Where the lesion is connected with the pulmonary artery,
Eld there is an open ventricular septum to act as a safety-valve, the a[ui-
brium of the cireulatitm may be retauied to such a de*^ree that the child
ill live fur a numljer of veal's. Where the only malformation is au i*i>eii
iramen o\^Ie, life may be prolonged for many years. Where, however,
ther malformations are present, esiK'ciuIly of such a ^rade a^ to overcome
le compensatory power of the heart, dt^ith generally takes place at an early
Briod. Where there is transix»sition of the main arterial trunks, the infant
y lives but a short time. Infants and children with congenital dis-
of the heart are very apt to die suddenly*
ordinarily results from some affection of the lung, sometimes
hsemoptysis, and it is quite common for tuberculosis to develop in
cases of cougcuital cardiac disease.
In some mre eases the compensatory power of the heart is m great
lat the ecjuilibrium of the circulation is maintained, and adult life may lie
Bached.
Treatment, — The treatment of congenital disease of the heart is essen-
ftlly hygienic and symptomatic. The infants should be ciire fully pro-
jcted frt)m atmospheric changes which would 1k^ likely to produce bronchial
citation, as in many cases linmehitis appears to play an important part in
Iterfering with the maintenance of the equilibrium of the circulation and
destroying compnsjition. In a number of cases I have found that the
flministration of digitalis in small doses and with the grc^atest caution b
alnable when hyjM?rtrr*phy has l>egun to fail and dilatation to increase.
Inhere the dyspuopa is distressing, a few drops of ai-^miatie spirit of ammonia
ill often give rc*lief. Stimulants are U8ually indicated.
Freedom fn>m excitement and over-exertion should l>e constantly en-
iroed, but the child should be kept in the open air as much as possible.
Here ia another infant (Cws« 493]^ three months old, in whom the moat striking feature
iti congenital cardiac disease is oxirbme wasting. It has a vardiac murmur at the ba«e
the heartt and h^ aa you seei slightly cyanotic. Yau will notici> that the cyano&i^ aome-
ici JtflTecbi the tnucouB membrane of the mouth, and that the naiU are hluo. A hanh
lUc murmur can be detected at the base of the heart. At times the infant has seriuua
lAcks of dyspDcea and sudbcation, but by simply placing it on its Hght tide immediate
Bcf U obtained from these ^ymptomSi thi$ procedure evidently bringing intti aolion a
Itty-valve by which some overtaxed portion of the circulatory mechaniflm is tcmpomrily
Irom its burden.
ACQUmED DISEASES OP THE HEART.— Acquired diseases of
heart may be functional or or^^anic, acute or cbronk%
Functional. — ^Functional affwtlons of the heart do not usually ooear
fttil the later years of childhood. Functional c^ardiac disturbances amy
1028
PEDIATRICS.
arise from anaemia of the nervous centres and from cardiac irritants, st
as tea and coffee. They are significant symptoms in the course of sc
neuroses as exophthalmic goitre.
In these functional cases there are no pathological conditions beyoj
a weakened condition of the muscles of the heart, and possibly, at times,
slight dqjree of dilatation of its cavities.
The symptoms are palpitation, a weakened irregular pulse, attacks c
dyspnoea and fainting, and sometimes cardiac murmurs which are seeming,
ha^mic in their nature.
A marked example of this class of cases was a boy (Case 494), eight years of age, wl
came under my care with attacks of fainting, palpitation, and dyspnoea. He was take
from school and made- to play all day in the open air, and in a few weeks these sympton
disappeared entirely.
A considerable quantity of tea is given to some children at as early ai
age as four or five years, and this often leads to fimctional cardiac disturb
ance. A striking example of this class of cases was seen by you at one oi
my previous lectures (page 469, Case 201).
In these functional cases the subjective symptoms are more apt to k
marked than where there are organic lesions.
Organic. — Organic diseases of the heart may be of mechanical or
of inflammatory origin, and may also be primary or secondary. I have
arranged this table (Table 110) showing the various conditions under which
organic cardiac disease may arise in early life, and shall ask you to examine
it before I speak of the various diseases.
TABLE
110.
Mrchf
Acquired Organic Cardiac Disease.
1 71 lea I.
E^
1
Inflammatory.
1
1
Dilatation.
\
Hypertrophy.
ridocarditis.
1
Myocarditis.
Primary.
Secondary.
Secondary.
Over-exertion.
Pericardial and
Rheumatism.
Puberty.
pleuritic adhe-
sions.
Any infiltration of
luni^-tissue.
Pertussis with its
accompanying
emphysema and
atelectasis.
Increased blood-
pressure, as from
renal disease or
narrowing of the
Chorea.
Acute exanthemata
(scarlet fever).
Diphtheria.
Pneumonia.
Endocarditis recur-
rens (from old
cardiac malforma-
tions or lesions).
aortji.
Organic diseases of the heart are more apt to attack the left side of the
heart than the right. I shall not dwell in detail on the various physical
DISEASES OF TH£ H£AST.
1029
I
mgDS of cardiac disease, suet as murmurs, thrilk, and duliieas, as they are
very aimilar to thone with which you have been made familiar in your study
of the adult's heart. The im[3ortimee of recognizing tfie relative size and
]>cidition of the heart at di ill rent ages I have already spoken of in my
lecture on development (page 122), and I shall therefore refer you to what
id on that cKx^asiou. Tliei-e are wrUiiu diflereuoes, however, lietween the
iptoms of cardbc disease in infancy and early life and those in later life.
In young children murmurs are more apt to be difiuse than in adults, often
being heard over the entire chei^t ; and the rate and rhythm of the heart are
80 easily disturbed by nervous influences as to be of little diagnostic value.
Progressive emaciation is a symptom which is apt to appear sj^eedily. An
enlarged heart dependent on adheesions from a preceding pericarditis is
more common in early life than in adults, while compensation, as I have
already told you, is much more readily acquired.
I have had children with cardiac disease pi'esented for treatment at my
children's clinic one year with cardiac symptoms so severe that they had to
be carried ; they wen* emaiiatcd and cyanotic, the ai*ea of cardiac dulneaa
was increased, and souffles were present ; yet these same children would
return and be shown to the next class of students in the fiillowing year,
walking up-stairs without ilyspnrea, looking well nourished, of good color,
witli much less enlargement of the area of cardiac dnlness, and with the
cardiac st>uffle scarcely perceptible, showing that the cardiac comjiensation
was ctimplete.
As an illustration of this class of caaes you will perhaps remember the little girl
(Cue 496) who wtifl brought to the dluic bj her mother to be shown tu & child who woa
then wellf but whosi^ ehiince^ of livinp^ had seemed at one time very slight.
When flrst »ven »he was idmnt Bwe years old. She had never bad any of the acute
dtseiy^t^, such as scarlet fever^ diphtheria, }>ertu&sis, ttrtioular rhoumatiam, or in fact any
bance except blight pain* in htT limbs. Far the previous six months she had lost in
ite and wei^^ht, got out of breath very ejisily, euffered from palpitation^ and in the
li^^nning of her sickness was confined to her bed for a week or ten days with u high fever
tod (lain n^ft*rred to her left 8ide. On examination she was found to be somewhat cyanotic.
The area of vi^ibk* cardiac puUation was much increased. The apex of the heart was in
the sixth interspace, 3 cm. (IJ ipch^a) U> the left of the mammary line. The area of abso^
lute canliat^ dultie** extend<*d to the ris^ht pHm.-Htcrnal line, (rom the third to the flflh carti-
UgGf and I cm. ({ inch) to the left i^r the mammary line on a level with the left nipple;
the TfTTtical area of dulness to the luft of the sternum extended frrjni the second to the sixth
interfrpaee. There was a loud mitral systolic murmur. The lungs were normal.
The chief points of treatment io this case were the careful administration of nourishing
&nd the enforcement of ri«t. She wa* alway carri^ up and down stain for almost a
She grew worse for a time ; she he<*ame irritable, and for some time when Uie
cyauosii^ and orthopncea were mi^t marked she had a oough^ and once or twice biemoptysu.
By the following winter, however^ the general symptoms were much improved^ and in
another year the dyspntt^a, cyanoei^, palpitatiort, and pain hail passed away. The apex of
the heart wa^ found to be in the Hhh interspace in the mammary line, and tho aroa of
dtdnest very little greater than normal.
Carrliac 8ym|}toms dependent on or^nic lesions may ariae^ and yet no
Bioa] signs of encb lesions be detct^tcd during life.
1030
PEDIATRICS.
Mechanical. — The mechanical conditions in cardiac disease play a v(
interesting and important part in many diseases in infancy and early chii
hood, and by their results often interfere seriously with the general physi(
condition and normal development of the child. These abnormal com
tions may result in hypertrophy or dilatation from over-exertion ; they m
occur at puberty ; they may arise from direct mechanical interference wi
the heart's action, as from adhesions or from undue pressure on the cardii
cavities, as in pulmonary disease, pertussis, renal disease, and narrowir
of the aorta. In all these diseases there is a greater liability that acui
dilatation may take place in early life than that it may occur at a late
period. You should therefore always remember to examine the heai
carefully during the course of all these diseases. The processes wbicj
suddenly cause great increase of the blood-pressure in the lungs may leat
to acute dilatation of the right ventricle, while where there is a diffus
renal disease, as in scarlet fever, acute dilatation of the left ventricle maj
take place, and be followed by hypertrophy, as I have explained to you ii
my lecture on scarlet fever (page 569, Case 245). In all these diseases this
acute dilatation may take place rapidly and disappear almost as rapidly,
a phenomenon which is somewhat characteristic of cardiac disease in early
life.
I have already referred to the great changes which take place in the
heart, and to its rapid growth, at the time of puberty. At this period the
general growth of the child is apt to be very rapid, and symptoms of car-
diac weakness commonly occur, especially in girls. These symptoms are
debility, lack of energy, i)alpitati()n, and dyspncea on exertion. There may
also he signs of slight cardiac dilatation, and murmurs, probably hamic
in their nature. This })erio<l, therefore, is one in which cardiac disease from
any cause, such as rheumatism, is of more serious import than at a later
period, when the heart is not taxed by too rapid growth.
These cases should be treated by mild physical exercise, care being taken
that the children do not over-exert themselves. Complete rest for two
or three hours every day should be enforced. Under this treatment, com-
bined with nutritious fo(xi and possibly a tonic of iron or nux vomica, the
signs of cardiac disturbance usually soon disappear.
I must again remind you of the importance of mechanical interference
with the action of the heart arising from adhesions. Adhesions of the peri-
cardium or in its ncighborhoijd are so latent in infancy in their symptoms
that they arc often overlooked until the mechanism of the heart has become
so seriously interfered with as to present the symptoms of disease of the
heart itself, such as dilatation or hypertrophy.
Inflammatory. — The chief inflammatory lesions of the heart are endo-
cardithi and myocarditis.
Endocarditis, — The most common cardiac disease which occurs in chil-
dren is endocarditis. Endocarditis may be acute or chronic, primary or
secondary.
DISEASES OP THE HEART.
1031
I
I Erioixxiry. — The elaborate investigations of J, H. Wright, W. E,
Stokes, and others have shown that acute endoearditis is of bacterial origin.
Weichselhaum ha^ eontributixl more to our knowledge of thij^ ilisease tlinii
any other investigator* He htus |>ryvitl that then? L* no essential difleivuee
between the various forms of endm^u'diti^, either histiilogieally or palho-
logieally, and that no one sj>et*it^ of baetiria is? ex(*UisiveIy eoueerned in the
pnwluetion of the disea^* Sometimt^s the strept^jeoeeus pyogenes? is found,
sometimes the .staphylococx'us pyogenes mi reus, and st»metimes the diplowRX'us
pneumonia. We thert^fore no longer need make a distiuetion between simple
endtx-arditif? and nleerative or verriicose endiK^irditis. There is merely a
different in the degrt^e ui' the malignant nature^ of the es[jeeial organism
which has prtxluoed the dii?ease, or in the vulnerability to infection of tlie
individuaL
Pathojxvoy. — While the same lesions of endocanlitis may be fonnd in
children as in adidt^, yet in infancy, although markctl acute cardiac ftvm|j-
trmis and murmur;^ fretiuently arises tlie autO[)sy almost invariably fail^ to
show any endrwardial lesions or growths. In two thousand autopsies at the
New York Foundling Asylum, Dr. Northrup and Dr. O'Dwyer never
found an acute inflammatory lesion exwpt in one ca^e, whi<?li showed the
lesions of acute matigoaot endicartlitis. Where the legions of endix-iinJitis
are found in children, the etmntvtive tKsue and the basement substance* are,
according to Delatield and Pniddeo, principally concerned in the inflam-
matory process. The endocardium which forms the valves is that wliiclj is
most fre(]uently inflamed, but other (>orti<»ns of it an* by no means exempt^
In some ca^^es tlicre is swelling of the valvt^, which are thickene<J, their
surfiifies remaining snnH»th, the basement srdjstance is swollen, and there i^
a moderate productitm of new connective-tissue cells. In other cases the
growth of connective*tis8ue cells is very much more marked, the basement
snlistance is broken uj>, ami little cellular fungus-masses^ culled visitations,
project from tlie fret* surtacc of the eudocanlium. In still other c^ses the
cellular growth in some phiL-es forms vegetations, and in othei-s degenerates*
and thus jiortions of the valves are destroyed. This i^ simple acute ulcer-
ative' cmhmt nlitis.
In some cases the children recover, and the valves seem t^:* return to
ilieir normal condition, while in others the valvt^ are left permanently
damaged.
Cfironk endocarditw may succeed an acute endocarditis, or the inflamma-
tion may be chronic from the onset. It afleets mo^t frequently the aortic
an<l mitral valves and the endiw'ardiuni of the left auricle and left ventricle,
similar clianges in the right side of the heart being much less frequent. In
iiiesc casi^s the endocardium may be thickened and tenae, and its surfacses
smooth or covered! with small, hani vegetations or ridges, or tlien^ may be a
growth of wmnective-Ufisue cells in the endocardium, with a splitting up of
i the basement substanoe.
While eodocarditis may be primary, simply arlHtBg from the infection
DIBEASEB OF THE HEART.
1033
the latter uf which may amouut to orthopnoea, increase. There is apt to be
cough from an accompanying brooehial irritation, produced most frequently
where there U obstructiDn at the mitral orifice*, and, fullowin^ a geueml
venous stasis, enlargement of the liver, hemoptysis, and teilema of the flit«,
legs, and arms appear. Children show such a wonderful recuperative power
that even in tliese advanced eases under proiKT treatment the st*rious symjj-
toras may gradually jiass away, and often such complete cardiac ajmpensa-
tion takes plaw that they are lefl with no symptoms of cardiac disease
except a munnon
In eudocurditis relapses are common and there is a great tendency ta
recurrence. Enibolij^m may take |ilace» and sometimes the first symptom of
c^urdiac disease which has been noticed is a hemiplegia following a lesion
of the mitral valve. Antemia is a very common symptom, esijecially where
endocarditis accom|ianies rheumatism. Cbugestion of the lungs, with result-
haeraoptysis, may arise where there is insufficiency of the mitral valve.
Although when the valves are aftect*:^! murmurs am usually pn[\sent, yet
sometimes where there are lesions of tlie valves murmurs caunot Ix? detected.
In endijcarditis murmurs are most frwpiently he^nl in the region of the
mitral valve, and insufficiency of the mitml valve is the most common of
ihe inflammatory cardiar* Unions in cliildhorrfl.
I.)iAGN<iSis, — The diagn4wis of endwarditis deiM^nds ujmju the physical
rigns. These signs are an increase in the area of cardiac dulness and a
changt* in tiie canliac sounds. The change in the area of caiiliac dulness
must be diilerentiated frum that which occui's in a pericardial effusion, of
which I shall s|>eak later (page 1056).
The change in tlie rnixliac s^nuids may be prt>dnc€'<l by changes in the
blood or by organic lesions of the valves. The differential diagnosis between
these two ctmditions Is tlie same as in adults, and there^fore I shall not dwell
upon it. In insufliciency of the mitral valve the mnrnuir is systolic, and is
transmitted to the axilla and the back. In some cas(?s the mnrmurof mitral
insufficiency is closely simulated by a valvular sound produced in thec«>urse
of pericarditis. Stenosis of the mitral valve is much h*ss common than
insufiBciency. It is represented by a presystolic murmur heard in a limittxl
area in the region of the hearths ai)ex, and is sometimes accom panics! by a
reduplication of the caitliac sounds at tliu ajR^x and by a thrill. Pain is
said to l>e more common in connectiim with this lesion than with other
cardiac deiects. Lesions of the fwiiir vfdve are almost invariably ass*x*iaittl
with rheumatism. Stenosis of the a*>rtic orifice is very apt to be associated
with a mitral lesion. There is nothing es^K-cially characteristic in chilflhtM»d
of these lesions of the aortic valves, and the same may be said of lesions of
tricuspid valves*
AVlicre endo<'arditis ha^ Ixx^ome chronic and comiK»nsation has only
[lartially taken place, the children are atrophic, anfcmic, and have a ten-
dency to imperfect circulation and to broachitis. In some casiSB the fingims
beoome club-6ha]ied.
DISEASES O? THE HEART.
1035
I
I
I
um of ciirdmc dulneas did not extend under the »ternum, but wa« found to eotTMpond
lo the impulse of the heurt, which was 1.4 cm. (J inch) outride of the left nmmnmry line,
During the la«t week of its lifu the child became very weak, ])ad marked dy^pna<a, &nd
showed Bigna of efliision in the right pleural cavity, but presented no other symptomB. It
died yesterday.
The pttet-mortem examination was made by Dr, Councilman.
Both pleural cavities conttiined a considerable accumulation of blood-Atained fluid.
The anterior tnediastiuum was deeply inject^ and reddenni^ and the mtHliaatinal lymph-
ginnda beneath the eternura were enlarged. The apex of the pericardium waa tightly
adherent to the left pleum, and about this point the ti^uea were thickened, deeply injected,
and a&demat*>us. The right lung wtis adherent Ui the pleura by compamtively fresh udhe-
itons. Herii and there owr the pleura! surface of the lung is a slight librinouft exudation.
The lymphatics over the surface of the pleura are greatly dilated. The upper lobt* of the
right lung is congested. Small nodular masses can be found beneath the pleura, and on
lectioQf as you see, there i« a distinct lobular consolidation throughout the upper lobe of
the right lung. The solid portion of the lung is of a dark-rod color and comparatively
imouth on section. MuiH>purulent matter can he squeezed from the larger bronchi. The
imall consolidated areas are more or less separated from one auotharf and between them
are eavitie* in the interlobular septa. The appearance of the lung is somewhat similar to
that presented in bovine pkum-piieumonia. The bronchial glands are enlai^ged and
reddened. The lefl lung was not ao adherent as the right. All over the posterior portion
of the pleura there was a flight fibrinous exudation. This lung has been s^imewhat com-
precsed by the accumulation of fluid in the pleural cavity, but otherwise tshows about the
same condition fis the right lung, the consolidation being in the posterior }>ortioni princi-
pally. The pleural cavity, as you seCi is obliterated by the adhesions. Th« parietal peri-
CRidium is greatly thickened, and in and between the connective-tissue adhesionf there ii
a thick fibrinous exudation. The heart U somewhat enliu*ged. At the ajiex of the left
ventricle, at a point corrc*i|>onding to the adhesions of the pericartiium, the myocardium
feels si>fl and is F^omewhat whiter than the remainder of the tissue. The interior of the
right heart contains tolerably firm, fresh clots. The myocardium of the right side of the
heart is pale and soft Along the free border of the right a uriculo- ventricular valve there
are a few fresh vegetations. The left side of the heart is dilated. The edge of the mitral
valve is thickened and eroded. There appears to be a slight loss of substance in the thick-
ened ptirtion of the valve^ and the edges are irregular and eroded. The muscular substance
of the heart is generally pale. Beneath the end^jcardium there are small, whitish pointe.
Similar points are seen on the jwipillary muscles and on the inner side of the auricle. The
aortic valves are intact, except for a few fibrinous deposits just at the edges of contact.
The oorooary arteries are normal.
The spleen Is enlarged and comparatively toft. The mesenteric Jymph-glands are
inlftiged and also slightly soft The liver is large, dark red in color, and the lohul(» are
prominent.
The left jugular vein is filled by a firm, adherent thrombus^ which extends downward
into the subclavian vein» the innominate, and the superior vena cava, and oompletely ob-
literates those veins.
A microscopic examination of the lungs shows a dJatinct lobular pneumonia. The
alveoli contain very little fibrin^ but art? filled with large, pale cells. Among theee are a
few leuoocytes, but usually the leucf>cytes are conspicuously absent. The conaolidation
*u quite geueral, oompanitively few of the alveoli in the most afiected portions haing flw.
At numerous places in the lung there are wide paasagea, apparently lymphatics, filled with
fibrin and large^ pale cells similar to those in the alveoli. The bronchi arc in most cases fVee.
The lung consolidation does not appear to take its p<3int of departure tnym the Itronchi.
Typical maasea of streptococci are found in the alveolar contents and in their walls.
The lymphatics of the pleura are enlarged , and correspond to the large pasMgea jufi
des(*rilH'd in the lung. Sections of the bronchial and cervical lymph^Unda ahow eculA
BW(-'lling of the glands, with micrococci here and there in the sinuMa.
A microscopic examinadoti of the heart showed the vegetation* on the mitra) valve to
^^P BI6£A8£S OF THE HEART. 1037 ^^H
H Thft boy (Case 497, pAge 1036), eight and a lialf yena^ old, vai well until nine weekt ^^^^|
V ft^. He tuui never bud nny disesifiefi, eiteept mctislca and varicella when he wa^ four ye^ti ^^^^M
m old. Nine vrvek& ago he was attackt*d with chor*?a, which lasted for about svvcn weeks ^^^^|
and wa£ i^ucceeded by symptoms of dyspucca on ex^ertion, losf of appetite, and alight ct»u^h. ^^|
There has l»een no history of rheutnati^m in the caj$e, Yau see that he b cyanotic, but ^^^^|
o|benrb« lookA comparatively well. ^^^^|
There is nc» cedema^ and an examination of the lungs detects nothing ahnomia). The ^^^^|
impulse of the heart h in the k«ft muninmr>* lini/ in the lifYh interspace. The cardiac arcM ^^^^|
H of ahsniute dulne&s i$ as I have indicated with this black curved line. I have alKci rnurkrd ^^^^|
H the lower border of thf> ribs with a plain black line, and have shown the slightly erthiri^t^d ^^^
H liv«F and fpleen with a broken line. The duln«^^6 doe» not extend beyond tho middle of ^^^H
^^Ibe iiemum, but i:^ increased in the vertieul line a^i high as the second intei>puci* and ^^^^|
^■L^nd^ ilightjy beyond the left mammary line. There is a murk»xl syt-tolic uiurmur, hfard ^^|
^PlSoit loudly at the ape^, and transmitted to the axilla and tbe back, al^o to the base of the ^^^H
B Thia appears to be a ease of acute endociirditi« ariaing during an attack of chorea. The ^^^H
H prognoaia h good^ as the child i^ already improving;, ^^H
■ (Subaequent hiatory.) The child wa-* tr»'Ut*xl «mply by rest in bed^ and a month later ^^^H
H his general aymptoniM improved, the arvae uf hplenic, hepatic, and cardiac dutne^^ were ^^^^H
H touch decreased, and the cardiiic murmur was not &o dislinct. Tw* werk"? I»l»'r eomp*>nHa- ^^|
B tion WAS apparently e^ttiblitfLbiHl, he had gained in weight, hiti color bei^ame better, and he ^^^H
left tbe hospital in good condition. ^^^^|
H CHART 45. iC.ssT. 496 ) ^^H
1
yr.
l>ay» of Di^ase.
1
Jc.i
107*
4 r\R
Ml
M K
V E
U I
M E
it c
H e
ut
H«
Mt
41.6^
41.1'
40.5'
40 O'
39 4*
105
104
103,
102
38.8"
38 3*
lOi"
100
/
\
37.7'
372-
37.0'
36,6^
36.r
35,5"
1
/
/
y
/
/
/
>
/
96
97
0
96
/
^
95
|360'
I have here a g
always b<?en a delicat
wa» attacked with fei
hnspitAl the was cya
piomi nonce over the
ipoce, 1.4 cm. () incl
K A AyHtolic murmur ti
^^Wft» slightly enlan^cd
^BlMDg tbe acute infla
irl (Ca^e 498, I., page 1088), nine years old, wl
e child, never had any e«|»ecial diM^a^e unill tw<M
rer, palpitation, cough, and a rapid, irrei^ular pu
notic, the face and extremitit** wen^ cold, and ll:
cardiac region. The n**onance of the lung9 wi
^ at both bases. The impuUe of the htf^art was i
\) outride of the mammary line, and then* was i
■ansmittwl Vi th*» a\illa and hpard distinctly in t
Here is the temperatun* chnrt (Chart 46j, sboi
mmatory stage of the endocitxditiA.
althoQgb tlM bM ^^^1
nreeks ago, when ibe ^^^^|
sc. On entering Uie ^^|
lero WAS consiiierable ^^^H
AS nomuil, but there ^^^^|
n the fifth h-ft infer- ^^^k
1 markHl thrill with ^^|
he back. The liver ^H
ving the temp«r»ttti« ^^^H
1038
PI-n>IATIUC8»
The impulse of the henn U scarcely perceptible. The area of caidiac dulnea* txtum
M you see, u» the ri^ht cnl^e i»f the sternum, and «UghUy beyond the right poxaftenutl li
Umeatb th*? third iatepeostal fpace.
Camm 498.
I.
I
Acuu* eniloc&rdUij, MiUu.. ,i. ...,,.. a^ucy. Lack of eoaBpeottiUtifi. Drthopacea. Ftemale^ 9 yean old
The case iltiutrates an attack of aeuto apparently primary endocarditis. The a<nitfi
inflammatory atiige has bi^en pae^ ; dilatation has taken place, and tber^ is at pivsent
marked failure of compensation. This is shown by the fi.*t'l>le impuUo of the heart, the
weak and fluttering: pulsei the cold and blue extremities, the nrtbopnoea» and the tendoocy
to csdeuia of thn face, let^s, and feet. You see the pT*ition which the child a^uuiea on her
right side, how &he supports herself with her arms, and her anxious expreasion as she on-
deavors to keep herself in a poeilton in which she can breathe easily.
ti "^
A(?tite endooanlitl& Dilated heart. (JMLnrnau. Poidtion assumed when sleepini?. F^mmlc,
y years old .
A case of this kind needs to be very closely watched , as the child b liable to die sud-
denly. A few days a;e*>, in thiis next bed, ihere was a boy (Cose 499), four aod a half
yeaia old, who was sufiering from an attack of acute endocarditis : he had the same symp-
DISEASES OF THE HBABT.
1039
lomi of dilated he&rt with a luck of compensation as you tea in this little girL While
k bt WB§ aleeping in the eame jKisjlion which she has assumed since I have been describing
lllfr cue to ytm [Vm«i 498, II,, pagtJ 1038)| he died suddenly. Ho hwd be^n subject to
Vtcidden vitdtrnt tttou^lcs of dj^pnoea^ and once or twice while in the hospital had an attuck
[ of angina pect(.»ris.
This next child (CiU'^e 500), a girl, thirteen years old, has a history of pcrtuaais «om«
I yeam ago, but has not had any other disease except an attack of rheutnatisin two years ago.
It^tnco then «hv hns ^Kx^asionally had attacks <>t dyspn4£4i when at play and when going up-
fftairs. She has also at times had oedema of the feet. One week ago she complained of pnin
in Uie cardiHC rt^gion, so severe as to interfere with her sleep. On entering the hofipitid the
had a tempemture of 88. S** C. (101,2° F/), a pulse of 104, and r««rpiratioiif 65. An exaini-
aition ahoweil uutUiog abnormal except in the cardiac region.
Case 500.
de endocarflit
rheuiiuUiKm. Mitrtut «1cnfi»i''
13 y«ftis old.
Fsmato,
The impulse of the heart is in the fifth lof\ intenpace in the mummary line. The area
f of aliftMluto cardiac dulness is enlargeil, nud I have represented it by a black cun'e<l line.
You see that it extends l>eni'ath thi* .*tertHirn, and at the junction of the up|;»er border of
I the fourth rib extendi a short digtancr to tbc right of the sternum. The upper boundary,
[ at I have said, in the upper bonier of the third rib, and is about 5.S cm. (2 inches) outiido of
] the mammary line* Tht»re h a presystolic munnur at th** apex, whioh U t'onflnod to a limited
(area. There is also a systolic murmur at the apex transcmitied to the axilla and the back;
the pulmonic second *ound is accentufit*»d.
(Subsequent history,) Four wcck« later, after being treated by e«>mplct© fi»tt In h*4,
I the cnrdiac fympu^ms Nlnittst entirely dij<appeared, the area of carxliac duloeat was mttoh
i diminijihfd, and th*? munnur* were leu distinct. Two week* later the child lelt tlie
pttal, much improved in her general health, hut in a very ansmic condition.
DISEASES OF THE HEART,
1041
panied by a thrill He has ako had a cough, He seenia to represent a case of stetiosis
of the nntral valve. There ifl, aa you ftee, decided enlargement in the cardiac regbn to the
left of the fttemum.
(Subsequent huit^ry*) After remaining in the bospitnl f^r two months and boing
treated by real, compen«»ation wm establbhedi and he left the hospital in gocNi condition.
' .k'ing of left aide of >*tfrTitim. Ma1«, 11 yean olil.
Siikce then he ha£ returned from time to time with a renewal of the symptonoi of cyanu«U|
dyipncea, and lack of compen<!ation.
TbiB next boy (Case 503, I ., page 1042), ten yean old, u intereeting a^ Uluttrating ceiw
tain ehaimcteriitics of cardiiK* disease in eurly life.
Two yean ago he entennl the hospital with marked oedema of the fkce^ body, and limb«»
aicites, a alight amount of fluid in both pleural cavitie^i and oedema of the lungs. There
fraa no definite history of rhe uinatism nor any other cau^e for the cardiac diaeiue which wbj
oaufing tlie«e gymptomS} and which had apparently dt'veb»ped insidiously^ though if be had
been under closer observation a definite period of onset would probably have been discovered.
The impulse of the heart ws-f found to be lA ova. (J inch) outride of the mammary line
in the flflth left inttar*|>Hce Thu area of cardiac dulne^s was ftomewhal in^-P^aMed. Th»^re
wai a loud Bystolie munuur at the cardiac apex trunsinitttHi in the axilla. The w?cond
I umnd wa« much accentuated. Here h a pictuPL* (Caie 608, 11, , facing paije 1042)
i at that Utne, and showing the marked aHiema of the legs and th»? much diatendtnl
I abdomen. He was treated by complete rest in bed for five wcck«, and in the beginning
[4i^ttali« was administered until the urine, which was lessened in quantity, had increased
I and thi) (odema of the lunp had diifapf reared. On entering the hospital the ascites was
removed by paracentesis al>domini*. Under this treatment the chili nij»idly impmviMl,
the genotml €9dema disappeared, the liver returned to it* nonnal feiy,e, the area of cardiac
i was markedly decreased, the cardiac murmur became leM marked, and tit wmkM
ftmn the time when he entered the hospital complete compensation was established and he
left the hoepital seemingly perfectly well. This picture (Oaio 608, 11 1. « facing page 14M2),
66
clixunit^ eiidcH-ftidUis. Ojmplele compeoaatloa, (Six weeks alter beAlmeiiL) JkUle. tO f can old.
DISEASES OF THE HEART.
1043
nr&l cikvitiai. The liver is enlarged so that it extenda 7.8 cm. (8 Inches) betow the margin
|he ribs. Ascites is present, the fluid rising tci alK^ut the line of the uinhiUcua The
pen 19 normal in size. The t^hild \s piling only a gmull amount of urine^ which LHintaint
pace of albumin. I have marked the crtrdiac and hepatic areas of diilnei^ and the upper
llerof the ascites by black lines, the margin of the ribs by broken lintssi the point of
iiac impulfe by a black ring^ and the c&dematous r^les in the chest by smaller black
pi. The prognosis in this case, although from the child *s present condition very serious,
|e if liable to die suddenly ut any tinie if extra bloi»d'prej!6ure should be brought to bear
jin the dilated and crippled hearty is not entirely unfavorable, as he has previously shown
b great powers of compensation and recuperation. As there is no great distention of the
lonien, I shall not at prasent remove the ascites by paracentesis, but ^hall have the child
ftfully watched, and^ if the ascites increases, shall have it removed at once. He is taking
gaion of digitalis, 3,75 c.o. (1 dmchro), every three hour*, and diuretin, O.Sd gramme (6
Ids), once in six hours as a diuretic. His diet is milk.
(Subsequent history.) Within forty-eight hours rapid relief was obtained from the
^nt sym^ploms, and at the end of three weeks the cedema of the lungs^ the general
bma, and the ascites had disappeared entirely. The urine became normal in quantity and
I firom albimiin. One week later he was well enough to be out of bed for an hour each
1^1 and at that time this picture was taken (Case 603, IY>), which shows the heart and
ir to be still enlarged^
Cabs 602.
i IV. V.
, canonic endocarditla Mitral Iniuffictencf. Chiooic txuikicftttLitia. Uitnl iii>ufflcteiicy,
fnOag aampepsattoD. BnlatKod Uver. En- Broken line iDdJcatei enlaiftd luazl Black Use
indicate* area of cantiao dttlni with tvUmiMl
and complete odmpeiuatloti.
' Sotne weeks later the liver regained its normal tize, and still later the cardiac aff*a of
jlieas was fuund to Ire much reducerJ and in the vertical line almo«t normal. Thli pictitf«
tie GOS, V.) shows the enlarged heart, which femftiiied longer Uum tho amlugod liver,
1044
PEDIATRIGB.
and is represented by a broken line ; the area of dulnesa of the heart aa it appeared wh
he left the hospital is shown by a black cunred line.
This next case, a girl (Case 504), nine years old, is instructive as showing the dliferen
between the cardiac area of dulness produced by an enlarged heart and that produoed by
distended pericardium. She had pertussis when she was three yean old, and meadei whi
she was seven years old. This was followed by an attack of rheumatic feTer. which laiti
six weeks. So far as I can ascertain, she had no cardiac disturbance at that ttme, as
recovered compleU^ly from the attack of rheumatism. Two months later she had aaotiu
attack of rheumatism, which was accompanied by pain in the cardiac region. She the
apparently recovered, but one year later had a recurrence of the cardiac diiturbuioe, whie
was, however, of short duration. From that time she remained well until fimr month
ago, when she had a severe attack of bronchitis, and since then she lias been Ikiling ii
strength and has suffered fh)m dyspnoaa. Three weeks ago she began to have csdema ol
the feet and of the abdomen, and this has been progressively increasing. She is very
anemic, and, as you see (Case 504, I., facing page 1044), the oddema of the thee and legs ii
marked. The distention of the abdomen is found to be produced by ascites. An examina-
tion of ihv heart nhows the apox-beat to be in the sixth interspace, 4 cm. (1} inches) be-
yond the nianiiimr\' line. The area of absolute dulness extends f>om the third left costal
cartilage downward acrt^es the sternum to 2.8 cm. (1 inch) beyond the right parMtemal
line in the fifth interspace. It also extends to the left and downward outside the mammary
line until it joins the impulse of the heart in the sixth interspace. This area of dulness if
not that which we meet with in a dilated heart alone, as I shall presently explain to you.
On the contrary, it suggests that there is ftuid in the pericardium.
In connection with the general oddema and absence of symptoms of pericarditis there
is probably present the condition called hydropericardium. The liver is also enlarged. The
pulse is regular, 140. There is a systolic murmur at the apex of the heart.
She is being treated by absolute rest in bed, a milk diet, infUsion of digitalis, and
diuretin.
(Subsequent history.) After she had been in the hospital for forty-eight hours the
hydn^pericardium disappeared, the skin became less tense, the urine increased in amount,
Cask 505.
Chronic endocarriitis. Greatly dilatc<l heart. General redema. Extreme distention of abdomen with
ascites. Female, 11 years old.
and thore was rapid improvement in all the general symptoms. Two weeks later the oadema
and ascites disappeared entirely, as is shown in a picture (Case 604, II., facing page 1044)
taken at that time. The enlarged heart at that time is indicated by a broken line, while
mi.
Chnmlc etidoe&rdiils. Mitral ImnifDcieDcsr. HydropBTicanilum. General ttt]ema and iificlte<i. The line
of ascites uid; of the cardiac az^a of dul^ew marked In black. (Before treatment )
Ommle eDdocatdUia. Enlarged heftrt. Entaciatlati. (Two WMka afl«r tfMUaMOt j nanftlo, t ystfl QI4.
1
DISEASES OF THE HEART.
1045
\
the area of dulnew, whicli waa found »oroe weeks Uter when compenaation ww eftablbhed,
ii represeated by a bliiok lino. The child was left in a very aufemtc and emaciated condi-
tiuHf but the liver resumed \U normail size, the area of cardiac dulne^ gradually became
•mailer, compensation was finally established, and ah© left th<^ ho-«pitiil in good condition*
Here ia a girl (Case 505, page 1M4)| eleiren years old, who haa just been admitted to
the hospital.
She fthowSf as you aee, extreme dyspnGea, orthopncea, cyanosis, marked geneml a?dema,
and great distention of the abdomen prtduced by ascites. Percussion of the chest shuws
extreme dilatation of the heart over an areti which itu-Iude* the entire sternum fnun the
tecond interspace and extend* 7.8 cm. (8 inches) to the left of the mammary line^ the
impulse of the heart being in the seventh interspace. There i^ also extensive a?dema of the
lungs. The pube is weak und feeble. It is very evident that there is an entire lack of
compensation in this case, and that, unless the heart is quickly relieved, cardiac failure
will take place and the child will die. I have therefore told the mother that paracentesis
abdominis must be performed at once.
(Subsequent histo^)^) The mttther reflised to have parmcentesia performed, and took
the child home: it died suddenly on the following da}' from heart^failure.
I have already referred to ttie deformities which may arise in the chest
from the pressure of an enlarged heart during a period when the thoracic
walla are still pliant and uudevelo{>ed.
Here is a little girl (Cast* 5CK3) who six years ago had an attack of rheumatism followed
by endixuirditis^ and^ although c^^^mpensation hafi taken place and she U fairly well and
strong, you see the di^phiccment of the sternum mid of the costal ends of the left riba
which baa resulted from the curdiac enUrgement*
Case 60*j.
Case 6<>7.
I>it[|tlftre<l ftenium niid eL«tal cmlilages from
enhin$e4 heart Fonmle, lo yeiLre old.
MalibrmauaD of ]i*n
carl '
kv fttjin
Ucre is anothtT caj^e (Case M)l) of cardiac dlseai^, in which the cudocarditis with its
rseulting cardiuc dilatation and hypertrophy oceunvd at a »till earlier period of life, and, as
1 you sec, there ia great deformity of the left side of the thorax produced by the inlmthoraci^
1046 PEDIATRICS.
LECTURE LII.
DISEASES OP THE PERICARDIUM.
The anatomy of the infant's pericardium, so far as I have been able to
determine by the dissection of sixteen infants of various ages, appears to
approximate so closely that of the adult that there is nothing distinctive
to note concerning it. The amount of fluid which normally occurs in an
infant's {pericardium, although of variable quantity, is probably under 5 c.c.
The chief diseases which affect the pericardium are hydropericardium,
hsemopericardium, pneumopericardium, and pericarditis. The first three are
very rare in early life, and therefore need be merely referred to. Absence
of the pericardium may occur, and may be complete or partial.
PERICARDITIS. — The most conmion disease of the pericardium is
pericarditis. It can occur at all ages, but the earlier the age the less often
is it met with. It has been found in the foetus and in the new-born, and
well-marked adhesions of the pericardial surfaces have been observed in
an infant which died thirty-six hours after birth.
ExioLCKiY. — There are a number of organisms which seemingly give
rise to pericarditis. The most common of these is the micrococcus lanceo-
latus. In the new-born peric»arditis may l)e the result of a septic condition
following infection of the cord. At times it follows periostitis and ostitis
in young children, here also probably being associated with septic infection.
TraumatLsm may also be a cause of jiericarditis. Rheumatism, especially
after the third or fourth year of life, gives rise to as much periendocardial
disease as at a later j^eriod. The inflammatory lesions may arise before the
rheumatism has appeared elsewhere, and the intensity of the arthritic pain
and the number of joints affected do not correspond to, or rather do not
influence, the frequency of the jxiricardial complication. Inflammation of
the pericardium is also frequently associated with pneumonia. It may be
secondary to any of the eruptive fevers, but occurs most frequently as a
complicuti(jn of scarlet fever. When it occurs in this latter disease it ap-
pears usually in the second or third week of the attack. The pericardium
also sliows an especial tendency to invasion by the bacillus tuberculosis
following tuberculosis of the pleura.
Pathology. — Pericarditis may be circumscribed or diffuse, and there
api)ears to be no essential difference between the pathological conditions
affecting the pericardium in early life and those which occur later. The
pericarditis sicca of the adult is comparatively unusual in the child, in whom,
as a rule, an effusion of greater or less extent almost always takes place.
The effusion may be sero-fibrinous, hemorrhagic, or purulent. Not only is
the tendency to effusion in the child greater than in the adult, but its forma-
DISEASES OF TH£ PEBICARDIUH.
1047
I
tioD is characterized by greater rapidity and it is more likely to be punilent
than in the adult. A pericardial cftusJoo tinged with blocxl b not uncom*
mon in €»arly life, and k not nwe^s^arily so significant of tuWrculosis as is a
pronounced Iicmorrliagic efliisiun. The white, opaque tliickeniDg:?? of the
inner pcTicartlial surface so frequently found in achdts are rare in children*
but have becm found at all agot*, and where there is a deformity of the chest,
as in certain cases of rhaehitis, they have been especially noticed. Tuber-
culosis of tlie jKTiciirdium as a primary disease is even more rare in the
child than in the adult. Tubci*culosis secondary to tubercle of the pleura
may «3cciir, csptvially when the left pleura is affected. The younger tlic sub-
ject tlie less likely arc there to Ix^ aflhesioiLS between the jxTieardium and
the pleura, an important fact, to be taken into consideration later M'hen I
shall s]x*ak of the diagnosis of jjericardial effusion in infancy.
Symptoms. — Pcritiiixlitis may l3e acute or chn>nic, primary or secondary.
The subjective symptoms of acute pericarditis in infancy are very
indefinite, and tlirougljout <'hiIdliotxl this latency of the early symptoms is
m marked and <jccurs so frec^ueutly that it may be said to be characteristic
of the symptomatology of |xricanlitis in early life. It ia so difficult to
locate pain when it tx^iirs io the infant, and a tumultuous action of the
heart with gcncmi ciivulatory disturbance is so CHiramonly the res^ult of a
diseBsed condition outside of this central organ, that it is impossible to
formulate a practical general symptomatology for the onset of the disease.
When, however, the disimse has progi-essed, dyspnnpa and orthopna^a be*^>me
marked. Large effusiims apjK^ar to aiTvci the functional activity of the
heart more rapidly in childiTu than in adults, and to occasion earlier the
signs of disturban<'e of tlie cin*ulation. Diminntiim in the amount of the
urine in cases of ix^ricaidial ettiision, with a c^>rits ponding increase in the
urine as the effusion dwrtuses, has been noticed iti children* The usual
physical signs supjK)Hed to be characteristic of perieanlitb are often very
misleading, and where a }ic>rii'ardial friction -sound is absent the dettTmina-
tioD of a case of pricaixlitis in a y<mng child may present gi'eat difficulties.
Owing to the flexible thorax of the t^liild, there is a greater opi)ortunity for
the neighboring i>arts to yit4d l)eiore the pressure of an effusion, and we are
more likely to have bulging of the iutcrci>stal spaces, and on ins|ieetJon a
visible alteration of the c-ardiac* area, than in adults. Be<:auBe of the small
aixie of the clnld*s thorax, the lieart and j>ericai'diura are much nearer to
the anterior surtiice of the thoracir' ca\'ity than tliey are in adult** This
occurs both normally and iu diseased conditions, especially where there in
flattening, and thus levelling, of the cliest. Under these latter «t>nclitions the
heart and [XTinirdium ai-e brought in such close contact with the tlioracic
wall that on )mlpation you can feel the heart's impulde^ and on auscultatii>n
the heart-sounds, in a much more advant^-d stage of a pericardial effusion
than would be possible in tlie adult with a proi^rtionately large amount of
fluid. It has abo been noticed in early life that on aasciUtation the sounds
in iiericarditif* and endocarditis simulate each other quite closely. Perous-
DISEASES OF THE PEBICARDIUM.
1049
I
In addition to the difficulties in making a differential diagnosis arising
from interference with the contractility of the lungs, such complications aa
pneumonia of the right lung, es|>ec'iaIJy its mid<lle lobe, pleuritic effusion on
the right side, an enlarged liver, and an enlarge*! heart must be considered.
Where this pneumonia^ or pleurisy, or hepatic enlargement is present, an
efliisiou into the ^lerieardium cannot be diagnosticat<ed by means of pen^us-
sioa, but these diseases can asnally be readily determined by their esjiecial
^mptomB. The differential dii^osis, on the contrary^ from an enlarged
heart, especially a dilatetl heart where the murmur may be absent, can oflen
be made only by means of perctissioii.
Experiments with artificial elTusions on the cadavers of healthy indi-
viduals should, therefore, first be made, and later furtlier investigations be
carried out, when |K)?sible, on individuals in whom the various oonditiona
which interfere with the typical jiercussion outlines of a typical case are
present. It is doubtful if these latter investigations will be carried out for
many years, owing to the apparently insurmountable difficulties of pro-
ducing the&e different abnormal ctniditi^ms ailitieially. We can, however,
learn raucli fi-oni the uncomplicatt*d cases. Various methods of introducing
fliiidj* into the perioanliuni tmve been tried, and have faihxl to give satisfac-
tory results. Although by dividing the sternum in the median Hue tlie
pericardium can Ik* enteriHl without jxTfttratiug tJie pleural cavity, yet when
this methixl is employctl the results of percussion are rendered void, since
under these conditions air enters not only tlio anterior me«liastiuum but
als<j the p<'ricardium. The mtthiKl which I finally devnsal and louml to be
most satisfacTtory in its mechanism was a* follows. The infant was placed
in the jKisition of orthopncca ; thai is, the trunk was bent n|^H>n thi- lower
limbs at an angle of alwiint 120^. TracluHjtomy w*as |>crfurnKxl, and a
clamped rubber tube was attached to the glaj^ tracheal tube. The lungs
were then inflatf^l thningh tlu^ tul>e until on (tirefnl {lercussion the absolute
area of cardiac dulness ajrrf^iHiud«xl to that of a normal cxpiratiun. Under
these conditions the area of abMihite dulne-ss, as you see in this diagram (Dia-
gram 14, page 1050), begins at tiie junrtion cif the upper b<jrder of the fourth
left costal cartilage, and extends dijwnward and iuitward to the left in a
curved line, with the convexitA^ outwaixl and kct^ping 2 or *3 cm, (J or 1|
inciies) within the nipple, until it joins the dulness of the left lobe of the liven
From the same starting-point at tlie fourth cartilage it extends downwanl in
the left pamsternal line, or ratlier within that line, towards the middle of
the sternnm^ until it reaches the liver. The abs^jlute dulness, therefore, is
determine*! not by the shape of the heart itself, but by the marginal lines
of the lungs, varying according to their exjiansion or retraction. This is a
point which it Is w^ell to understand, — namely, that the fjericanlium itself,
whetlier it is distended with fluid or not, does not by its own ahape^ as
has been delineaUH:! so often in tlie plates illiistiiiting {K*ricanHaI eSnsionBp
aid us mati^rially in determining the shafK* of the area of absolute dulness
in a pericardial etftision. This area is marked by the retracting or rather
1050
PEDIATRIOB.
displaced borders of the lungs. After the inflatioD was aoeomplished the
tracheal tube was clamped so as to retain' the lungs in position. An in-
cision was then made in the median line of the abdomen, from the pubes up
to within 2 cm. (f inch) of the ensiform cartilage. The liver and stomach
were gently drawn away from the diaphragm, and on palpation of the cen-
tral tendon of the diaphragm four centimetres to the left of the median line
DlAQRAlf 14.
Normal Thorax.
H A, physiological area of percnflSion-flatneflB of the heart on expiration ; || B, Uver ; H B', that
portion of the liver which is covered by the right lung ; 'j^ C, lung ; S. sternum ; ^^ nipple : 1, 2, 3,
4, 5, 6, ribs ; --- (broken line), border of lung.
the heart was felt. This y>omt of the diaphragm was then carefully drawn
down away from the heart, and a dagger-pointed trocar pushed through the
diaphragm into the pericardial sac, which is adherent to the diaphragm at
this \K>int Here is the trocar (Fig. 147) which, after many failures with
other instruments, I finally devised, and have found to be satisfactory.
Fig. 147.
Artificial pericardial efl!\ision trocar (ftill sijge).
The trocar is made of brass, with a conical point and a rounded shoulder
forming the base of the cone, so that although it easily enters the pericar-
DISEASES OF THE PERTCARDIirM.
1051
ditim it is difficult to withdraw it, the ixiint actiog like the barb of a fish-hook*
A abort piece of rubl^er tubing titt^l tightly to the neck of the trocar can,
as soon as the point and shoulder have entered the ijericardium, be pushed
tip tightly against tlie undr^r side of the diaphragm, thus holding the trocar
ill pQgition, and the dia[jhragni, hAn^z lirriily rompn^sstHl Ix'twt'en the shoul-
der and the rubber tube, preveut^^ tlie entrance of air. The trocar h con-
nected by means of a piece of rubV>er tubing, which is ako provided with
a clamp, to a simple wa*sh-lx>ttle graduated for cubic c^ntimetrci^ and con-
taining melted cacao butten Before intnxlucing the trocar the cacao butter
is allowed U) fill the tubing and the trocar ^it ns to displacA^ the air. As
Boon as the tn)mr has entei*eil the j>ericanlium the tra<:4ieal tube is un-
damped, in oitler that the lungs may be free Uj retnict l>efore the fluid.
When sufficient floid, a^^ indicated by the gradnati^l lK>ttle, has entere<l the
pericai'dium, the cacao-butter tulie and the tni(*heal tulx* are again clam{)cd,
the thorax is carefully ^>ercusi4ed» and the line of al>solute dnlness is marked
in ink. After twenty-four hours the sternum is rt^moved from above down-
ward, remaining attachetl below, and we tind the lungs in [wsition surround-
i>!AOH.\i| 15.
finuUl unoum of llqald (ntrotluced into aiio (Rotch). ■ A, tlie portion of Oie u^a of sbaolute dul-
Dw which tostlU catawd by the pbjviologicAl dulncM of the hetm : ■ B, Uver; H B', ttut pottloci of
lh» Urtsr which Is corend bf the right lung : ^ C, lonc ; | O, effU^oo ; A 4 D, nrva iif aI«i1iiI«
dtotaiea Ibumd when the eihilaD It snuil; 8* Btemum; ^, nipple; h % 3, 4, 5, 6^ riUii **- (brokao
line), border of lung.
ing the hardened fluid. 1 have rejiresented in this diagram (Diagram 15)
the relations of the lung and the pericardium where a small amount of fluid
has been introduced.
1052
PEDIATRICS.
By replacing the sternum and verifying by means of needles penetrating
the lines marked in ink, we can determine accurately the shape of the ares
of absolute dulness with this amount of efiusion, which represents the re-
sults obtained when from 70 to 80 c.c. (2^ to 2|- ounces) of fluid were intro-
duced into the pericardium of an adult There is a slight increase in the
vertical as well as in the transverse area of dulness. The curved line which
bounds the area of dulness starts at the sixth rib, to the right of the
sternum, passes upward to the junction of the fourth cartilage with the ster-
num, impinges on the lower part of the third left interspace, and then
descends just outside of the mammary line to the sixth rib, to pass in-
ward until it meets the dulness of the left lobe of the liver. This line
forms, as you see, an irregular semicircle, with a shorter radius to the right
of the sternum and a longer one to the left. It is important to understand
what causes this, area of absolute dulness. This you can best do by refer-
ring to this next diagram (Diagram 16), where with the same amount of
Diagram 16.
The luDKs have been removed (Rotch). m A, portion of the normal heart enclosed in the pericar-
dium ; m B, liver : H D, etlUaion as it appeared in the sac, the cacao butter being in small amount,
and the lungs having been removed after the butter had hardened ; S, sternum ; A, nipple t 1, 2, 3,
4, 6, 6, ribs.
effusion tlie lungs have been removed, leaving the heart and the distended
pericardium exposed to view.
It will be seen on comparing the digrams that a small section of the
dull area, corresponding to the junction of the fourth and fifth ribs with
the letl side of the sternum, is formed by the heart itself, which is free
DISEASES OP THE PEKICARDIUM.
1053
from effusion at ibis pointy while the rest of the dulue^s m produced by the
efliision. Od exammiog also the hardened cacao- butter east of this efiusion,
it was found that the layer of fluid was very thin all over the upper jxir-
tion of the eHusion in the region of tlie fourth rib and fourth interHpaee, while
the mass of the effueion, as shov^Ti by the greate^^t thickness uf the cacao
butter, was, as would te expected from the laws of gravity and the shape
of the pericardium, in the lower [mrt of the nm^ on CM-h side of the sternum
ill the fiflh interspaces, the east riding the arched diaphragm like a saildle,
and the lai^r part of the mass being on tlie leil side. These points should
be carefiilly noted, as they are significant for diagnosis and treatment.
The same result as to the area of duiness was obtained with a propor-
tionately small amount of fluid in an infant alwiut two weeks old ; and
of sixteen injections, of infants of various ages, the areas of dulncss were
identical in all, and in all the lungs were normal and there were no pulmo-
nary or other adhesions.
This next diagram (Diagram 17) represents tlie position assumed by the
Diagram 17.
A hage nmotmt of liquid tui been latHxluoed Into tbe nu! (Botch).
tkn or Ihe hYer whli^ ii vsarweA bf the tight lnog ; g| C, lt>^ ; ■ D, tho *reft of d^Iii(«« ^Itilne
etHMil bx « Urge «Ai>t(ia ; a itenrnm ; 0, nippLe; l. 2.9, 4.6,^ itbi; •• (bcoUn UneK bolder of lazic.
I B, Vtfv: m B\ that PC*.
, of M^Il
marginB of the lungs and the resnlting area of abeolute dnlneas where the
pericardium was distended with a lai^ amount of fluid so aa to cover tbe
entire heart
Here tbe transverse area of dulness produced by the much distended
1054
PEDIATRICS.
pericardium has increased so that it extends fiirther to the right of the stc
num in the fourth and fifth interspaces, and then, rising to the third intE
space, it occupies a small area on either side of the sternum under the thii
second, and first ribs and the second and first interspaces, the upper lob
of the lungs having retracted from beneath the sternum. As the efiusic
increases the lungs retract still more, and the upper curved lines of the effi
sion on either side of the sternum present areas with still greater diameter)
This next diagram (Diagram 18) represents this same large efiusion wii
the lungs removed, and also shows the relations of the heart and grea
blood-vessels to the ribs and sternum before the pericardium has been dis-
tended with fluid.
Diagram 18.
The lungs have been remoTed (Rotch). H A, nonnal shape of the heait in its pericardium ; JfJH B,
liver ; B D, eflHisiun ; A + D» the shape which the pericardium assumed in a case where ooDBidexable
fluid had been introduced into the sac ; S, sternum ; ^ nipple ; 1, 2, 3, i, 5, 6, riba
As ordinarily seen on the injected subject, the heart would of course not
appear as in the diagram, as it really was suspended in the pericardial sac
with the effusion surrounding it and causing the entire area of dulness
represented by A and D.
The fact that on oix^ning the abdomen the diaphragm remains arched,
and that the lung, by means of the trat^heal clamp, retains its position and
does not collapse, warrants us in assuming that we can fairly judge of the
position of the fluid during life by this method of investigation, especially
as the contractility and distensibility of the lung appeared to be perfectly
retained after death, except in very cold weather, when it was found neces-
DISEASES OP THE FEBICABPrOM.
1055
I
I
I
I
I
I
sarjr to warm the cadaver. It might have been objected to these exjieri-
ments that the fluid was iotroduced at the liottom of the pricardial sac,
while during life it might originate at the base of Uie heart. The fluid
was, therefore, iu several cases introduced where the jiericardium is reflected
over the great vessels ; but even when it was in very small amount and
insufficient to cause any increase of duluess, it immediately ran down the
side of the heart to the bottimi of tlic [K^rieaiYiium, Even when it was
mechanically retained at the ba^» of the he-art by inverting the cadaver,
the resulting cast had its broadest part toward*? the diaphragm*
Diagnosis. — Fi-om what I Irnve told you regarding the latency of the
general symptoms of perii'arditls in childhood and tlie ditMculty of inter-
preting the local symptoms, it will be n?adily understood how impt»rtant it
is to recognize any especial symptoms which may characterize the disease.
Instances have been reiM>rted where a distendetl [)ericaniiura was mistaken
by experienced diagnosticians for an effusion into the left pleura*
The condition^ however, which most closely simulates a [MTicnrdial effa*
gion, both in its general symptoms and in its physical signs, is a dihitc<l heart.
The most distinctive of all tlie physical signs of pericarditis is the frio-
tion-sound, when it is present. When, however, an eff'usion has taken place,
the friction-sound may not be heanL This absence of a friction-sound is
especially frequent in young children. The hearths impulse may be clearly
perceptible, even when a considerable effusion is present, owing to the thin
layer of fluid which covers tlie heart in the area between the left nipple
and the sternum. We are therefore forced by the similarity which at times
exists between the general symptoms, io the ins|>ection, pal{>atiou, and aus-
ciUtation of a dilated lieart antl i>f a jjericanlial eff'usion^ to depend upm
percussion in making a ditlereiitial diagnosis. In onler, however, to make
a differential diagnosis between this area of percussion and that produced
by an enlarged heart, it will l>e neetissary to consider the j>ossible area of
dulness which may l>e protluced by an enlarged heart, and, by comparing
this area with that which I have shown to exist in a pericardial effusion,
to determine the differential diagnosis between the two diseases.
Aix-ording to c^i^ful observations which have been made by oom[>etent
observers on the ai'ea of didness whicli can be pnxluced by an enlarged heart,
whether by hypertrophy or by dilatation, ventricular or auricular, although
the relative dulness may extend to the right of the sternum from the sc*<><)nd
to the sixth rib, aud in adults pjssihly to the distance of 3 or 4 cm. (1 J or
1| inches) on a level with the fourth rib, yet it is rare to find this dulness
invading the fifth right interspace more than 2 or 3 cm, (} or 1 J inclies), and
still more rare for the absolute dulness to be foimd in the fifth intcrsjunH:* at
all, and even in the fourth interspace for more than 1.5 or 2 cm. ( j or } inch).
This diagram (Diagram 19, page 10o<») n*presents the combined \iew9of
authorities on the dulness of an enlarged hmrt, and \*ill be useful to refer to
when we are considering the question of paracentesis. I have myself fre-
quently verified these percussion-outlines, and in my experience it is exceed-
DISEASES OP THE PKRICARDIUM,
1U67
I have indicated the top of the sternum, the boundarie^s of the enlai^:©d
hearty the ensiform cartilage, and the lawer border of the ribs by plain
black lines, the boandaries of the small effusion by a broken line, and the
area of the large effusion by a larger broken line. The figure 5 marks the
n, beiirt.
flflh right liiteiFpa4?«;
fifth right interspace ; the letter H marks that portion of the heart which
has been left unt^ovei^l by the small effusion. The small blac*k circle rep-
resents the normal [M^sition of the a|iex rif the h*^rt, the lar^^r circle the
apex of tlie enlargtxl heart, Yi»u will also notice how the enlarged heart
extends beyond the riglit edge of the etemnm at about the fijurth rib and
fourth interspatxs and tlien returns beneath the lower part of the sternum
within or very little outride of the right para*4temal line*. The outline of
the small effusion, as well as that of the lar^e effusion^ is, as you see, to the
right of the sternum as low as the sixth rib.
The following cases (Table 111, page 1058), taken fn>m a numl»er whieli
have oome under my care, illustnite the difBrulty of making a diffenntial
diagnosis between cardiac and |)erieardial disease where, as at timet« happens,
we fail to find a friction-sound or murmurs:
DISEASES OF THE PERICARDIUM.
108ft
Bibtmcl in the fifth right interspace, while where it was absent dulness was
Huot found. These typical cases with friction-sounds and murmurs were
■simply chosen in order that there should be no doubt as to tlie disease with
H which I was dealing when testing the value of percussion as a means ibr
H differetitial diagnosis.
H I have referred to pericarditis with its accompanying effusion as Wing
■ likely to occur in the later stages of scarlet fever. Acivvrding to Steflen,
■when dilatation of the heart occurs in the later stages of sc^arlet fever, lu
^MpBB where from the age of the child, three to eight years, the physiological
1iypertrf->phy of the hcmrt is jiresent, the tendency to enlargement is still
further pnimnted by the inercas(?d blood-pressure ironi tiie disi^ascd kichiey,
■and a differential diagnosis between a pericardial effusion and an enlargnxl
heart thus Ix'cc^mes necessary.
In connection with pericarditis we should consider the possibility of
both complete and |iartial obliteration of the |x*ricanlial cavity occurring in
children. Where severe cardiac symptoms arc [ircscnt and no valvular
— murmurs are heard, we should in ynimg cliildreu think of dcgencmtiou of
f the heartHnuscle itself or of |H*ricardial adht^sions. When, figain, the abso-
lute area of duluess remains unchanged and there are well-marked sysUilio
retractions, the presence of pericardii! tKlhesions is highly pnikible.
While in older childrm and in adults {>erii^rditis is maniiested by
weakness of the a|)ex-beat, the latter sometimes being irajierceptible, and by
■ a friction-sonud, in very young childi-en these symptoms are oftpu absent,
bei^ui^ the exudation is mmlcrately thick and may not Ix- abundant enough
to oause friction-sounds or to mask tlie apt»x-beat,
^ Chf*onu'! peru*artlltfs may occur in infancy and in childlKMtd as in adult
"life, and is the result of acute intiammatory pnxt^sst^^ which have ivsulted
in adbe&ions. It is oiien very lateot^ m is shown by autopsies.
■ PROGNasis. — In c^iirly infancy diffuse jxrlcardttis is a very dangerous
^Ldiaease, and usually sotju ends fatally. In later child IkkkI its i^iirse and
^Plwilts are much the same as in adults, and iu tlie acute form the disease
has a tendency to recovery. Among the unfavorable aim plications of the
(disease which render the diagnosis esjMHi'ially serious may be mention* J adhe-
sions of tlie two layei-s of the jw^ricai'dium, which may paralyze the i-artliac
muscles and from the resulting stasis of blood may lead to extansive
dropsy. The princijml symptoms of this form of nirdia*^ {landysis are a
imall and frecpjent pulse, subn^jrmal temperature, rwlema of the cheeks,
lids, and lower extremities, and the presence of a small quantity of albumin
ill ilie urine.
Treatment. — The treatment of pericarditis in infancy and in early
childho<xl does not differ materially from that in later life, and depends
ujKin the various causes which I have referred to in s|)(*aking of the eti-
^ olog)* of the disease. The tendency to heart- failure, however, which is so
■ pronounced in the child, should be guarded against. Early in tlie dv^
Bm^ absolute physical and mental rest should be enfortinl In tJie acute
1060 PEDIATBIG8.
stage of the disease, before an efixision of any extent has formed, cold cai
be applied to the cardiac r^ion by means of coils of tubing containing ice
water. An important part of the treatment is the judicious administratioi
of digitalis to aid the heart in the crippled condition in whidi it is usually;
left after the early days of the disease. Stimulants should be freely used
when there is any indication of heart-failure.
The most important part of the treatment when an efihsion of any
extent has occurred is paracentesis of the pericardium, which should unhesi-
tatingly be performed, no matter what the cause of the disease may be, when
life is in danger from undue distention of the pericardial sac. The pericar-
dium has usually been aspirated to the left of the sternum. The possibility
of wounding the heart when the aspiration is made to the left of the ster-
num should be considered, and, if possible, avoided. An important point
both in the diagnosis and in the treatment should be here spoken of. It
has been held by certain authorities that the heart's apex is foimd in
elTusions to be tilted upward and inward towards the sternal end of the
fourth left interspace, — that is, floated up by the effusion. Direct proof
of this is wanting, and I believe, from my investigations on this subject,
that it is an erroneous view. It would seemingly be impossible for the
heart not to sink rather than to be floated up, unless the specific gravity
of the effusion was greater than 1050, as I have shown by experiment It
is highly improbable that the specific gravity would be greater than 1050
in an ordinary pericardial effusion, for the specific gravity of a purely
punilont fluid is only about 1032. How, then, can we explain the clinical
pheiioinenon of the heart-beat in the region of the fourth left interspace,
where it is so fre(juently found in cases of pericardial effusion ? Referring
to Diagrams 15 and 16, and to Case 508 (pages 1051, 1052, 1057), it seems
plausible to account for this pulsation by the tumultuous action of that por-
tion of the right ventricle which is seen to be free from the effusion in the
fourth loft interspace when an effusion of any extent is present.
On examining the cacao-butter casts it is also found that this portion of
the heart is in the larger effusion, as I have already described to you,
coven^d by a very thin layer of fluid, through which the impulse of the
heart can easily be felt and seen. This fact is of especial significance when
we consider that both Ludwig and Bowditch have observed that the impulse
of the heart as seen normally in the fifth left interspace need not be caused
by the heart's apex, but may be caused by a portion of the heart above the
a})ex striking against the thoracic wall. We should also consider tliat the
impulse of the heart in children is often chiefly in the fourth interspace. In
Case III. described in this table (Table 111, page 1058) it is recorded that
the impulse was found through the whole cardiac area, but that it was still
pronoun(»e(l in the fifth interspace. Now, if in this case there had been a
larger effusion, the apex and the lower segment of the right ventricle being
surrounded by a mass of fluid, the impulse would have been lost in the fifth
interspace, while in the fourth interspace, where the ventricle is covered by
DISEASES OF THE PERICARDIUM.
1061
I
only a thin layer of ovorlymg fluid, the impulse would have continued to Ije
both seen and felt, thus simulating an a[iex-I>cat, I believe that this is tlie
explanation of what has been called misplaced apex-beats and floating
upward of the heart in jK^ricardial etiusions.
From the abi>ve factn, — namely, that the heart, 'when an eifusion h pres
ent, remains in ifes usual position, and does not, even when much enlarged,
impinge on the fi flh ri^ht interspace, and tliat the eifusion, even when in so
small an amount as UX) c,e., is found in the tirth right intei-spac*, — is it not
more rational to choose the fifth right intei-space as the point for tapping,
thus avoiding al! question of iujuring the heart? When we tap tlie pleura,
we avoid the heart as much as possible : w hy not carry out the same rule in
paracentesis of the pericardium? I have tapped the |>erieanlium in the fifth
right interspace a number of times on the cadaver, and have removed the
fluid as easily as in the fifth left interspace.
The pericardium has b^^^n tapptxl during life in the fifUi right interspace
by Ebstein, of Gottingen, and Wilson, of Nashville.
As an illustratitm of how imixirtant it is to tap the perieai-dinm when it
is mneh distenfleil with fluid and when syniptoras of failing heart have arisen,
I shall report to you a case which occurred a few days since in the wards.
I IS mni
■ Ishal
^^^_^ A boy (Ca&e S/0&)^ six ycjirs uld, centered the hospital with li history of having hud
^H^pbma of the fac<*i bunds, feeti and ankla^ for four week]». There wa^ no history of rhcu-
iUllUm, und the case was apparently one of acute primary endocarditis with rnitml insuf-^
Hciency. The cardiac area of dulne^s was increfi^ed^ and extended from the middle of the
■ tternum U^ L6 cm. (^ inch) boyond tht? U*t\ iiiamniHry line, where the impulsi* «»r tlie ht>art
could he fidt. The child was kept cjuiet in ht^d^ and after a few days tho cpdrrna lot«5i»nod
and he wat very comfurtahlc. While i^till under treatment, two wtn^kf^ liitert th« tenifiera-
ttire, which had been normal, npe to 39.1^ C, (102.6* F ), Ihe pulM* waf* quicki^ne*! und
Mmewhat irrej^lar, and the respirations were increased. A few days later a perieiirdittl
(Hcttori>«fiund was heard over the upper part of the *tenium, and the tempt^mturv foil to
87.7* 0. (100^ F.). There was no change in the cardiac art?* of dulneA*. and no uridetiee
Pof » pi^ricardiftl etfusion.
On the fullowiiii^ day the cardiac sounds were found to he rather muffled ; the child did
not *eem fto well, and wa-* unable t*> lie on hig left tide. Twt» day* lat«^r the area of pnKHir-
dial dulne^s extended farther t4» thi* right, and a little beyond tho rit^bt panuternal Unv in tho
fifth ri^ht interspace. The attendants wert^ directed to watch the child cl*»Mdy, and warn-
ing wiL*» piven that the m^essity for pitracentesi* of the periciinliuni ini^ht at any time arise.
Early the following morning the child began to have marked dy^pncua and bocam* very
cyanotic. The houie^officer found that the pnecordiat duloi'^s hati oAtendf^d 2.7 cm, (1 inch)
beyond the right edge of the sternum in the tilth interspace, and be therefore gat tho
instruments ready for performing paracenUds. Suddenly thi* ehild'A pul^e h«»OAmo very
wenk an<l intcrmittentT the cyano^iii increated very much, tli».* dyspncea b-came vi?iy marked,
and, aUhough stimulantK were quickly given, the child suddenly gaaji4>ti und ftdl hai^k on it*
pillow dead, Thia 4>ccurrt'd within three-quarter** «tf an )u*ur fn>in th«' time wh*'n the flrit
»erintm eympttims arcme. The house-offlwTi Dr. 8tickney» immetliiitrly introduiM^l ihe
Aipirating ni>ed1e in the fifth right interspace and withdrew A<»me Duid from tlie |)«(rii»rdtutti.
Th« child, however, did not revive.
This case of pericardial effui^ion^ as well as the caM of pleuritic effUnlon (Caae 481,
puKto 1011), should warn us that whenever a pleural or a perioimJijil eflb^on i* prwent tho
«hild should be watched with the greatest cars, and pamoentecii shuuhl be parCbnoad M
•cmn aa any urgent symptomt ariie.
1062
PEDIATRICS.
Here u ji littla glii (Out ilO)i six aud one-half vears old. 8ho ha^ Tvevcr bad rbeatm
tism, but fibe bud an attaek of measles wben she wa^i two yetin old, pertu»&iB whi^n she wi
two and a half years old, wnd paroiiiii wbeti she wa« three and one-haJl' yeai* old. P<iu
monthe ago she bad ati attack of chorea, of so mild a grade, however, that she baa b«ei
able to go to schcnd uutil entering the hospital. Ai that time, although she did not tboi
any e^^pecial cardiac ^jniptfuus, an examination of the heart showed a laUimt and inBidioni
endocarditi^t represented by an increase of the cardiac area of dulness to the left of thf
mammary line, but not extendini; under the sternum, witli ft systolic murmur transmitted
tt> the axillary line, hut not heard in the baek. Compeuiuitiou aoon became complete, and
*ibe recovered Injtn the chorea.
Two dajs ago ahe was attacked with djspncBa, rapid redpirationfl, and cardiac pain
CiLSE 510.
Chronic endocarditis. Mitrnl insufficiency. I\i
right Uiten!|Hice.
i\ ^'criciLrdlal friotioD-flOUiid ; b. AfUi
On examining her to-day the child se^ms very sick, and in addition io the area of
cardiuc dulness which I have market! in block, nnd which, as you see, ahows the presence-
of a diluted heartj I find at the junction of the third rib with the sternum a marked
piwcordifll friction -sound,
(Sub??equent bi§tory.) Tin* prwMMmliul pain, discomfort, and heightened temperature
lasted for a few day?, iind were in the iNPt^nnini^ accompanied by orthopncoa and by the fric-
tion-sound becoming more intense. There wtia at no time, however, ikny evidence of an
ettiision in the pericardium, and one wet^k afterward* the friction-sound betmme !e>s distinct,
disappearing three daya later. The ehildj however, grew much weaker, and, altbough she
was treated by eomplele rest in bed and with digitalis, slrophanthus, and stimulants, the
pnecordial pain returned, and fibe gnidually railed and died. The chart (Chart 46, page
1Q»J3) shows the temperature during the attack of fiericardltia. The pulse varied from 130
to 150, and the reapimtJons from 5f> to 80,
The autopsy gbowed tha pericardial i^ac to be obliterated everywhere by firm fibrinous
adhesions. The heart was enlarged. Along the edge of the mitral valve were numerous
small gn\yish- white vegetations. These were also present on the aortic valves and on the
portion surrr^unding th*^ tricuspid valve. The lungs were denser than normal, and were
deeply injected and oedeijiatous. The pleura on the inner surface of the right lower lobe was
^^^^^^^^^^^ DISF.AB^ OF THE PERICABDIUM. 1063
^^^^B^^t to the pericardium by fibiinouB adbesioTu. The surface of the liver wta covt.'Te<j
^^^H|h & thin layer of fibrin. The liver and kidneys were a little denser than normal, but
^^^w«TO not noticeably congested.
P
Days of Disease,
W.
i 2
3
4
6
6
7
8
9
10
11
12
13'
14
1&
16
17
18
19
20
21
c.
107
•
UK, MS
K I
m
II K
M E,
M E
U 1
MI
M K
M %
MK
MY
ME
Ml
Ml
MB
11 E
VE
M X
Ml
44 fl'
41.1'
40 5*
ifM
inA
Ai\ A*
«e%^
ao4*
I wo
102
lOi
4nn
_J
33 8*
/^
y
J
J
J
' 1
j
J
}
i
38 3'
/
r
\
/
f
/
l^
/
/
/
i
i
\ /
37.7'
37 2'
99
98
97
/
/
\
f
1
f
f
/
/
^
J
/
/
/
/
f
/
/
f
37.0'
36.6'
aei'
35 6*
95
35.0"
^1 Perlc<Lnlitl» fricca
^^^^ Anatomical DiagriiOBis,
^^^^H Chronic adhejfivo peric^arditlB.
^^^^H Acute vegetative cndoearditia.
^^^^B Acute fibriuous pleurisy.
^^^^V Acute fibrinous ppH hepatitis.
^^^H Hypertropliy at id diluutioo of the heart.
^B Here is a little ^rl (Case 51 1)^ eight years old, who daring the int two yean of her Ufo
^m had scarlet ft^ver, vuricc'llu, and pertussis. When she was two years old sho hud art attack
^V of mernlm^ arid when abe wa^ seven years old an attack of chorea. Ihiring thu liuit y^ar I
*be has been fairly well until two weeks ago^ when it was noticed that her feet began to
^_ swell, Bhe complained of pain in her limbs, and occasionally of headache, she k«t in weight,
^B ftnd lately has bad orthopncua with fnequent paroxysms of dyspnfjua. She bos abo at times
^" complained of pain m her left chest. Her extremities are apt to be cold. For the past two
days the has had a short, dry oou|?b, A physical examination shows the impulse of the
^K hL*art to be fet^ble^ but it can be fcU all ovr^r the cardiac area. There is an area of pncot^rdial
^B dulness extending U* the ri^ht of the gternum almost to the right mammary line, as low as
^m and involving the fifth interspace and as high a^ the third int4?rspac« and U> the left a little
^r beyond the left mammary' line to the 8ixth rib. There is a systolic murmur at tb«< apex,
which IS transmitted to the axilla. The pulmonic second sound is accentuated. Thcrw ia m
pmcordiul friction-sound heard at the upper part of the sternum. The hifttory of the ctm
and the area of pnecordial dulnc^s show us that it is a v^&e of pericaitlitis with eflhsfon.
^m Thefv may also be some endocarditis, evidence of which is given by the mitral syatolid
^H murmur. The child is being treated by nsst in bwl and bv digitalis.
^^^^ (Subsequent hifrtory.) Two weeks later the friction-sound diiUippearvd, and the pnecor*
^^^B|dalii«M grew lea^, so that it extended only tn the middle of the sternum. In the next
^^^^^^Sfai|[s the dulnei«« Iteneath the etemum di^ppeared, and the mitral murmur lessened ,
^^^IBBHd still be heard 2 cm. (] inch) outside of the mammary line.
DIVISION XVIIL
UNCLASSIFIED DISEASES.
LECTURE LIII.
IttACHlTia. — SrORBUTlTB,— KhECMATISM.— PtTRPUBA.— DlABKTBS.^TirDBRCtJXaftlB.—
Epidemic Ikklujenza.— Diseases or the Thyroid Gland. —Dug eases or TUft
Certicai. Lymph Glahdb.—Pabotitis.— Bis eases of the Ear.
I SHALL now speak of a number of diseases which are not readily
eliissified under the divisions that I have fuund most useful for teaching,
and which will therefore Imve to be s|H>ken of s«*panitely.
RHACHITIS.— Rhachitis is a disease of infancy, rarely of early child-
hoiKl, and is closely asscK'iated with iin|>ain?<l nutrition. It shows itself
mostly in alterations of the growing lx>ne.s. Its most marked symptoms are
met with lietween the sixth month and the second year, but it can occur at
all ages, and may be ningt^nitab
Etiology. — Altliough the cause of rhachitis is not yet clearly under-
8to»xl, it is evidently closely conneeti*d with interference with the nutrition by
impro|jer food and lack of suitable hygienic surroundings. Although it
most trcfjuently exists after the first six months of life, yet probal>ly many
cases occur tMrller, but are so mild in form that the rhaehitic Unions do not
beoome sufficiently marked for recognition until the ktter part of the first
year. It is well known tliat rhat^-hitis is much more common in its occur-
ren*^^ among all classes of* life than was formerly sapposed. As a eon-
genital drsease it is probably associated with lack of proper intni-uterii]€
nourLshmcnt, corre8i>ondiug to the rhachitih which is met with in <mscB of
prolonged lactation. Like all diseases assot^iatcti with imjmirment of nutri-
tion, it is less likely to oet*ur among breast- fed infant^i than among those* who
are deprived of their natural food. For the same reason it is more likely
t^i develop in the latter part of the first year than in the early raontlis^ since
in so many cases the bnast-milk deteriorates in quality after the first six or
seven months of lactation. The dis*^ise sec*nis to occur when? the ibod is
not properly adapted to the especial age. CVjrtain nicc^, such aa the lower
dfiases in Itily and in England, are notably affcctt^l by rfaachitifl. The
in a marked form is not common among native-bom Americans.
1065
Pathology. — Although tliere are lesions of the various organs which
seem to be closely connected with rhachitis, such as eulargemej.it of the
epleen and of the liver, yet the bines i^how i^o markedly the most imj>ortant
changes that practically and cliaically, in the present state of our knowledge
concerning the disease, these changes in the hones cx>nstitute iU patholi»gy.
We must rememher, htt\vcver, that the nutrition of all the tissues is j>ro-
fouudly aii'eilcd, and that the ei|uilibrium of the nervous system is ve
I
I
ffa
unstable.
According to Dehitield and Prudden, the growth of the Ixmes dejKSBds
upon three conditions* They grow in length by the production of bone in
the cartilage l)etwecn the epiphysis and the diaphysLs, and in thickness l»y
the growth nf hone from the inner layers of the jieriosteum. At the same
time the medullary canal is enlarged in prf) portion to the growth of the
iMiue by the disapi^earance of the inner layer of bone* In rhachrtic chil-
dren these three conditions are abnormally affectcfL The cartilaginous and
subperiosteal cell growth which produces ossification goes on with increased
FiQ. 148.
-z,p.
L Normal booe : Z. P., zone of proliferation. U. Bone of a cietiti : Z, P., £oae of pfolifemtion.
ill. f&haehlttc botw : Z. P., Eone of pruIlferaUon.
raj>idity and in an irregular manner lx*th between the epiphysis and the
diapliysis and Ijencath the periosteum, while the actual ossification is markt^lly
irregular or wanting. At the same time the dilatation of the medullary
cavity goes on irregularly and often to an excessive degree. If we examine
mi<n-oscopically the region between tlic cpiphyt^is and the diaphysis usually
called the zone of proliferation, we find that the cartilaginous cells are not
regtdarly arranged in rows around a definite zone in advance of the ring of
ossification, as in normal tissue, but that there is an irreguJar heaping up
UNCLASSIFIED DISEASES.
1067
Flo. 14a
of cartilaginous cells, sometimes in rows, sometimes not, covering an ill-
defiaed irrt^gular area. This zone of proliferation also, instead of being
narrow and sharply defined, is quite lacking in uniformity. Areas of eal-
<^cation may be isolated in the region of the pi^lifrrating eurtilagiilous
cells, or calcitieatiou may lie altogetijer aljsent over considerable areas.
Here is a section of a normal bone (Fig. 148, I.) taken from an infant
which shows the normal zone of proliferation (Z, P.) between the epiphysis
and tlie diapliysis.
Here also is a section of a rhacliitie ijone (Fig. 148, III.) which ehowd
the broad, irregular, and abnormal zane of proliferation (Z. P.) which I
have just desoril>ed-
Here is a section of another rhat^hitie bone (Fig. 149), which shoH^
the great enlargement of cartilage at the epiphysis, with the irrc^ilar foci
of calcification. The dfajihysis of the iKine shows
periosteal thickening to such an extent tJiat it en-
croaches on the medullary cavity, which, as you see,
is much diminished.
All exclusive pnjliferation of cells in the inner
layers of the periosteum, the irregular calcification
which oc^curs al>out them, and the al>sence of (mi-
formity in the elalxjration oi' the structure of the
bone, j>roduce an irregular, spongy bone-tiasne in-
stead of the compact lamellated tissue which is so
necessary for the unifiirmity of the structure. The
increased eelb growth btHween the ejiipliy^is and the
diaphysis prrNiuees tlie peculiar knobby swellings
which are charaeterii^tic of rhachitis. At the same
time die medullary aivity incivascs rapidly in size,
ad the inner layers of the bone become spongy.
The medulla may hi* amgesti'd, and fat, if it has
formed, may be absorbed, and a species of ostritis
ensue. The result of these process^ is that the
bones do not possess milidity and cannot resist the
strain of the muscles or outside pixissurt^ After a
tune the rlmchitic process may stop and tlie bones
may assume a more normal cliaracter. The parous
bone-ti^ue befY>mes crmipurt, and even unnaturally
dense, so tliat in later childhoml the rhachitic Ixme
is unusually hard, like ivory, a condition noticed l>y
those who have to openite on these lx>nt_^.
The swelling at the epiphyses <lisapi»ear8 as tlie
disease passes oftl Many of the deformed bones may
becjiirae of a normal shape, but in severe cas4^ the
deformity may continue through life, esjHH'ially if there \> ition of
the growth of the bones in their long axes, so that tlie children are d^nrfed.
8p4li*l]c--hiiT--l rtifj* hlUc
I7NCl.ASStFI£I> DISEASES.
1069
Id striking (x>ntrast to the large srjimre head is the narrowed and
flattent?il thorax. There is usually a eampression of the chest laterally and
a protnifeion of tlie sternum and lower nhs, due to a constriction following
the line of the diaphragm. The costal cartilages are frei|uently enlarged at
the junction with the ribs, and can Ix' felt and otlen seen as a line of
rounded prominences, Tliese pnimineutres are called the rhaehitic rosarjf*
Phi^ rosary, although most commonly occurring in the latter part of the
Bt year, has been notic^^d by Jacobi at the age of two months^ and it has
also been met with in the early weeks of life. The sternum may be de-
pressed, or with the costal e^irtilages it may Ix? pushed forwani, forming
what is known as pectus carinaium (pigiHin-bi-eastj.
Fio, 150.
loser sorflice of sUsrnum. with canilAgfitt anil partloiii d ribs aUncbed, thowki^ rhAchlUc rtAAij.
Here is a s|K^imen (Fig. 150), taken from a rhaehitic child, of the
sternum ti» which ai*e attaclitnl the t-artilagL^ and portions of the ribs.
It shows on the inner surfatt^ a distinct rosjiry. During life this rosarj^
could not be detected on the outer surface of the thf»rax.
This infant (Case 513, page 1070) shows vi^ry markedly a rhaclntic
rosary, with depivssion of the lower part of the thorax, and cnhirged
epiphyses at the wrist.
I have described in previ(»ua le<'tures (pages 71, 1019, 1045) the various
deformities of the sternum which arii*** in connection with a delay in ossi-
fication, and which may also <H:»cur in such defective ossification as takt-s
place in rhathitis. In addition to these* anterior and lateral deformities of
the thonix, kyphosis is quite frequently seen in t-ases of rhachitis n\ the
junction of the lumbar spinels when the childrt^n begin to stand cri^^'t and
to walk. Ix>rd(»sis may be present Lati^ral curvature may alsi3 occur*
UNCLASSIFIED DISKA8E8.
1071
I
Slight lateral curvature is present. The abdomen u distended^ She ii how-legged and
knock-kneedi and has ftat^fo>nt.
Here is another child (Case 516) who shows markedly the rhachitu^
deformities of the wrists, the distended abdomen, the rosary, and the
rhaehitic head.
Case 615.
Cask 516*
I
I
RJiiichitle (kforrnUiea.
The ealAiKe<l «plfih]rwt Of th« tf ba afi mar Itad
with black ipoti.
CoKGENiTAL RhaiHITis. — Althoy^jh tlie ocxntrrenoe of iiitra-utcrine
rhachitis has been dis|iiited, yet theiv si'euis to be sufficient evidence of Buch
sdiaeaae in new-born infants to warnmt the i?tatcment that rhathitis may
be met with in this early stajre of existence : it i**, however^ a very rare
aftwtion* I have stt'U a fa.se of o>ng*'nital rhai'hitis in whicli thr rhurhitio
process had nin its eoui^e and the hardening of the bones hail ap[Kirently
been ojmpleted before the infant was l>cjrn.
Another ease of tx^ngeiiital rhachitis which has come under my obser-
vation was seen by me in consultation with Dr. Townsend (Case 617, page
1072). The parents were young and healthy, and there was no history of
syphilis or rhachitis. The father was American, the mother Sc«>tch* There
was one other child, three years old, stning and well. The mother during her
pregnancy was much worried, and her nourishment was both insufficient and
poiir. The infant, a male, was one month premature. The labor was easy.
The infant weighed seven {>ounds and was 43.3 cm, (17 inches) in length.
I have here a pliotograph which was taken on the fourth day of the
UKCLASStFIED DISEASEa
1073
I
Symptoms* — The symptoiiiB of rhacbitis are thoee of a slowly develop-
ing ooDstitutional disease. The early symptoms are those which may occur
in a number of diseases, and are clos^cly connected with disturbance of the
gastro-enteric ti-aet* The cliildren» altliough they are ofteu quite heavy,
are anfemic^ and their muscles are soft. The increase in weight de{x>nds
more on the increase of fat, the nornuil relative pmportion between tat and
muscle being alterc^d* Their appetite is capricious ; they become fretful, and
perspire at night, espti^ially about their heads, Tliey do not learo to walk
so early bs> does the normally devclopcM:! infant, and they soon show tlie later
and more characteristic signs of rliachitis, I have already sjx^ken of these
dgns when describing tlie pathology of rhacliitis. As a rub, however, the
picture of a rhachitic child Is one w ith a sqimre, prominent foreliead, and
with an anterior fontauelle remaiuiogo|M^n after the age of eighteen niontJi^j
dentition is delay chI ; the tliorax is narrow and compressed laterally ; the
rhachitic rosary and enlargement of the epiphyses of the wrists and ankleB
are present, and tlie alxlomen is distcndtnl. The bones of tlic extivmitiea
may be bowed, an<l the feet may U^ Hat* In some cases tliere Ls tx^tnsidemble
tenderness of the bones and muselcs. The muscles are often so weakened
by the depressing etl'wts of the disease that the child has not suiEcient
strength ti> walk steadily. There are also a seri*?s of nerv^ous phenomena
connected with rhachitis which play a very prominent part in the disease*
Convulsive attatis are more fretjuent in rhachitic children than in those
whfise nervous system is in e<|uilibrlum. The ccmdition itf laryngi>spasmns»
which I have di^scribed to yon in prc% ions Itrtnrt^s (j>ag«As 747, 1*49), is at
times a prominent finture in the symptoms uf rhachitis. Rhachitic children
are more liable to die than otlier children when attacke<l with such diseases
as pneumonia or broucliitis. Attacks of the acute exautlicmata are of
serious imp«irt in rhachitic children, and these children are espetnally liable
to the invasion of the bacillns tidiermlosis.
DiAGNf)Si8, — The diagnosis of rhachitis shonid Ix- made fmm a num-
ber of diseases in which the general nutrition of the I'hild is pnifbundly
disturbed. When the <lisease is fully developed the diagnosis is not difti-
cult. In its early stages, however, the manifestations of rhachitis may be
go slight that the diagnosis must (»ften \yo kept in alieyance. I have ali-eady
spoken of the diagnosis of rhachitis from hereditary syphilis^ and, as a rule,
DO difficulty arises. You must rcmemlM^r that syphilis and rliarhitis have
no direct c^^mnection with each other, but nrv \uAh chrouir (.constitutional
dbeaBea^and that it is possible to have lioth «]i > a ^ fn^ur in the same indi-
%'idual. I have diserilxtl tht* sypliTlitic Ixme in a previous letlure ({>age
497). When their is enlargement of the long bones it is not limited to
the epiphyses, as in rhachitis, but involves the ends of the diaphysia. It
b often ac(*ompimjtHl by a amdition which cli>sely simulates* a ealluA, and
there is a distinct tendency to fracturt* in syphilis rather than to the
bending which is nunraon in rharhitis. The noti'hed twth and tfie iTanio*
tftboB may occur in both disias(*s, while the le8ion:» of the mouth and
68
1074 PEDIATRICS.
lips, which I have already fully described (page 494), are distinctive of
syphilis.
The diagnosis from scorbutus I shall speak of presently (page 1077).
The heightened temperature and the adUte tenderness and swelling of
the joints in acute articular rheumatism are easily distinguished from the
subacute or chronic course and the characteristic enlargement of the epiph-
yses in rhachitis. .
Rhachitis, where it causes kyphosis of the spine, may simulate Pott's
disease very closely. It occurs at the dorso-lumbar junction, which is a
frequent seat of the deformity in Pott's disease.' The spine is held rigidly
in severe cases, just as in Pott's disease, and the deformity may be angular
rather than the usual gradual curve. The coexistence of enlarged epiphyses
and other rhachitic conditions makes it very probable that the affection is
rhachitic ; but both diseases may coexist
In general, the age of the child, the absence of much pain, and the
existence of other signs establish the diagnosis of rhachitis. It is, more-
over, in children under two, much more common than Pott's disease. In
doubtful cases the diagnosis can be made only after several examinations
and a period of two or three weeks of recumbency, under which conditions
the rhachitic spine becomes somewhat more flexible.
Cases of rhachitis which do not walk until late, on account either of
muscular weakness or of tenderness, may resemble cases of organic nervous
disease with true paralysis. The diagnosis must rest on the presence of the
general signs of these nervous diseases already described.
The existence of flat-foot in children over two years old should lead to
an examination for knock- knee. The combination of these two conditions
will in most cases be found to be dej^endent upon present or previously
existing rhachitis.
Prognosis. — The prognosis of rhachitis is favorable, provided no com-
plications arise. A spontaneous arrest of the disease may take place in
any of its stages, but, as a rule, if the affection is at all pronounced, serious
deformities are usually produced. If a hydipcephalic condition, which at
times appears in rhachitis, is present to any degree, if there is much diar-
rhoea, or if the infant is subject to frequent attacks of bronchitis, the prog-
nosis is ver}' unfavorable.
When properly treated, the health of these children improves slowly,
and, unless the deformities which have occurred in the bones have advanced
too far, more or loss complete recovery usually takes place in the third or
fourth year.
Treatment. — The treatment of rhachitis is essentially dietetic and
hygienic. The infants should be kept in the open air as much as possible,
and should live in rooms accessible to sunlight. The food should be adapted
to the age, according to the rules which I have given for the feeding of
normal infants during the first two years of life. There does not appear to
be any drug which pnxluces a specific effect upon the osseous changes which
of k'« IFI U r-;r-- m I !.■'■,' i ' - ' ' ■
fi^tauf And tflHs
(jTIIm* Cull«CV of |<|i|«i*
UKCLAS8IFIE1) DI8EA8B3.
1076
m Ti
^toasts
take place in rbathitis. Phosphorus is considered by some observers to be
a valuable adjunct to the general dietetic and hygienic treatment, but,
aooording to our experience at the Children's Hospital, it has not proved
to be of any especial benefit*
Where the anaemia is marked, iron in some form should be given, and
at times an inci*ease in the lat in the food seems to be l>enefieiaL
There has been much dist^iission w^^ to whether a form of acute rluichitis
apart from the disease scorbutus, which is now well recogniiced as
ring in young infants. There are certain eases of rhacliitis in which
the disease is in tlie lieginning more proiioiioced and more acute in its
development than usual. Again, in the cnui^e of an ordinary ease of rha-
chitis acute sympt<iras may arise. But cases j>resenting the symptoms to
be descriljed under the heading of scorbutus should not be considered neces-
sarily as acute tbrms of rliachitis on account of the severity of the symp-
toms, but for tlie present should be classed as scorbutus sujierva^ning on
rhaehitis.
SfJORBUTUS (Scurvy), — Scorbutus is a constitutional disease closely as-
sociated with imperfect nutritiou and having a definite relation to the
deprivation of tlie individual from fresh ftxKL It is characterized by
anaemia and a tendency to hcniorrhage, and in most cases is accompanied
by tfie c<->Ddition of the gums which is present in stomatitis ulcerosa.
EtioijOGY, — In addition to the view that the cause of scorbuttis is
of chemical origin, o\dng to the significant relation which tlie di8ea.sc has
to a lack of fresh f<j»od, it Ls supposed that there may be a special micro-
organism which causes the disease. This, however, has not been proved,
and we have no further knowledge r^;arding tlie etiologj' of scorbutus,
PATiior.fMiY, — So few jK>st- mortem examinations have as yet been miide
ou infants dying of sct)rbutus that the imtliologit^l legions have not been
finally established. A sufficient number of autopsies, however, has been
rejK>rted by Barhiw and uthers, notably Northrup, to settle at least the more
imporUmt leatures in the i>atholog;>' of infantile >corbatu9.
There are no alterations in the blot>d» eitlier anatomical, chemical, or
hacteriologieal, which can Ix* considered [peculiar to ^"orbutns. There are
deep hemorrhages into the mnstdes and occasionally aliout or even into the
jointa, but the hemorrhage in infantile sc^orbutiis is essentially subjKTicjstcal
and chiefly of the long bones. The femora are most commonly affe<:*te<i,
and tlicre is a tendency to s<.*paration of the epiphyses. There miiy also
be a varying aniniiut of interstitial hemorrhagic in the lungs^ sphx'u,
kidney, and intestinal glands- Hemorrhages into the mucous surfacefl are
usually present, tlie gums being chiefly affc^titl and presenting the condition
of stomatitis ulcerosa, which I liave dcscrilxxl in a previous lecture ([)age
781).
By permission of Dr. Northrop, I have had a section made of tlie bonea
of the h^ of an infant (Case 518, Fig* 151, facing page 1074) who died of
Boorbutns, under his tare.
UNCLASRIFtED DISEASES.
1077
I
I
' TTiese swellings are most eoranion and most prominent in the Icj^, but
may also appt^ir in the bone^ of the turcarm. They are usually pyriibrm
and symmetrical in shajie, the skin over the swelling being more or leas
tense, but not fiuctuatiiijr. There is commonly some tetidernesH on pn^snure,
but, as a rule, no especial heat of tlie atfeetetl part. The pain and .swelling
do not seem to be in the joint, but in the diaphysis and ei>iphysis. Signs
of hemorrhage may oeeur in the skin over the affected parte, apjiearing at
first as small blue raaenhe and later involving larger areas, as though a
deep hemorrhage were coming to the surliiee. In advanctni teases hemor-
rhage may take place to such an extent in the deei>er partcS an*und the eyes
that the eyes will be pUi^hetl forwaixl {proptosi^).
Where the infant ha.s not cut any teeth, the mucous membrane of the
gums, according to my exijerience, has not been aifected ; but where a tooth
is pressing on the gum and is almost through, or even where a 8m all portion
of a tooth has penetrated the gum, small areas of congested muc*>u» mem-
brane appear, and are of great aid in the diagnosis. In some cases a few
hemorrhagic maenlie apjx^ar in other parts of the skin, as of the forebeafl.
In addition t4i the sym|)tom8 of epi|>hystiil \nim, the infant kee|>s the
ted limb j>erfe<'tly still, so that, unless it weix? understoo<l that it is pain
which prevents it i'rom moving the limb, it might be sup{>oseil that it \%ns
paralysis : in fact, this symptom in st^vi^rbiitus has been termed psendin
paralysis. It has, of etjurse, nothing to do with true imralysis, and cori'e-
sponds to what is seen in rheumatic affect ions of the joints.
DiAGXasis. — The diagnosis of infantile sct>rl>ntn3 is to be made fn>ni
rheumatism, rhachitis, pnrpnm, syphilis, and spinjJ jiamlysis.
In the diagnosis from rheumatism the absence of heat and tenderness
of the joint and of a pronouncc^l rise of temperature is usually sufficient
to distinguish tlie two diseasL^s.
The diagnosis tVom rhachitis is to be made by the |jresenoe of hera<»r-
rhages, tlie intenst^ |Kain in the rt^gion above the epiphyses, the alisence of a
rhachitie rosary, and the absi^nce of syrapt^ums of rhat^hitis when it is not
coexistent. If teeth are present, tlie occurrtMitx' of stomatitis ulcerosa
usually makes the diagnosis clear. Out of all my eases there have been
only a small nunibt^^r, prhaps a dozen, that have shown any sym|ii»»ms
wliatt^verof rhai'hitis. In thest* eases where rha(*hitis was present tht- ^yml»-
toms of scorbutus appeared to complicate a primary rhachitis, and when tlie
eoorbntie symptoms jitisscd away the rhachitie mauifestiitions remainwh
Purjnini, exempt in the sc*verc lornLs in wiii(*h the joints are aflW'ted, is
easily differentiated by the absence of the peculiar osseous sympti>ms of
scorbutus.
Sot»rbutus is diOerentiated fi-om syphilis by the extreme tenderness, tlie
b€*morrhages, and the nimmonly €>ceurring stomatitis uhH*nisa which <Kx?ur
in the fiu*mer disc^ase, wliile syphilis has distinctive syfnpt4)ms which ar©
not found in sefjrbutus, and which I have already des*rrilHxl (jwigt* 491),
The ditlereudal diagnosis between scorbutus and spinal paralysis is made
1078 PEDIATRICS.
by the presenoe in the former of enlargement and tenderness in the neigh-
borhood of the epiphyses. Pain is present only in the initial stage of spinal
paralysis, and tenderness is absent In spinal paralysis, also, the onset is
sudden, and there are no premonitor}^ symptoms.
Prognosis. — Scorbutus is very variable in its duration. If left un-
treated, all the symptoms may become more pronounced and the infant
finally die of exhaustion. When properly treated, and uncomplicated by
any other disease, the prognosis is very favorable if treatment is begun early
in the attack, before the vitality of the infant has been too much reduced.
Treatment. — The treatment of infantile scorbutus is essentially by
changing the improper food which in most cases is being given, to fresh
milk and orange juice. Under this treatment the pain and tenderness of
the limbs rapidly disappear, sometimes within a few days, as does also
the stomatitis ulcerosa. In the beginning the juice of one orange should
be given in the twenty-four hours. If a rapid improvement does not take
place, a still larger dose should be given within a few days. These scorbutic
infants usually take orange juice with avidity, but they should be forced
to take it if they do not like it The nurse should be cautioned to move
the affected limbs as little as possible, and the in&nt should be kept on a
comfortable pillow on which it can be carried about
In my earlier cases, before I recognized the scorbutic element in the
disease, I treated these infants with a number of drugs, none of which
appeared to have the slightest beneficial effect In some of these cases
the symptoms grew progressively worse, and the infants died. In one of
them, however, where the hemorrhages in the skin were extensive and
where proptosiri was marked, the infant recovered entirely when a properly
mcKlified fresh milk was substituted for the artificial food which it had been
taking. In some of the later eases which I have seen in consultation,
where infants living in the country w4th good hygienic surroundings were
being fed on one of the many artificial foods, the disease had progr^sed to
such an extent that the infants were extremely anaemic, had hemorrhages
in various parts of the skin, were unable to take any food, and were seem-
ingly dying ; in fact, they were as much reduced as were the cases which I
have just spoken of as having terminated fatally. These mfants, after
taking orange juice for a few days, invariably improved rapidly, and usually
recovered entirely in two or three weeks.
In my exi)crieuce there is no evidence that sterilized milk is a cause of
scorbutus. If the milk is properly modified it can be heated to 75° C.
(167° F.), or even to 100° C. (212° F.), without, so far as I am aware,
having a deleterious effect upon the osseous system.
All my cases have presented in different d^rees the symptoms which I
have just described, and which are well represented in this infant whom I
have here to show you to-day.
This infant, a female (Case 620), ten months old, was healthy at birth and weighed
8680 grammes (8 pounds). It was nursed at first, but later was fed on a patent food, on
UKCI^ASSIFIED DISEASES, 1079
which it did not gain. When it wn,^ eight mi^nths old it tost lomewhtt in weight, had pixv
fuse sweating, and began to have tiMidernesa in iUt timbs. It has six U*Hh. <Jn ]^H)kirig at
the infant you 8(?o un expresaion of fear on its face, and al«o that it keep its arraa and legg
perfectly iDotitrmlesa.
Case 520.
I.
InfiuilUe Boorbutiia. (Second month of diraej Femnle, 10 months uM.
Whenever it thinks that I am about to Umch the legs or the anns it oriefi with fear.
There is no evidence of rlmehitig in tbia intani. You see thul then? u a swelling of the
diaphyfiis just above th*3 epipbysis of the bones of the right wrist, and also in the lower part
of the femur of each leg and the lt>wer part of the tibia. The swelling does not fluctuate,
has a iiatd, tense fei^Ung^ and appurenlly k not connected with the joints. Th*'n* i« no
increased heat of the ^kin^ but then? are certain circunij^cribed area« of hemorrhage in the
sidn over the swellinga. The gums show the condition of stomatitis ulcerosa to m mnrki.'d
a degree that they almost cover the teeth. They are purple, bleed eaaily, and are very
limilar to those seen in the case of »corbuius which I showed you at an earlier lecture
(Piute YML, Scorbutus, facing page 781).
Infuuiile scorbutus. <Oue mouth After treaUnenU) F«mAle, 10 mouthi old.
(Subsequent hisUiry.) The infant's diet waa changisl to a modified milk^ and it waa
given the juice of one orange daily. Within two days it mfived it« legii and ami» (Viy^ly,
the anxious expression left its face, and in a few weeks it bad gained much in weight and
VM perfectly well (11).
There was no evidence of rhachitis.
An examinatioD of the blood in this csase gave the following result :
1080 PEDIATRIOB.
BLOOD EXAMINATION 88.
Red corpuscles 4,485,000
HsBmoglobin 85 per cent.
White corpuscles !
Small mononuclear 8 '*
Laige mononuclear 44 *'
Polynuclear leucocytes 67 "
Eosinophiles 1 *'
The blood examinations in two other cases gave the following results :
BLOOD EXAMINATION 89.
Red corpuscles 4,660,000
Hsemoglobin 45 per cent.
White corpuscles :
Small mononuclear 5 '*
Large mononuclear 78 **
Polynuclear leucocytes 22 **
BLOOD EXAMINATION 40.
Red corpuscles 4,602,500
Heemoglobin (not obtained)
White corpuscles :
Small mononuclear 10 per cent.
Large mononuclear 68 *'
Polynuclear leucocytes 21 "
Eosinophiles 2 "
RHEUMATISM. — Rheumatism is a non-contagious febrile disease, when
affecting children usually subacute, and characterized by pain sometimes in
the joints and sometimes in the nuiscles.
Etiology. — The cause of rheumatism is not known, although that the
disease is incited by ex|X)sure to cold and dampness is evident. It is pos-
sible that it is microbic in its origin, this view being strongly supported by
the intimate relation Ix^tween rheumatism and endocarditis, since the latter
disease has been proved to be of bacterial origin. Acute articular rheuma-
tism is rare in early life, though it may occur at any age. Subacute attacks
of rheumatism, characterized by pains in various parts of the body and
limbs and a moderate heightening of the temperature, are very common in
childhood. The more severe forms of rheumatism whic;h occur in adults,
such as arthritis deformans, are very rare in children. The chronic form
of rheumatism is also rare in early life. The chief characteristics of rheu-
matism in young children are that often it does not involve the joints, and
that tlie milder forms of the disease are much more apt to be complicated
by endocarditis than is the c^ase in adult life.
Pathology. — There are no lesions which esi^ecially characterize the
pathology of rheumatism. The lesions which occur in the course of the
disease are those of other diseases, such as endocarditis or {)ericarditLs, which
so frequently complicate it. Small subcutaneous fibrous tumors at times
appear during an attack of rheumatism, especially in children, and may be
UNCLASSIFIED DIBEA8EB.
1081
I
I
N
found in any jvart of the body or limbs. They seem to be closely conoected
with rheumatkin, and the easels in which they oct'ur are frequeoitly a?i3<K'iated
with endocarditis.
SvMFroMS. — The symptoms of rheumatism when unec^m plicated vary
according a^* the disease i.s the aeute articular form or hx^ally atltH^s the mus-
cles of various parts of the body, such as the neck (torticollb) ; sometimes
the disease is simply represented by indefinite pains, which may last for a
number of days and then disappear to recur at a later period. The symp-
toms are, as a rule, not so severe as in later life, even when the joints are
affected, and in the few eases of articular rheumatism in children which liave
come under my eare the suffering has been very slight iu aimparlsou with
wliat is experienced in adults. In the acute aiticular form tliei*e are swell-
ing, tenderness^ and i*ediie«s of one or more joints, aeconipajiied by a height-
ened temperature and loss of appetite, A very t*ommon acoom]>aniineut
of rheumatism is amemia. The disease runs a varying course of three to
six weeks, unless complicated by some other disease. The most common
complicatiims are endocaniitis and [K^ricanlitis, and when tliese diseases ap-
pear the sym|)tom8 of these t^jmpl legations bet-ome pn^minent. In S4jme
cases the endoeartlitis may appear Ijefore the develo[iment of the rheumatic
qrmptoms«
PRtXJNOi^is. — The prognosis of rheumatism in children is very favorable,
unless complications arise, in which case it depends nj>on the severity of
the comiilication.
Treatment. — rtheumatisni iu the articular form is a s<'lf-liinit€*d <lis-
ease, and the treatment is purely syiuptomatic* The child should be kept
in Ixd in a n.)om of an t^iuablc tcmjuTature, 20^ to 21.1° C. (68° to 70**
F.). The atVei'ttxl joints should be* wrapficd in cotton wooL No applica-
tions to the joints are, as a rule, indicatiAl. Vlw the alleviation of tlie pain
salicylate of sodium in mtKleratc dost^ aci-ording to the age of the cliild is
valuable ; but there is uo drug which is in any sc»nst* curative of rheumar
tisra, and salicylate ot* s^nlium has not bccu found to lessen the frequency
of eanliac complicaiii>us. The oil of gaultberium can also be uscti, and hns
about the same cfliciicy as salicylate of sixlium. Opiates are seldom needed.
A careful pliysical examination should l>e made every day in thf*ie cast^ of
rheumatism, in order to detect the cardiac complications which are m likely
to arise. During the acute stage uf the attm^k tlie diet should Ix* hi'oths and
milk. A numlwr of ciireful ol)servers l)elicve that an alkali, such as riti*ate
of potassium, sluudd Ite given in (conjunction with the .salicylat*^ of s*>dium.
I have some cases here in the wards which illustrate the different forms
of rheumatism in children.
Hen? is a boy (CiL«e 621, pflg^e 1082), throe yemn ftod four mmitbs old, who h«t 1
trQ4tted in the ho«ptLiL] for bronchitis, And when h« wn* ociovmldicent from IbaX dbwur wi#
ftiUeki'd with acute articulur rheum Mtism*
There b nn rhi>umatic hliton* in hi£ family, nnd hi hns ncyer hud rhimTTUitHm normajf
other diaeaie eicept the bronchitis for which he w»* iidmltied U* the bmpital AtWr 1
UNCLASSIFIED DISEASES.
1083
This next child, u girl {Cuae 522), five and one-lmlf ve&re old, k interectitig bb Ulus*
imtiog II number of chftmc-teHittcs in connection witb tfae rhi^umatisDi of childreiK
CHART ^
19.
Days of DiM'aae,
F-
4
5
6|T
Sh:>
10
11
1 2 1 1 3
1'*
15
16
c.
107*
106
i05*
M E
U E
M ElM E
M t
M E
M E
U E
M £
M E
M &
M E
M E
41 rf
41 1*
1
40 5*
tOi"
E
40.0'
39 4'
103
102
101
10(f
'5
i
i
9
I
9
38 ST
IV
38.3'
37 7"
37.7
\
l>
/
>
^
X
^
J
OT o'
1^^'
/
■^
n::;;;;-!!
r
r
1^ ' ^.
88
©7
am
|36,6
36 1
36 5*
9b
35.tf
l&O
140
130
120
i
\
J
k
llO
100
eo
60
70
60
3^
J
J
Y
/
h
1
J
/
^
/
/
--^
50
1
45
40
35
ao
25
k
J
\
^
\
/
/
v"
^
kl
^
/
20
r
^
15
10
Acute AitScutar rticunmttniL Acute endocArdltiB on aevcotli dAy ftcHo. IwnlfiiLlnyc of lUtAcfe.
Sh<^ ^fifl MttJt<"kHl ol^lit dftys ap^ with (min, AwriUiniG;^ and t<»ndom««<M» \r\ \s^x l**fl ankli^«
On entering tbo hospital ht?r iemperaturu Wii* 40^ C, (104** F,)^ ht*r pulw? ira» 1I6» and bi»t
1084
I'KMIATRIOB.
I
n'iipiPHti«m8 were 40. Th<?rB wns verr (»l*|:^lit jmiti iti the joim^t ^^^^ althou^
was lcse4.Mit?d, 8h6 otiierwiM teemed wi^H^ tiiid ^be has noi coinpluined of any pain since t
b45pi fining of tiu* iitlML'k. On the sixth day the temperutvjni fell to 37,2^ C. (9ii** F.).
hii* btwti intepe.«iing to nott^ tlit* extreme latency of the dUejise^ and hnw the child
fieemed to be perfectly c<jnifortjible (nnn the )i«giiitiin|j: of the att^ick, except when
atiklefiT both of which ure swollen and tender, were t*«uehed YebU-rday» the i«?vefilh i
tit the diM?ll^e, the tenipefature ro»e tc* ltt5.6** C* (10L6** F.), and an eitami nation of i
chest hhowed a xnitml syst^jlic murmur. To-day tho murmur is more nutrked, andi
transmitted to the ajjilli* and the hack. Tho area of absolute cnrdtnc dulneid U ftlighlj
ineretuied, and extends to the middle of the eternum.
(Subsequent history.) By the end of the ^leond week of the iitta<*k tho pain
teiiderneiLH had left the JinkU*s. itnd the child seemi*d cjuite well. The area of absolute dlj
ne*A wag found t" be n^frtiiHl, but the ^y-ntolie nmritiur ^tiM nmtinu»xl
The L'htirt ((^Imrt 49^ pwp? 1083) t^ht>ws the rheumutitfm gradually ffub&idltig up to 1
seventh day of the di!*c*B*e, when the endocarditis arose as a coDiplieatiou.
I have here a boy i^Case 628) who during «n attack of rhemnatism developed the tu
leciuit fibrous nc»dub'@ which I have just described.
Cauk 523.
Rheumatism, 8ul>outaneous fibrous nodulen
When he was seven years old he bud tin itttack of rheumatism affecting his ankle* and
the muscles t^f his neck, Bh tempeniture was 37.2*> C {9^° P) ; bis urine was normab
During this attack a systolic souffle tnintiraitted to the axilla developed, and the area ^
Case 524.
Acule rheiinmiwj torticollis. HUlh 1
tftjj ttiUi^k, Kt'ioreTy, Mnle^ & yvan olti,
UNCLASaiFt£D 0t8£A8ES,
1085
I
ftbsolitte cardiac dulneaa wna inorojL&ed. Thi« attack liiatcd eight daja. He b now thirteen
ytttis old^ and ever since his rheumatic attack, six years ago* be has had iiu»re or Igh
dyspnoea on exertion^ and at times cardiac pain^ but he biu; never had an^^ marked return
of the rheumfttiFm. He has lately noticed these small lumps appearing under hU skin.
When they were first noticed ho had indefinite pains in his limbic, iM?vere headache^ and
malaiae. Some of the lunipii arc slightly tender. You ^ee that they are on the di^tf arms,
nbdonusn, and legs, mostly on thi- unterior surface.
I have here ao interesting case of the acute localized form of rhetitiuiti^jm
which sometimes occurs in children,
Thif boy (Case 524, facing page 1084) is five yean old. Since ho wa« throe y«^n oM
be haA been »uhje(.-t to atUioka of loHiGolWhy apparently of rheumatic orlgirh Five dayt a<o
bewai hmui^ht intf* the liospiiiil in one of tbeiie attnok^. His tetnpiTature \a soiriowloil
raised, and he has a slight loss of up^yetite^ but i»therwiM' Iw U jx^rfe<^!tly well, and hv ihw&
not suffvr any pain ♦■xet-pt wIk-o hi34 n<'ck is touehfMl. The \wm\, as you ff?*', is drawn rigidly
back. Thest* paroxystnal uttiu'k* Uriually hii^t two *jr Ibrti' duys, when they paw off » •ud-
denty as Ihey came. The likst attack whirh ho had wai' on** year ago.
(Subsequent histi^ry.) On the following day the stillhess and the pain in the neck
passed olT, and the head resumed its normal position.
Various drugs have been given in these attacksi but none with any especial beuefli
except salicylate of »odium, which ^eems to control the pain,
I have also had under my care a little boy (Case &25), about four yean of age, who
was attacked with fever, pain in the region of the epine^ and spasm along the entire length
of the spinal column. Thcrt; was no pain or tenderness anywhere except over the vciv
tebral cnlumnT and these symptoina were not so marked in the cervical region a» hiwer
down. The child had m* mental disturbance, but for a number of days was in a condition
of continued opisthotonos from the hips upward, and be had to be kept in a reclining chair
with pillows under his arched back. The normal functions of the bladder and intestine
wer^ not interfered with. The pulse was quick, the temperature was moderately raised,
and the respirations were normal. The appetite was lesaened.
He remained in this condition for about a week^ when the spasm of the back be^an to
disappear. The musclm^ relaxed tor a short time and then stifieued again. Finally com-
plete relaxation took plac**, and the child recovered entirely.
The attack was acute in its onc^ett and did not follow any injury. Tlie treatment was
with bromide of poiiissiiurn, 0,3 gramme (5 grains) three or four times in the twenty-four
hours.
It seems to me that thii^ case can be classed as one of spasmodic rheumatism.
^
Although acute artinilar rheumntisiu is rare in infancy, I have met
with a number of casej^ at this early jxTitaJ of life.
I have already referred to the little girl (Case 41, page 127)» two yvturs
old, who, after exposure, wa^^ attacked with acute rheumatism in hoth hj[i»
joints.
I have also met with a case of general acute rheumatism attacking all the Joints, in an
infant (Case 520) two weekj^ old, after expo&un^ to a cold draught while being bathed. Any
movement of thej^int* caui*ed the infant to *ert?am. He lost rapidly in weight, hi* aurfaot
elreiilation was disturbed, and the attack la^t**d for four UKinths; but when he was aix
months old he was perfectly well, and no cardiac complication developed during the attack.
Another case of this kind was an infant (Case 627) who was attacked with general
acute rheumati&m when she was seven months old, the attack luning until »he was flfteea
nionthii old, when she nfixiTered without any cardiac cuiiiplication» and who is a well, stn>0|[
ohild to-day.
UNCLASSIFIED DISEASES.
1087
I
there were smaller ecchymoses all over tbe rest of the trunk. Oo poet-znortem examinatioa
nothing ubnorrtial was found except a slight atelectasis of the lower lobefl of both langs^
with pieurilic adhesion f^ at the base of the rig:ht lung and slight granular dcgeDemllon of
the heart, liver, and kidneySt with hyperpliuia of the meflenleric lympb-g lands.
In the simple forms of ptir|>iira the disease in children is often mild, and
18 aooompaoitNl bv a loss of appetite, slight anfemia, a slight degree of fever,
and the apiK^anmc** of f>et<L*ehiLe in various parts of the skin. The pmgnosis
IB good, and tlie i In rat ion of tht^^ attik'ks in iLsiially from one to two weekri.
They are at times ass<K'iattM^l with paitis located in varions places. It is po«*-
gible for purpura to dc%'clop iu the course of a rheumatic attack of great
severity or where the hiikut's vitality is much reduced, just as it might
appear in any proHt rating discn^^e.
The form which has been called purpura rheumaOcn fpeliosis rheu-
matic *a ; Schoulcin's dint^ast^) probably has no connection witli rhcnmatiHin
l)evond the iHKSsibility of tlicir iK^th l)cing microl>ir% and nicTcly sinmUitea
rheumatic arthritis from the fact that it affects the joints. The diagnosis is
made by the characteristic a^^K'iation of multifile arthritis with [lurpura
and urtiuaria. CIos€*ly sinuilatiug and probably representing purpura
rheumatic-a, except that the gastroenteric symptoms are more prtmiinent,
is a fi>rni wliii-h lia,s l:>een called Hnioeh^ft purpura. It <xvurs esi)ecially in
children !)€'tween the age>5 of tliret^ and nine years. Its diixn^t cause is not
known, although it nsnally occurs among children who have bail hygienic
surroundings and have been ill cared for.
The symptoms are nioif or less malaise, and pains not especially hw-al-
ized, but chietly occurring in the extremities and back, s<;»metinies a^xvini'
panied by slight a?dema of the part aftected. These early symptoms of
pain occur in one or more joints, usually on the outer sides, and sctmctimes
there are swelling and rfJness simulating articular rheumatism. In tliis
stage there may be a sudden rise of teraperature. Acx»m|ianying tht'se
gymptoms there may Ik? a few purjiuric s[xits, but, a*? a rule, there is a peri<Kl
of several days between the apj-vcarance of the pains in the joints and the
purpuric apjx^arances on tlic skin. The purpuric S[x>ts may c<mk*siv, and
thus form et*i'hym*)se8 of various sizes and of various colors. They are
very apt to Ix^gin <jn the lower leg and spread up to the thiglis, genitals,
atid bxly, S^^mewhat later intestinal symptoms develop* While the
purpura is spreading there is severe colic, and the pain is very intnictalde
to treatment. The alKlumen is retracted and tender. Then* U <»bstinnte
vomiting. Tlic puls^ is weak, and the face has an auxiou> • \|»ns>irn>.
There is more or le^s diarrha^a, which usually occurs at tlic rud oi an
attiit'k of colic. The ctilic and vomiting sometimes last for one <>i
days. There may be a little bIrH>d in the vomitus and in the movcrn
The vomiting then diminishc^s, the colic cn-a^iit^, and later the disu*rhfT«
stop^ the pain in the joints passes away, the purjiuric »pots grachmlly fade
and disapfiear, and the child, although left in an exhausted eouditiou, ia
otherwise well.
UNCLA8SIFIKD DISEASES.
1089
^
»
m adults* A voratvif»im a|>jx*titi% tiuirktxl thirst, pmgressive ansemia, and
gometimes emaciation, witli the pa.^sage of large quantities of urioe of a
high specific gravitj' and coottiining from five to ten per ceat of sugar^ are
commonly pi-esent. Owing to the irritation from the urine, ineontinenoe is
quite fret[ueut.
The pnignosiB is unfavorable, though eases of recovery have been
reported. The duration of tlie disease varies from a few daya to a number
of months and even years.
The treatment is to retluoe the amount of sugar and starch in the food
BB much aiJ possible. The diet which is most beneficial is milk. I have
not found that there is any esf^ecial drug wliich is aseful in the treatment
of diabetes mellitiis. Oxleia, from 0.003 t4j 0.01 gmmme (^ to i grain)
three times daily, has been thought to be useful in reducing the amount
of sugar in the urine.
I have met with cases in whicli there was a transient appearance of
sugar in the urine in such diseases as nephritis following scarlet fever. In
thei!»e instances the sugar disapjx'ared from the urine as the disease in which
it occurred impmvcd.
DIABETES INSIPID XJS,^ — Diabetes insipidus is a disease characterized
by the passage of large quantities of urine having a low specific gravity and
not containing sugar or other abnormal elements.
The etiology and origin of this aUk-tion are not known. It is a very
rare disease, but is more common in early life than diabetes mellitus^ and has
been known to be congenital.
Intense thirst, a dry skin, disturbance of the surface circulation^ and
general nervous 8ympti>ms are common in this disease. The children are
not apt to show the emaciation which ixx^urs in diabetes mellitus,
Dial)etes insipidus is essentially chronic, and so few post-mortem ex-
aminations have been made of children dying with this disease that our
knowledge concerning it is very limitetl. There are no drugs which ap-
pear to be of benefit in its treatment. The essential part of the treatment
IS to protect I he child from exposure and to see that it is warmly dressed,
as sudden changes fi-om heat to cold are liable to increase the general
symptoms.
Death usually results from some intercurrent affection. Spontaneous
oures have been known to occur.
TUBERCULOSIS, — TubeiTulosk is a very prevalent affection in early
life. While, ac^Yirding to Osier, it is ver)' rare in the new-born, and
uncommon in the first three months of life, after this age the number of
cases increases very rapidly, und it is very common in the latter part of tlie
first year and in the second year.
It is now supposed that tuberculcx^Ls is hereditary in the sense that the
infant inherits tissues whicli arc favorable to the development of the dis-
ease, except in the rare luscs where direct iutra-uterine infection ha*? taken
place.
e9
"feNCLABSIFlED DISEASES,
1091
Anatoznioal Diagnosis,
Miliary tubiTcuIifMis of the pleura, spleen, kidney, and liver.
Chronic tuhi^rculosig of the bronchial lymph-glandfi and of the lun^.
Brunchu pneumonia.
Here is an infant (Case 531 ), gne and one-half yeam old, who was brought to the
iital a few days ago to be treated for an attack of brunebitii^. On entrunca it wa.^ much
naoiated) and it has since been rapidly failing. 1 am able to Mnd no marked ftigns beyond
Cask 581.
GtsneraJ tubtirculoeia Altiltlpl^ abecen, Inf&nt, l}^ years old.
cute bronchitis. There U &t times a alight cough, the temperature Is moderately
failed and of an irregulur typCf and I euspect that the disease it one of the latent forms of
general tuberculo^k witb a tuberculiir bruncho>pneumonia. On examining the cbtst, back,
and legfet eMpeclally the buttocks^ you will notice Ibut there are numer^^ua 6utx:utaneouA
absoeft&es of variouf si^e^ and there are also a few on the head. Theae absceuec are prob-
ably of a tuberculous nature, and a provisional diag-
Qoeis of general tuberculogis^ with involvement of CHART 50.
the skin and the subcutaneous tissues, can be ma/de,
(Subsequent history,) The temperature in tliifi
bliad been of an irregular type^ and notefipeeially
until five days before the infant di"^!, when
H "befi^n to lisei and is as represented in this chart
(Chart 60).
The pfjst-mortem <^xami nation, made by Dr.
Malb^ry, sihowed thut tbere was chronic tubereulosis
of the bronchial gknds^ with acute miliary tulnT-
ctilosis of the pleural hmgs, spleen, kidneyii^ liver,
and meninges of the brain.
In addition to general tulierculosis, there
an? certain lot^iilized fornix of tlie diiscase.
The mt)i^ inijx)itant of these I have already
spoken of, but I have here a hoy (Case 532,
page 1092), nine yearn old, who, when three
years old, had a loralizod tnlx^rculosie of
the little fingcT (tubercular dactylitis) of his
left hand, whidi has recovered entirely.
I have had him brought here t** show
you how coraplekly tliesc hx^aliztxl foriDs of tuberenlosis may reoover, and
I shall call your attention to the cases of tubercular and syphilitic dactylitis
whirh I showed you in a previous lecture (pages 602, 509).
Tlie onlv ritfuT ira(x>rtant form of tubereulodid which I bavt* no! y^
Acute miliary tub«nni)oda
ITNCLASSIPIED DISEASES.
1093
as in adults, are at times quite serioiis, es|)ecially if contimiotis vomiting
occuiB, Severe headaolie and delirinin aii* pi'esent in some i^asas, and ex-
treme emaciation, out of prt^portion to the fever or to the morbid oonditions
detectable on physical examination. Severe symptoms connected with the
larynx and the lungs may also ari^e and ra]>idly disappear.
DiAGNQSLS. — The diagnosis of epidemic influenza h often difficult, un*
less influenza is present in the eomm unity , and is to l:)e made hy the careful
elimination of other diseases.
PBOGNasis. — The disease in itself is not dangerous, but complications
are especially liable to arise and make the prognosis much more serious.
These complications are very numerous. They may be meningitis, otitis,
ileo-oolitis, broncho-pneumonia, and lobar pneumonia. The most common
and dangerous complicvation of influenza is pneumonia, which is usually a
broncho-pneumonia, and is of serious import, especially if the child is de-
bilitated at tlie rime of tiie attack by rtfjmc previous disease.
Treatment. — In the treatment of epidemic influenza in infants and
children I have ibimd that drugs ha%'e very little eB'ect upon the general
discomfort caused by the pain. Small df>ses of phenaeetine, 0*06 gramme
(1 grain) ouoe in thi'ee or four hours, with teu or fltWn drojie of brandy,
seem to yield as good results as any other mode of treatment. Where there
is severe and i."ontinuons vomiting, small doses of itxHl champagne by the
mouth and enemata of bromide of potassium, and, if ne«x\ssary, hydrate of
chloral, are indicated. The diet should be milk and l>eef tea.
During the epidemic of influenza whicli ix'curred in Boston in 1891 I
had under my care at the Infants* Hospital seven infants, varying in age
from a few months to one and a half years, all of whom had epidemic in-
fluenza. The symptoms were such as I have described. The infanti^ cried
continuously, the temperature was slightly i-aised, 37.7° to 38.3° C. (100°
to 101° F.), and the duration of the attJiek wii.^ al30Ut one week. Pneu-
monia occurix?d in two of the cases, aud in Ijotli of tliese the infants died.
Here are the charts (Charts 51 and f52, |iage 1004) showing the tera[H^rature
in these cases during the cxairse of the influenza, and the rise when the
infants were attacked with pneumonia,
I have in my notes the report of another case, when^ an attack of in-
fluenza was complimtetl im the eleventh day of the disease by a lobar
pneumonia.
The infiitit (Cti£e 533), sixteen months old, wa^ atUcked with CKtarrliA] ijaiptotiu of
Ifae ncwe and thrjat, fi t^Iiju^ht eom^b, and ii tempenturt? of 40,b^ C (106° F.). The mpim*
tlona were only i^lightly increased ; the pulse was rapid. Nothing abnonnft] iraa found on
physical examination* The infant was very fretful, had no appetite, cried inceaaatitlj, and
aeeroed to have considerable discomfort- On the ninth day fr*>m the on*et of i\w attack
the temperature fell to 89.1° C. (li)2,6° F-), and on the following day lo 38.6° C. (101-6*
F.). On the evening of thi^ day the infant, who had be«run to be brighter and to notice
Itf playthingSi again »eemed very Melt. Its respirutionft incfeaaed in fraqueocy, thQn» wia
motion of the alto nasi, and the tempemture To$e to 40, S° C* (106.4° F.), On the fullow-
Ifig day the temperature fell In the mornings hut began to Hm in the eveningi and by iht
UKCLASSIFIED DIBfiMn
10JI5
(102* F.) ; on the following day it roee u> 39.7° C. (103.5® F.) in th« evenings and in the
next two days jErradually fell to 87.2° C. (99° F,)- On tho following day it roee to 38.6® C.
(10L5'' F.), and in lh« next forty-eigbt houre fell gniduaUy to 36.6° C. (98° F.). At tUU
time the* dulneee begun to disappear, moist niles Ap\¥*tirtd^ the infant became much better,
and ill a few days, altbuugh very weak, seemed bright and well, and the physical sign^ in
the Iting had entirt'ly d]i^appeilred.
Here Is the cbtirt ( Chart 53) ^ which shows the temperature during ton days of the
influenza, when a lobar pneumonia appeared and ran a course of five days, after which
the temperature gradually fell to the normal point. It ia possible that this caae waa one of
pneumonia from the beginning of the attaek, but it showed ail tlie characteristic symptoms
of epidemic influenza, and no dulnefts wa^ found in the lung until the infant had appiarently
recovered firom its intluenza.
DISEASES OF THE THTEOID GLAND.— The tljyroid glaiul is
a highly va^iilar organ. It njver^ tlie froot and Ades of tin? upiK^r jwirt
of the trachea, and also exteodri up onto the hiryux. Its fiinctiuii Is not
koown, I shall not dejicribe such diseases of the thymid gland as exoph-
thahiiie goitre, which are very rare in early life, but shall refer only to
those morbid c<Joditi(ms which you are mo.^t likely to meet with, — najiiely,
hyperemia, inflammation, hypertropliy, and complete absence, Absetiee of
tlie tliyroid gland, disturbance of itjs function, or actual disea^ of it« tigsues,
are usually accompauiKl by peculiar symptoms,
Hyper.^mia. — A temiK>rary c^mgestioD of the rich vascular tissue of
Uie thyrfjid glaud occurs under varioits conditioD.s, sucli as the approach of
pul)erty. Thi.s amditiou Is u.sually m transient as to lie soarctdy noticeable
so far as the symptoms are (xmcerucHl, but st>metinies it is sufficient to cau^
dyspncea from pressure. This usually trivial ecmdition has been thought,
however, in certain cases to lead to the pnxluctiou of one of tlie forms of
goitre*
C^E 534.
Bjperaemia of the thyroid gland. F^emaio, 19 ymn old.
Tbi* pirl (Ca*e 584), thirteen yean old, was firet noticed to have a swelling of the thy-
roid gland two or thr^e w^ki a$o. The iwelhng ia bec«>mIog more j»rainJii«nt, The cat*-
tJNCLASSIFIED DISEASES*
1097
Th(^^ various disturbances of the thvroid fiinction may be endemic or
sporadic. The eiKleiuic eases are repi*esented for the unmt part by syniiv
toQis i>eciiliar to disturljaoee of the thyroid futietioo, and also, where goitre
is present, by &ymptnnis of mec4ianir*al pressure. Cases of p litre without ere*
tiQism may, however, fx^cur sporadit^ally, and the spuratlie en?tin, as a rule,
has no goitre. Atrophy of the thyroid gland may or may not Ix? aecom-
panicTl by goitre. I shall not sjK^ak further eoucennng endemic cretinism,
whicli octnii^s in certain localities, such as pjrtiuns of Switzerland, and is de-
pendent ap(»arently on scjme unknown endemic cause which is also liable to
proihice goitre. As a race, cretins are distinguished by their atuntc<l stature,
lai'ge, deformed heads, sickly-tookmg eoimtenant^es, coarse and prominent
lips and eyelids, uTinkhxl and ^lendalous skiu, l(-M>se and flabby muscles,
and imiierfect mental development, to whicli are often added goitres of all
sizes.
In certain individuals there is a congenital absence of tlie thyroid gland.
This is a conditi<m found in gjxjrfidic cretinism, in whicli the function of
the thyroid gland is lost, just as its function is disturbed in goitre and in
atrophy of the gland,
Whei^ the thyroid gland has bet*n removed surgically tliere is at times a
condition similar to that which is met with in myx(Edema* This condition
has been calk*d by Ilorslcy caq/uwla ^frtuRipriva,
The head in sporadic ci^etinism Is usually brachyeephalic; Uiat is, it is
contracted in its antero-posterior diameter and increased in its transverse
diameter. Virchow was the first to observe that in these cases there is a
premature ossification of the sphcno-lMsilar b<3ne. The sphenoid and the
basi-occipital bones should remain separate until about the fifteenth year,
and their early ossifi^ition explains, according to Virchow, the changes
which take place in tlie form of the cretin skull and face. The character-
istics of the cretin bone are ao enormous overgrowth of cartilage, an arrest
of growth at the distal ends of the bones, and a premature assification of
the shaft. Here is die tibia (Fig. 148, II., page I0<3*i)of a cretin child.
The section was made by Dr. Whitney, and is distinguished, as you see,
anatomically by tlie almost entiiT absence of the zone of pmliferation.
This narrow line (Z. P.) marks thv boundary l>etween the bn.*ad area of
cartilage above aud the pn^maturcly ossific*! bone of the sliatl below.
This little girl (Ciiae 685, page 1098), whom I have had brought to the hoftpiul to *how
jou, mnd who is just able to stand, and kK>lci oa though ahc wofe about one aod a half
jean old} fleems to be a ca»e of myxtfidema.
She is five and a half years old. Her parentB were healthy AtnericaiifL, not hlcod
relations^ and did not biivo g'oitre. She was bom after a severe labor: it wa« a bead
presentation, and no instrument}^ were uited« Nothing especially abnormal wma noticed
about her until the twelfth month, when she did not seem no briicht as Is umibI at that age.
When four years old she was bnm^ht to the hoepitaL She could not f j»<»ak^ and her
mental condition wa& much enfeebled. She had never had any conrtiUions, but had always
had incontinence of urine and of Oeces. When seen a year later she appeared to be in
good goneml condition, but her musics wens largo and flabby and »he had not impfOT«d
mentally. The circumtereuce of her head u 46.6 cm. (18) im?hes). The
UNCLASSIFIED DISEASES.
1099
I have under my core a little girl (Cast? 53*1), iw<» y^ars old, who appenred to he per-
fectly well and *trc»ng during her first yeur, hut did not leArn to sit or creep until iho liiit
few muoths, und who cannot atand alone or walk. There are no Mgns of rhachitiB ulK>ut tlie
child, except that the afiterior foiilanelk* is not ck»s*?d. Nothing abnormal U found <*ti
physical examination^ except that the ti:^£ue,s of the hands and feet are thickened mid the
skin is dry and cold, with at tiiuc^ a bluish tint. Shi* has nlwiiya held her mouth open and
pr«)truded her tongue^ which scorns to be thicker than normal She is phlegnmticf and d(.>e^
not care to play. The bowels are constipated. There is ni> enhirgement of the thyroid.
Her case seems to be one of myxcedema.
She has been under treatment two months with the extract of the thymui gland.
During this period she has grown much brighter mentally, and nf>w cn'epa abaut m<iri%
wisbesB to play, and take> more interest than formerly. The ttaigue h not *o much enlarged
as before the treatment wav begun, and the boweU are tio longer constipated. Several timet
during the course of the trcainient the thy mid extract has hud to be omitted, m it H^^med
to cau&e digestive disturbance with a rise of temperature, 87.7** or 88.3° C. (100** or 101*> Fj.
Omitting the thyroid extnict for twenty-four hours^ these aymptoma would pau away, and
It could then be given again.
This case (Cji^e 537) i^ one of great interest^ aa it represents so typically the mental and
physical characteristicii of sporadic cretinism. I am enabled to show it to you through the
courtesy of Professor Northrup, who gives the following account of it:
Cahi fiS7,
MyiOTrteina. Female. ^ years oU\. Slight im^^^>rt>nleat after eli^ty days' tivatxneni with thyroid extract.
' The parent* of the child were h4;althy Americans fri>m WMtftrn P«iiniylvmiiia, and
they were not consanguineous. The father was 46 yean old ; the mothor wia 80 ymn of
age, bad had several miscarriAges and four healthy childrent two of whom had dM of aooM
arnite disease. This little^ giri^ who is now nine ycurs old^ is the fifth child. The moibor
flr«t noticed that the child could not ait up when il was nioft months old^ that it practically
qeaaed to grow, and now at nine years il is miMitAily no older Ihwa H was iit nin** mofitha, aad
physically it hus menlv thickened. The Ur^t itnpreuion one g«to on Imjkini? at the child
UNCLJUSaiFIED DISEASES. 1101
truding, ia fast recsovering ite iic«riiml size. She can wiilk und talk a Httle, and Dr. Oiler
thinks tbat she mAy be considered to ropresent n eHutJ in which the thyroid extract bos pro*
duc€d decided improvement.
Cass 638.
-MyxcBdema. f^emali;, 4 ytius old. Marked improvemeni under thyroid treatmenl
DISEASES OP THE CERVICAL LYMPH-GLANDS.— The chmn
of lymphatic's in the net^k i.s so closely cx>nntN:'t<?d with the lymphatics of the
mouth aiid throat ttiat infection frcNjuently takes place. I have already
spoken of the enlar^ment of the cervical glands seeondary to absorption
m eases of di|>htlieria, Lot3alized enlargement t»f the eervical glands occurs
also in tuberculosis, and sometimes is the only manifestation of that disease.
The eerv'ieal glands may also be enlarged in lymphatic leuciemia and in
multiple sartxima.
Here U a little girl (Case 539, pni;^ 1102) who liaa, in addition to marked chronio
tubercuJusifl of the lunga, enlargement of tbe cenrical glands^ which ii very probably of
tubercular origin*
When tbe tubercular disease if advanced ifi other ciri;atis thei« la aeldom much benaflt
to be derived from the treatment of these gtanda« I show you this case more for tbe
purpose of comparison with some other cases having enlanf^xl cervical glands than fur any-
thing of especial interest in oonnection with this class of advanced tubercular <
The cervical glands may be enlarge] fmm a number of causes, as well
as from direct infection through the throats Any irritation of tbe ^alp,
ears, eyes, nose^ thn>at, gums^ or teeth may cause a temporary or |x>rmaQcat
UNCLABSITIED DIBEABES.
1103
I have here a Utile girl (Cose &40) in whom the cervical Ijinphtttics Are enhirged to
iuch an extent that they have l>ccorae a deformitj.
Nothing eUe abnormal nor any other symptom of tuberculosif cati be dtacoyered about
Cask 640.
Chroale cerrlcil idenitii (aiter tusatment).
the child. These gknd& should have been removed before they reached such a sixe a« thU|
as now on their removal a considerable scar will be left.
(Subsequent history. ) The glands were removed, and the picture fhowi what good
reaulta c&n be obtained In these cases by surgical interference.
Case 541.
Enlaigciiient of submoxiUary ghmda
'The submaxillary glaudB are enlarged id chiWn^n from varioim cauMi^
but s<^)metimes from no discoverable ctiuse^ At times the enlar^meut of
the gland* i^ accompanied by pain and tcndemesSi constituting a dii^eafle
UNCLAB8IFIED DIi5£A8£8.
1105
the neck in tbtt part wliicb corresponds to the position of the parotid i& swollen on both
lides, und how the ciinrftcteriatic nwelling whicli pushes the ear upwurd and forward u
teen on lcx)king at thc^ child from behind.
PiitT>UtL« Mule, 12 yeara old.
There is nr^ espw^ial treatment lor tlie tlLsc^ise, as it is self-Iimited aud
rnns a definite mtirso. The children should be earefully i^olatt^l, in order
that tliQve may U' no further sprwid of tJie infeetion. As de^hitititm la
jMiintnl, their diet is ii.soally milk and soups. They shoidd be t^i'etully
proteeted from exprisiire, and should inj t^jiitiwd to their nioms. Older
ehildren should Ix^ nniliiic^l to bed, as (uvhitia in boys and tmuble with the
mamniie in adnlei^triit ^irls arc less likely to arise under thesc^ rouditions^
It is usually better to apply s^ime sf>ft cotton wool to tlie |»ainful t«vvt4ling,
and to protect it fn*m any irritation*
DISEASES OF THE EAR.— We have, gt^ntlemen, studied the nor-
mal in fail! ut birth, and have t'ollowiil it thrtmirh its various e*tage8 of de-
velopment into (^liildluwKl, up to the age of pulx^rty, 1 have also en-
deavored to make you familiar with the various morlad conditioa'^ whieh
ai*e most likely to arise during thest- early porimJs uf life.
Befoi-e elosing this course of lectiir«?9, liowever, I wish a^in to eall
your atteiitiiiu to the grc*at importanee of bearinj^ in mind, in examintng
infants and t^hildren, the eommon r*eeurrenee of some raorlafl pn>eoss in the
ear. In many nis(*s where tlie more pronounetnl aural symptoms are not
evident, symptoms whieh api)ear tjl»sc*ure, but really are due to Rome latent
disturbann:' in the neiirldHirhiMwl of the ear, reflex or othenvise, are readily
explainetl vvfifU in ailditinn to the prescniee of s«ime i^ther disease^ the un*
QBual symjUoms are found to arise from the aural complication. The ques-
tion of dist*jLses of the ear in infaney and childhrKid has not received
from tlie j;eneml practitioner, nor indecnj from tlio^e who devote themselves
especially to t^iildren^ the attention that it deserves. Even leaving out of
70
INDEX.
Abdomen in the new-bom infant, 44.
of the premature infant, 291.
Abdominal band, 183.
organs, normal development of, 77.
respiration, 72.
Abnormal effects of vaccination, 152.
Abscess, cerebral, 648.
prognosis of, 648.
symptoms of, 648.
treatment of, 648.
peritonsillar, 815.
retro-pharyngeal, 817.
Acarus scabiei, 456.
Acquired disease, definition of, 19.
Acute atrophic spinal paralysis, 682.
catarrhal gastritis, 854.
corrosive gastritis, 856.
coryza, 801.
cystitis, 942.
fatty degeneration of the new-bom,
440.
follicular pharyngitis, 816.
gastric indigestion, 844.
gastritis, 854.
laryngitis, 951.
miliary tuberculosis, 1090.
nephritis, 982.
peritonitis, 920.
rhinitis, 801.
simple pharyngitis, 815.
tonsillitU, 809.
tubercular broncho-pneumonia, 994.
tuberculopiis of the lun^, 998.
yellow atrophy of the liver, 915.
Addison's disease, 940.
Adenitis, cervical, 1108.
Adenoid growths, 806.
Adolescence, urine of, 114.
Air for premature infants, 296.
out-door, 140.
Air-passages, upper, syphilis of the, 490.
Albuminuria, physiological, 927.
Alopecia areata, 461.
treatment of, 462.
Amnesia, temporary, 789.
Amyloid infiltration of the kidney, 988.
liver, 916.
Anaemia chronica gravis, 855.
levis, 855.
infantum pseudo-leuksmica, 859.
progressiva pemiciosa, 856.
rhachitic, 868.
Anaemias, primary, 855.
secondary, 365.
Anatomical points of new-bom in&nt, 26.
Anatomy, surface, of the spine, 68.
topographical, of the early periods of
life, 120.
Anencephalia, 409.
Animal heat of premature infants, 295.
parasites, 908.
Anterior poliomyelitis, 609, 676.
Antitoxin, 829.
method of use, 829.
Anuria, 946.
Anus, fistula of the, 880.
imperforate, 438.
syphilitic condylomata of the, 494.
Aphasia, temporary, 789.
Aphthiu, 774.
Apparatus for feeding, 282.
for fe(.»ding at home, 262.
Appendicitis, 47, 888.
diagnosis nf, 889.
etiology of, 888.
prognosis of, 889.
symptoms of, 888.
treatment of, 800.
Appendix vermiformis, anat(^my and de-
velopment of, 02.
Argyll- RolMTtsoii pupil, 6CK).
Arrestinl psychical development, 740.
Arteries, umbilical, 20.
Arteritis umbilical is, 425.
Arter}', common carotid, 48.
pulmonary, 48, 75.
1107
1108
INDEX.
Arthritis, acute, of infants, 1086.
Artificial foods for infants, 154.
Ascaris lumbricoidcs, 910.
symptoms of, 911.
treatment of, 911.
Ascending colon, normal development, 92.
Asiatic cholera, 887.
Asphyxia, 440.
Asthma, etiology of, 1004.
pathology of, 1005.
pn)gno6is of, 1005.
symptoms of, 1005.
treatment of, 1005.
Ataxia, hereditary, 689.
pathology of, 689.
prognosis of, 689.
symptoms of, 689.
treatment of, 689.
locomotor, 689.
diagnosis of, 689.
pathology of, 689.
Atelectasis, 440, 979.
acquired, 980.
congenital, 979.
Athetosis, CiGI.
diagnosis of, 661.
pathology of, 661.
prognosis of, 661.
treatment of, 661.
Athrepsia, 800.
Atr()})hic rhinitis, 804.
Atrophy, acut«' yellow, of the liver, 915.
infantilt', 809.
blood in, 377.
diagnosis of, 869.
pathology of, 869.
prognosis of, 870.
symptoms of, 869.
treatment of, 870.
myopathic progr<'ssive muscular, 768.
diagnosis of, 765.
pathology of, 764.
prognosis of, 765.
symptoms of, 764.
tn*atmunt of, 765.
neuropathic progressive muscular, 763.
of the intestine, 869.
proi^n'ssive muscular, 763.
Auscultation of the sick child, 822.
Autumnal catarrh, 1005.
Babcock fat-tester, 168.
milk- tester, 249.
Bacillus, diphtheria, 821.
Bacillus, diplococcuB pneumoniaB, 980.
gonococcus of Neisser, 948.
in human milk, 180.
Klebs-Loeffler, 821.
Koch, 887.
lactis aerogenes, 248.
proteus vulgaris, 248.
8tapbyl(»coccus pyogenes, 822.
streptococcus coli gracilis, 118, 248.
streptococcus pyogenes, 585, 822.
tetanus, 452.
tubercle, 485, 994.
typhoid, 901.
Back, care of the, 148.
Bacteriological examination of human milk,
180, 242.
Barley jelly, 282.
water, 281.
Basin as used in bathing the infant, 129.
Bath, temperature of the, 129.
Bathing, 128.
Bed for a child, characters of, 126.
Bednar's aphtha), 781.
Bibliography of the blood, 898.
Bile in the new-born infant, 52.
normal development of the, 111.
Bile-ducts, congenital obliteration of the,
438.
pathology of, 438.
symptoms of, 438.
treatment of, 440.
Bilious attack, 802.
Birth-paralysis, 438.
Bisnmth in the intestine, 839.
Bladder at end of term, 24.
acute cystitis, 942.
chronic cystitis, 942.
diseases of the, 942.
distention of the, 78.
in the new-born infant, 48.
normal development of the, 78.
reflex of the, 752.
Blood, bibliogmphy of the, 898.
chemistry of the, 334.
fcetal, 337.
circulation, 19.
erythrocytes, 838.
leucocytes, 388.
in individual diseases, 370.
broncho-pneumonia, 878.
chorea, 376.
diphtheria, 372.
empyema, 378.
hydri>cej>halus, 375.
icterus neonatorum, 107, 879.
infantile atrophy, 877.
^^^^^ IXDKX*
^1
^M^ Blood in imlivtduul diMiMi t
Boils, 459.
^1
^K malaria, 380.
Bone, normal development of, 107*
^^M
^H measles, 871.
Boue-marrf»w in the new-borii infant,
^H
^^B miliary tubcrculuEis^ 374.
Bow-legs, 146.
^^H
^^H n«:tpliritiB^ 376,
Brain, diseasea of the, 594.
^^^
^H periostitis, 378,
dura muter of tbe, 65.
^^M
^H pDetimoniaf 872.
gruwtb of the, 65.
^^H
^^v and empyema, 378.
in tbe new-born infant, 37.
^^H
^H scarlet fever, 371.
normal development of the, 64.
^^^
^H Bclercma neonatorum, 379.
Duharuehnoid space of the, 65.
^^H
" acorljutu.<5, 379.
Branchial ^tula» 417.
^^H
tubeRnilar meningitisi 374.
Breast, 15d.
^^1
pontrmltis, 377.
mastitis, 162, 418.
^^^1
ty pi If fid ftvcr, 370.
nipples, 161.
^^1
variola, 371.
Breast pump, 162.
^^^
in infancy and childhood, 329.
Brleger'a bacillus, 243.
^^^
broken cells, 345.
Broken celU, 846.
^^H
C^ranules, 345.
Bronchitis, 9&4.
^^H
in tbe new- burn infant, 52, 349.
Acut^, 966.
^^^
key, 331.
dingnoels of, 957.
^^^1
litemture of the, 829, 808.
patbobigy of, 956.
^^^
tnethfidB of examining the, in early life,
prognosis of, 957.
^^M
831, 380.
bvtijptoniA of, 956.
^^^H
nomencliiture of the, 830
ireatnienl of, 967.
^^^
normal, at birth, 339.
chronic, 961.
^^^
amount of. 339.
fibrinous, 962.
^^H
color of, 331*.
Bronchocele, 1096,
^^1
development nf, 111.
BroDcho-pneutnonia, 962.
^^1
erythrt>cytes, 340.
blood in, 373.
^^H
hajmoj^lubin of, 340.
complications of, 972.
^^1
leucocytes, 340.
diagnofti£ of, 972.
^^1
nucleated red corpuscles, 842.
etiology of, 962.
^^^
reaction of, 339.
pathology of, 063.
^^^
ipeciiif gravity of, 339.
pmgnoait of, 978.
^^1
origin of the, 33tj.
symptoms of, 9<i9.
^^1
parafliic« of tbe, 880.
treatment f»f, 978.
^^^
malaria, 380.
acute tubercular, 944.
^^H
methcfd of examining for, 381.
chfoniOf 979.
^^1
pathology of the, in early life, 348.
Br*>oder, 809.
^H
in premature infunt^, 348.
np^mratuti connect^ with the, 818, ^^|
in the new-born, 349.
Broth, chicken, 287.
^^H
leuctemia, 361.
niutt'>n, 28".
^^H
leuc*.x!yto8is, 350.
Buhr^ di«i^a9(% 440.
^^1
olig<K!ytba*mia, 358.
Bursa pharyngeal 86.
^H
primary a nw in las, 355,
^^H
anfl>mia infantum pseudo*
^^H
leuka^mica., 359.
c.
^^1
anamiia prrtgreisiva per-
^^^
niciofia, 356.
Cachexia strum ipriva, 1097.
^^^
chloi\>*i!», 855.
C»cum in Ujo n»*w-borii infiint, 47.
^^M
rfaachiUc amemia, 368
lymphatic gland* of the, 98
^^M
secondary ana^miai, 865.
normal development of the, 92.
^^H
typhili*, fteoondary, with en-
Canorum oris, 788.
^^H
larged spleen, 867.
** Canker,'* 774,
^^^
tefmi tutd in describing the, 380.
CiifMiclty of the stomach, 79| 298,
^^M
Blood-Teneki malformations of the. 440
Caput »uccedaneum, 404.
M
^^^^^^^^^^^^^— «•-■ ^^^^^^^^^^^^H
m^Bij^^^^B
^M
^^^^^^^^^^^^^^^^^^^^ IXBEX. ^^^^^^^^^^^^^Jlll ^H
^ CongenHiil disease, definition of, 19.
^^1
^H form of herniih 428.
^H bydmcftphalus, 40U.
Dactylitis ^yphllittca, 491 ^ 496. ^^M
^H mill form at iona of the a*&oph&giu and
tiiben.^ular, 502, ^^B
^H stoniaeh, 440.
'* Danger signal," 97. ^^B
^^M oblitt^mtion of thf; bile-ducts, 438.
Deafness, syphilitic, 606. ^^B
^H of the intestine, 440.
Deaths of infants and load of weighty 10 L ^^B
^V umbtlicnl hernLti into tile cord| 425.
Defects of posture, 142. ^^B
^H ConBtipation, atonit-^ 868.
De4;eneration, acute fatty, of the new-boraf ^^B
^B epa^modic, 808.
^H
^H Comumptiun, 1090.
Dejections, fieca], color of, ta Influenced by ^^B
^B Coutraetiori of the stomncli^ 848,
the per(?ontage of fat iu the food, ^^B
^H Cotitm-indicatione to maternal feeding, 159.
^H
^H ConvuMoii8, 754.
<:»dor of, 860. ^^B
^H prognosis of, 757.
Dental paralyels, 682. ^^B
^B treatment of, 758.
pi' Hi 4^1 69. ^^B
^m Cor hiloculare, 1025,
retiexei, 740, ^^B
^1 tnloculnrrs 1025.
Dentition, diffieult, 794. ^^B
^H Cord, hemorrha£(t of, 54,
^^M
^^^ nnromi €<mditioii o^, 24, 54.
influenced by syphilis, 493, 50a. ^^B
^^m Apimil, tj7(l
second, TO. ^^^|
^B utiibilicjil, 24, 110.
Dermatitis exfoliativa mxinatommt 464. ^^^B
^H Cor|)iiscles» nu{?Ieatcd red, 342.
Descending colon, nonnal development of ^^^B
^H red, fit birth, 52.
^H
^B white, at birth, 52.
Descent of the testicle, 432. ^H
^H Corv^tt, acute, 801.
Dovelopmental di^etutet of the intestine, 868. ^^B
^H Cough, tii^exj 751.
1 Din be t*?^ insipidus, 1089. ^^B
^H Cow, tbe, a<^ u source of milk-supply, 218.
mollitu», 1088. ^^M
^1 can- of, 21 n.
Diu]>hru^m, the, iu the new-born infkot, 4L ^^B
^m feeding of, 220.
Diarrhusa, 858. ^H
^H Cows, breeds ot\ 226.
acute, 860. ^^B
^H charHctf;n8tic8 of, which produce milk
symptoms of» 861. ^^B
^^r guitablti for infant feeding, 225.
treatmen t of, 86 1 . ^^B
^m Craniutabei, 491, 496, 10(18.
nervouH, R61. ^^B
^H Cranium of the newborn infanl, Bl.
pri.»phylaxt» of, 858. ^^B
^H nonnul development of the, 64.
DiffleuU dentition, 794. ^^B
^H Creeping, 120
Digestion, diJ^easi'-^ of, 844. ^^^^
H Cretin, 1091.
fat and priiteid, 295. ^^B
^H CretinUni, i»poradic, 1097.
Digestive disturbances in hereditary sy^phiUa, ^^B
^H Cricoid cartilage, normal development of
493. ^H
^M the, 59.
DilatiitioQ of the colon, 876. ^^B
^B Cro8»-legged progre^ion, 658.
of the stomach, 848. ^^B
H Cruup, 95 h
Diphtheria, bacillus vt, 821. ^^B
^H Cunaiu-s in the nursery, 127.
bbxtd in. 372. ^^M
^H Curvaturt'H uf the iipine, 143.
complications and sequels of, 826. ^^^|
^B Curves of ihc 8pinc, 27, 50.
dingncMift of, 827. ^^^|
^B Cyanosis, 1025.
etiology of, 821. ^^B
^B Cptitis, acute, l>42.
incubiitton of, 823. ' "^^^B
^B etiology of, 942.
infection, 8^. ^^M
^^M prog DOS iii off 942.
larynx In, 826. ^^B
^^H symptoms of, 942.
no«e in, 825. ^^B
^H treatment of, 942.
patliology of, 828. ^^B
^H chronic, 942.
prv>gnosift of, 827. ^^^|
^^H prognosis of, 943.
pmpbylajcia of, 82fi ^^B
^^H f^rmptoms of, 948.
toVnipt'iniM uf, 823, ^^B
^H treatment uf, 943.
ttvatment of, 828. ^^^B
INDEX.
1115
Hemiplegia, infantile, 655.
flemorrhage fh)m the nose in early child-
hood, 805.
from the umbilical cord, 54.
in early life, 446.
Hemorrhagic disease of the new-born, 446.
Hemorrhoids, 880.
Henoch's purpura, 1087.
Hepatitis, interstitial, 917.
Hereditary ataxia, 689.
syphilis, digestive disturbances in, 498.
insomnia a symptom of, 494.
Hernia, 879.
congenital form of, 428.
umbilical, into the cord, 425.
femoral, 480.
funicular form of, 428.
infantile form of, 428.
inguinal, 427.
treatment of, 428.
umbilical, 426.
Herpes zoster, 478.
diagnosis of, 479.
symptoms of, 478.
treatment of, 479.
Hip, congenital dislocation of the, 487.
History of a case, 819.
Hives, 467.
Home modification of milk, 245, 276.
apparatus for, 270, 277.
materials for, 279-282.
Hydrocele, 430.
encysted, of the canal of Nuck, 481.
of the cord, 430.
treatment of, 431.
Hydrocephalus, 629.
acquinni internal, 642.
diagnosis of, 643.
prognosis of, 043.
symptoms of, 643.
treatment of, 643.
blood in, 37 o.
congenital, 4(VJ.
congonital internal, 634.
diagnosis of, 636.
operation for, 637.
pathology of, 634.
pn>gnosi8 of, 636.
symptoms of, 635.
tn»atment of, 686.
external, 630.
internal, 684.
Hydronephn)sis« 941.
etiology of, 941.
prognosis of, 942.
symptoms of, 942.
Hydronephrosis, treatment of, 942.
Hygiene of the nursery, 125.
Hyperaemia of the kidney, acute, 980.
passive, 981.
Hypertrophic cirrhosis, 918.
rhinitis, 804.
Hypertrophy of the feet and hands, 486.
of the pharyngeal tonsil, 806.
Hypnotism, 735.
Hypospadias, 485.
Hysteria, 732.
diagnosis of, 734.
prognosis of, 734.
symptoms of, 788.
treatment of, 784.
Ice-box, 263.
Ichthyosis, foetal, 482.
prognosis of, 488.
symptoms of, 488.
treatment of, 488.
neonatorum, 483.
treatment of, 484.
Icterus, 914.
blood in, 879, 1072.
neonatorum, 107.
cause of, 107.
Idiocy, 670.
diagnosis of, 671.
pathology of, 670.
symp^)ms i>f, 670.
treatment of, 671.
Ileo-colitis, 891.
treatment of, 898.
ama'bic, 900.
catarrhalis, 892.
chronie, 9(KJ.
pseudo-membranosa, 892.
tubercular, \H)i\.
pathology of, 907.
symptoms of, 907.
typhoidal, 000.
diagnosis of, 902.
patholojry of, 001.
prognihfis of, fK)3.
symj>t<»ms of. 001.
tn-aimrnt of. <K)3.
uleerativa fi»llicularis, 892.
Imp<Tfnrate a?iiH, 433.
n*<'tum, 4:i3.
ImjM'tiico contajriosa, 468.
Impn*ssi(>ns, mat<'rnal, 404.
Incontinence of fa»o«*8, 867.
of urine, 946.
Incubator, 301.
liiDEX, 1117 ^H
InfttOt At term, ftiiaiotninil pot tits of:
Intestine, chronic ileocolitis, 906. ^^H
thorax, 88.
congenital obliteration of the, 440. ^^H
thyDiu^ glitiidj 42.
constipuTinn, 808. ^^H
tonsils, 85.
developnieiit, abuomial, 868. ^^H
touch} 51.
diarrhoea, 868, ^^M
uric Aiad iDfuretion, 44
diseases nf the, 836. ^^H
urine, 63,
climinative diaturbances of the, 837| 876. ^^H
uteruji, 48,
fcniicntal dtsi*H^<«, 880. ^^H
veitiK, 43.
funutiniuil diM^UJ^ct, 8ri0. ^^^|
vitality, 49.
infuntili' titn^phy, BtilK ^^H
voice. 61.
inUaiomui4»r)' i1lh*u»ch, 887, ^^^|
weii^hl, 49.
in the nt^w-bofn infant, 47, ^^H
distint'tiofi or, from child» 18.
mt*chanicnl diM'tm^^, 875. ^^^|
Infantile atrt»phy, 809.
new gntwths of ihe, 887. ^^H
hemiple^iH, 656.
nun*]nllaninmtory ilei^-cnUiis, 801. ^^^|
paralvi^iA, H82.
normal devi'lopment of the, 91. ^^^|
p«seudr'^-Hyphilitlc, 496.
ori^anic di^oie^ of the, 876, ^^^|
skeleton*, ilH,
polypi of t!ie, 880. ^^M
tulH*rciibr riii'niiigiti*, 612.
pr< Jape of the, 879. ^^H
Infdntilijm, M}i).
tubular, 861. ^^H
Infectiuuti hustnoglobinuBuiia of the new*bora,
tntra-cnmiul »yphilb, 668. ^^H
443
tun^or, (;G2. ^^H
Intlainmatory dboftst^ of the intMiineB, 887«
Intussusception, 47, 876. ^^H
InfluenKa, epidemic, 1092.
dJagno^i^ of, 877. ^^H
di<lgno^i9 of, 1098.
pro^^osb of, 877. ^^H
pn»^nonis of, 1098.
symptoms of, 877. ^^H
treiitnient of, 10t>3.
treatment of, 878. ^^^|
Injections, metallic, 22, 33.
Iritis in syphilitic iufanu, 493. ^^H
Iniitintty, 731.
Irrigation of the nose in diphtheria, 661. ^^^t
Infiolaiion. 73«k
^^H
dian:nt»sis of, 787.
^1
pn^l^iiofii* of, 737.
tn^atment of, 737*
jHckeonian epilepsy, 724 ^^^|
lu.^onitiia a symptom of hereditary ^yphiii^,
Jaundii.^, 107, 914 ^^M
494,
Jaws in the iK'w-lH>ni infant, 32, ^^H
Inspection cif tlie immth, 826.
Juvenib ty|je of muscular atrophy, 766* ^^^H
of tin- sifk child, 320,
^^1
Intemititit ht'putiti^, 917.
^H
keratitis, 006.
Intertriijn, 132.
Kapo«i'« dixeaae, 481. ^^H
Intervab of feeding, 181.
Keratitis, inti-ntitial, 506. ^^M
IrttF^tinal contents, 858.
Kemig's teat. 646. ^^|
ci>lor of, changed by dmp, 859.
Kidney, active hy^iervnmia of the, 96Qi ^^|
in prt^muture infants, 294,
acute nephritis, 932. ^^^|
dtAclmrg««, 117, 868.
acute pan nchymatoua dogenermtion of ^^H
amount of, StiO.
the, 930 ^^M
color of, 868,
amyloid inflltnition ot th% 986. ^^H
ot^mpoAtiion of, &60.
chr<»ntc interstitial nephritis, 987. ^^H
oonsiwlenoy of, 869.
chronic pan«nchyniat<}U« nephritis, 986, ^^H
in tho new-born, 58.
discjuos of the, 927. ^^M
odor of, 860.
acquired, 927. ^^H
indip'f-tion, 862,
congenital, SI27. ^^|
chronic, B63.
eifect of »<'nHrt fever on the, 667, 660. ^^H
Intestine, acute simple dIaiflMMi 660.
general jnithology und etiol<^g7, 926. ^^H
animal paniiitc«, 908.
generut Hyntptoinattitog^, 939* ^^H
rhronic functional diieaaet of tb*, 868.
hydronephn>ii», 942 ^^^|
1120
INDEX.
Microcephaliis, 672.
Micrococci, relation of, to inflammation of
the breast, 162.
Microglossia, 704.
Migraine, 742.
Milk, 164.
analysis of bad, 187.
cow's, 287.
human, 168.
normal, 187.
over-rich. 187.
poor, 187.
ash of, 174, 241.
ass's, 178.
attenuants, 240.
average analysis of human, 172.
bacteriological examination of cow's,
242.
of human, 180
bacteriology of cow's, 242.
biology of cow's, 221.
chemical analysis of, 172.
clinical examination of human, 169.
colostrum, 166.
corpuscles, 166.
period, 166.
constituents and properties of, 165.
cow's, 178, 221.
cows producing suitable, 225.
estimate of the proteids of, 171.
fat of, 170, 173, 287.
home modification, 276.
hc>us«'. the, 225.
human, 154, 167.
quality of, 168,
quantity of, 167.
laboratory, the, 231, 245.
meth<K]s of examination of, 170.
mioro.scopic examination of, 169.
nervous disturbances affecting the, 166.
normal lactation, 169.
peptonized, 282.
poor and bad milk, significance of the
t«'nns, 187.
production of, 155, 104.
properties of cow's, 28G.
proteids, 170, 171, 174, 238.
reaction of cow's, 223, 236.
of human, 172.
room, 247.
salts of, ltt9.
solids in, 237.
specific gravity of, 169, 170, 172.
sugar of, 170, 174, 237.
tester, Babcock, 249.
transportation of, 268.
Milk, variations in human, 177, 188, 190
192.
water of, 173, 287.
woman's, 154, 167.
Mind, inianity, 781.
normal development of the, 110.
Mirror writing, 678.
Miscarriage caused by nursing, 186.
caused by syphilis, 508.
Mixed feeding, 205.
Mixter, S. J., metallic injections ot ana-
tomical specimens, 22, 88.
Modifying-room, 249, 254.
Molluscum contagiosum, 459.
Mononuclear eosinophiles, 844.
neutrophiles, 344.
Mother, the nursing, 160.
Mouth, care of the, 141.
difficult dentition, 795.
diseases of the, 774.
glossitis, 798.
in the new-born infant, 86.
inspection of the, 325.
macroglossia, 794.
microglossia, 794.
normal development of the, 67.
stomatitis catarrhalis, 776.
herpetica, 779.
mycetogenetica, 784.
ulcerosa, 781.
syphilitic lesions of the, 494.
Mucous disease, 863.
polypus, 805.
Multiple cerebro-spinal sclerosis, 691.
neuritis, 704.
Mumps, 1104.
Mutton broth, 287.
Myelitis, 676.
of the anterior horns, 68.
Myelocele, meningo-, 420.
syringo-, 420.
Myelocytes, 344.
Myocarditis, 1032.
Myogenic paralysis, 682.
Myopathic progressive muscular atrophy,
763.
Myopathies, the, 763.
Myotonia congenita, 778.
Myxoedema, 1096.
N.
Nffivus, 454.
Napkins, 135.
Naso-pharjnx, diseases of the, 801, 806.
in the new-born infant, 82.
normal development of the, 65.
^^^^^^^^^^^^^^^INBKT. ^^^^^^^^^ 1121 ^M
^^KiiSSm skull, 505,
Nervous system, organic di^eaies of the: ^^H
Keck| diseases of the, in eurly life, 410.
cerebral abtioesa, 648. ^^^|
in the new-bf»rn infftnt, 80,
paralysis, 648. ^^H
normal deveJoproent of the, &9,
cerebro-spinal meningitis, 691. ^^H
Nephritis, acute, 932.
cord, 676. ^H
blood in, 876.
hereiiiury ataxia* 089. ^^M
capsular glomerulo-, 640.
hydri»cephalus, 629. ^^H
catarrhal^ 980.
idiocy, 670. ^^|
chronic interstitial, 937.
intra-crnniiil tumors, 662. ^^H
parenchymatous, 988.
syptiiliii, 668. ^^H
Nervous diarrhcsa, 801.
leptomeningitis, 696. ^^H
disturbances aflVctinp^ llif milk. 165.
locomotor ataxia, 689. ^^H
Nervous system, di*<eiises of thi^, 55*0.
meningitin^ 595. ^^^|
functional diseases of the, 732.
mirror writing, 678. ^^H
arre-sted psycbieal develop-
multiple cerebro-spinal sclero- ^^H
ment, 740.
^H
cmUlepey, 735.
myelitis, 676. ^^H
ooncuisiiion, 738.
neuralgia, 709. ^^H
convulsions, 764,
neuritis, 704. ^^^H
dental reflexes, 746.
non-tubi^ruular meningitif , 695. ^^H
headaches, 741.
diagmitb of, 698. ^^H
hypnotigm, 786.
patholi^y of, 696. ^H
hysteria, 732.
prDgnofiis of, 698. ^^H
insolation, 736.
symptoms of, 698. ^^H
myopiithies^ 768.
treatment of, 699. ^^H
myotonia c«»Dgenila, 778.
pachymeningitis, 695. ^^H
pan.>xysmal gasping, 749.
paraly&lA caused by caries of ^^H
pitvor n*»cturnii8 (central), 745,
the epine, 688. ^^f
pavor noc'turnuji (peripheral),
of the new-bom, 706. ^^H
740.
peripheral nerves, 704. ^^H
progjre-Bijive muscular atrophy,
poliomyelitis anterior, 676. ^^H
763.
syringomyelia, 690. ^^H
peeudo-hypertrophic muscular
thrombosis of tho eer«bml ^^H
pttralysis, 768.
iinuaea, 626. ^^H
reflex cough, 751.
tubercular meningitis, 603. ^^^|
nyitagmuii, 747.
prcfiumubly organic dL^ease^ of the, ^^H
of the hhidder, 762.
^H
of the ear, 747.
chorea, 711. ^^H
of the heart, 751.
epilepsy, 724, ^^|
of the larynx, 747.
insanity, 781. ^^M
of the lung, 7fi0.
Nettte-rash, 467. ^H
of the rectum, 762.
Neuralgia, 709. ^^H
of the stomach, 752.
Neuritia, 704. ^^M
of the vagina, 762.
multiple, 704. ^^H
reUrded speech* 740.
diagn<.i«ii of, 706^ ^^H
iensiitive tjane^ 744.
etiology of, 704. ^^M
flimuhvt4'd dis^aaet^ 7^5.
patboUfgy of, 704. ^^B
temporary amneala, 789.
aphasia, 789.
symptoms of, 704. ^^H
tetany, 744.
taoatment of, 705 ^^M
tremor, 762.
Neuropathic progroMiva mu»«niinr atmphy, ^^H
vertigo, 743.
^H
CfTganlc diseases of the, 594.
Neutrophilea In normal human blood, ^^H
athetoiU, 661.
^H
bmiii, 594.
New-born, abdomen in the, 44. ^^H
^ tynun and cord, 691.
acute (alty degeneration of lb**. 440 ^^H
INDEX.
1123
New-bom, diseases of the :
ophthalmia neonatorum, 415.
phlebitis and arteritis umbilicalis,
425.
prominent sternum, 419.
ranula, 414.
sclerema neonatorum, 458.
spina bifida, 419.
spinal meningocele, 420.
syringo-myelocele, 420.
testicle, 432.
tetanus neonatorum, 452.
toes, 486.
tongue-tie, 414.
trunk, 418.
tumors of the testis, 488.
umbilical hernia, 427.
New growths of the intestine, 887.
of the larynx, 949.
of the stomach, 854.
Night-dress, 186.
Night-terrors, 746.
Nipple-shields, 161.
Nipples, 161.
artificial, 288.
Noma, 788.
Nomenclature of the blood, 880.
Non-tubercular meningitis, 595.
Normal development :
abdomen, 77.
bile. 111.
bladder, 78.
blood, 111.
blood-vessels, 75.
bone-marruw, 107.
brain, 64.
caecum and ascending colon, 02.
cord, 54, 110.
descending colon, 94.
ear, 65.
Eustachian tubes, 66.
face and cranium, 64.
feet, 105.
fontanclles, 68.
functions, 110.
gall-bladder, 77.
hard palate, 67.
head, 60.
heart, 74.
height, 96.
infantile skeleton, 118.
intestinal discharges, 117.
intestine, 91.
kidney, 78.
lachr}'mal glands, 110.
liver, 77.
Normal development :
lungs, 75.
lymphatic system. 111.
maxillary bones, 67.
mental impressions, 1 10.
mouth, 67.
Daso-pharynX| 65.
neck, 59.
pancreas, 77, 111.
petro-squamosal suture, 65.
phar^'ngeal tonsil, 60.
pulmonary artery, 75.
pulse, 94.
respiration, 72, 96.
salivary glands. 111.
sigmoid flexure, 98.
skin, 107.
spine, 55.
spleen, 77.
sternum, 70.
stomach, 79.
supra-renal capsules, 78.
sweat-glands, 110.
teeth, 68.
temperature, 94.
thorax, 70.
thymus gland, 72.
thyroid, 111.
topographical anatomy of the early
periods of life, 120.
urine. 111.
vermiform appendix, 92.
voice, 110.
weight, 97.
infant's, 119.
North rup on the lung in the new-born
infant, 48.
Nose, diseases of the, 801.
hemorrhage from the, 805.
irrigation of the, in diphtheria, 881.
mucous polypus, 805.
normal d<'Vflopmpnt of the, 65.
rhinitis, K)l.
Nuck, ency>t<*«l hydnnx'le of the canal of,
431.
treatriiiMit of, 481.
Nucleated n*d oori)U'ich*s, 342.
Nursery, hy^i«*n«* nf thr, 125.
NurHcry-muids, 141.
Nursi^ for premature infants, 812.
Nurhing-bottlo. HVA.
Nursing mother, tho, 160
Nutritive p-riinl, first, 157, 168.
s^xM^ul, 284.
third, 287.
Nystagmus, 747.
1124
INDEX.
Oute, 281.
Obliteration, congenital, of the bile-ducts,
488.
Occlusion of the vagina, 485.
Odor of fsecal discharges, 860.
(Edema, acute circumscribed, 484.
neonatorum, 484.
of the larynx, 960.
(Esophagitis, 884.
(Esophagus, congenital malformation of the,
440.
diseases of the, 884.
foreign bodies in the, 884.
Oligocythsemia, 858.
Onychia, syphilitic, 506.
Ophthalmia, catarrhal, 415.
neonatorum, 415.
purulent, 415.
Orchitis, 945.
Organic diseases of the intestines, 875.
Osseous system, syphilis of the, 490.
symptoms of, 491.
Osteochondritis, syphilitic, 491, 495.
Osteo-periostitis, 491.
Out-door air for children, 140.
Oxyuris vermicularis, 908.
diagnosis of, 909.
treatment of, 910.
Ozaena, 804.
P.
Pachymeningitis, 696.
Palate, cleft, 412.
hard, 37, 67, 418.
Palpation of the sick child, 320.
Pancreas, diseast?8 of the, 918.
in the new-born infant, 62.
normal development of the, 77, 111.
syphilitic, 400.
Papers, wall-, in the nursery, 126.
Papilloma of the larynx, 949.
Paralysis, acute atrophic spinal, 682,
birth, 488.
caused by caries of the spine, 688.
diagnosis of, 688.
prognosis of» 689.
symptoms of, 688.
treatment of, 689.
cerebral, 648.
diagnosis of, 652.
etiology and pathology of, 649.
prognosis of, 662.
symptoms of, 660.
treatment of, 664.
Paralysis, dental, 682.
essential, 682.
in&ntile, 682.
myogenic, 682.
of the new-bom, 706.
diagnosis of, 707.
etiology of, 706.
pathology of, 707.
prognosis of, 707.
symptoms of, 707.
treatment of, 708.
peripheral, of the new-born, 708.
pseudo-hypcrtrophic muscular, 768.
diagnosis of, 769.
pathology of, 768.
prognosis of, 771.
symptoms of, 768.
treatment of, 771.
spastic, 655.
syphilitic pseudo-paralysis of the new-
bom, 496.
Paraplegia, spastic, 669.
Parasites, animal, 466, 908.
of the blood, 380.
in malaria, 380.
Parenchymatous degeneration of the kidney,
acute, 930.
Parotitis, 1104.
Paroxysmal gasping, 749.
Parrott's disease, 496.
Patent fotxls, 282.
Pavor nocturnus, 745, 746.
ceiitnil. 745.
periphenil, 746.
Pectus carinatuni, 419, 1069.
Pediatrics, importance of the study of, 17.
Pediculosis, 458.
treatment of, 458,
Peliosis rheumatica, 1087.
Pelvis, the, in the new-born infant, 48.
Pemphigus, 463.
treatment of, 468.
neonatorum, 462.
syphilitic, 492.
Penis, 946.
epispadias, 435.
hypospadias, 435.
phimosis, 946.
Peptonized milk, 282.
Percussion of the sick child, 321.
Pericarditis, 1046.
diagnosis of, 1065.
etiology of, 1046.
pathology of, 1046.
prognosis of, 1069.
symptoms of, 1047.
INDEX. 1125 ^1
PericarditU, tr^tniMit of, 10&9.
Pharynic, phar^^ngitis, 815. ^^H
Pericardiutn, dbeftses of Uie, 1D46.
acute follicular, 816, ^^^|
Period, nutritive, first, 157, 158.
simple, 815. ^^^|
second, 28i.
retro-pharyngeal abscess, 817» ^^^|
third, 287.
Um^illiti^, 809. ^^M
Perit>dic catarrh, 1005.
acuu% 809. ^^M
Ppriostitis, the blood in^ 878.
follicular, 810. ^H
Peripheml nerves, 704.
simple, 810. ^^^H
pttralygia of the new-born » 708,
chronic, 812. ^^H
Peritoneum, dbetiaes of tht*. UlS.
Fhimocia, 946. ^^H
inflammtttory, 919.
Phlebitis and arteritis umbilicatU, 426. ^^H
non-inflamniiUory, 919.
phthiais, imio, ^H
Peritonitis, acutv, i»20.
fibroid. 967, ^^M
piitliology of, 920.
Physiological albuininuria, 927. ^^H
prognosis of, 921,
lofi!^ of weight, 90. ^^H
gymptoms ol", ^0.
Picture-mouldings in the nunery, 126. ^^H
treatment of, 921.
Plgeon-breufit, 419, 10^i9. ^^M
chronic, 921.
Pillow, the, ^H
tutx^rcukr, 921.
Pln-wonn, 908, ^^|
blood in, 877.
Pityriasis maculata et circinnta, 480, ^^H
diajs^noeis of, 922
iCMii, 180. ^H
patht>logj of, 922.
rubra, 180. ^^M
progricjfeU of, 922-
Placental the lung of the fntus, 19. ^H
fiymptomti of, 922,
PhM)UGa muqueusee, 495. ^^M
tfeatjnent of, 922.
Pleium, discvaes of the, 1007. ^^M
Peritomillur abscess, 815,
Pleurisy, 1007. ^H
Peroiciouji anaetnia, progresfiive, 866.
diagnoaiit of, 1009. ^^H
Peroneal type of muicuLlar atrophy, 768*
pathology of, 1007. ^^|
Pereiatent vomiting, 841 .
prognosis of, 1011. ^^^|
Pertuasii, 908.
purulent, 1018. ^^H
com plication 9 of, lOOO.
symptoms of, 1008. ^^H
iiitttcn •*»»•* of, 1001.
treatment of, 1012. ^^M
)>iithi44)i:y of. 999,
Pneumonia, acute lul>ercular bmncho-, 991. ^^H
prognosis Mf, lOOl.
diagnosis of, 995 ^^H
prophylmia of, 1008,
pitjgnoais of, 995. ^^H
eyniptoms t>f, 999.
symptoms of, 996. ^^H
treatment of, 1001.
treatment of, 996. ^^H
Petit rnal, 724
alba, 490. ^H
Petro-fiquamofial suture in the new-born in-
lobar, 980, ^^H
fant, 88.
blcKjd in, 872. ^^M
normal development of the, 56.
com p) ^cations of, 98d. ^^H
Pettici.ut, 185.
diagu^i#ii« off 986. ^^H
6nnuc'l, 186.
etiology of. 980. ^^H
while, VAiy.
gangri^nc in, 986. ^^^H
Phuryngfal tonsil in the infant at term, 86,
pathology of, 981. ^^H
hypertrophy of the, 806,
pnignoAJi of, {f86. ^^H
normal development of the^ 66,
sympC^miM nf, 981, ^^^|
^ Pharyngitis, 815,
t4^nfpcraturc in, 982, ^^H
acute follicular 816.
tn^tmertt of, 987. ^^H
treatment of, 816.
Polioencephalitif, 655. ^^H
acute fimple, 816.
Poliomyelitis anterior, 676. ^^^|
Pharynx, 80t*
dingnofii of, 678. ^^^|
diaeoAc«of thp. 801,800.
dit!<-roiitial dingnoiis of, 679. ^^H
elongation of the uvula, 816*
patiiulogy of, 676. ^^H
lyniph-veiseU of the, 85.
frvmptoniA of, 677. ^^^|
peritonsillar abecesa, 816.
troatmcnt of, 681. ^^^H
INDEX. 1127
1
Recurrent tubotvulur meningitU, 617.
Rigidity, bpa^tiOf 665.
^M
Red carpusclejj ut iHrtb^ 52,
Ringworm, 460.
^^H
fate *>r the, 387.
Ritter's di^easei 464.
^^1
in the new-bom infant, 62*
Rose cold, 1005.
^^H
ouokatt^, 842,
Rotheln, 588.
^^H
Beflex t\iiictioiml di*eiu«?aT 746.
Round whouldeni, 146.
^^1
(jotigli, 761.
Bound worm, 908.
^^1
of the hUdder, 762.
Rubber, use of, 161.
^^^1
of th« ear, 747.
Rubella, 688.
^^1
of the heart, 751,
Rubeola, 573.
^^1
of the larynx, 747.
Bugi» in the nursery, 126.
^^1
of the lung^ 750.
^^1
of lh<? rectum, 762.
S.
^^H
of the fttODiuc'h, 752.
^^^^^1
of the vagina, 752.
Salivary glands in the new-bom infant, 62.
Beflexei, dental, 740.
normal development of the, 111.
^^1
Regimen of lactation, 182.
Scabies, 456.
^^1
Ke#piriitiun in the new-born bfant, 40| 48.
treatment of, 467.
^^1
normal development ufj 72, 96.
Scales, 128.
^^H
of the premature infant, 297.
systematic and frequent use of^ 95.
^^1
of the i*ick child, 82(1.
Scarlet lever, 662.
^^1
Retarded speech, 414, 740.
benif^n form, 541.
^^1
RetPi*infeelion, syphilitic, 488.
blood in, 871.
^^1
£etru»pharynj^eal abscess, 817*
<:ervieal glands in, 587, 558.
^H
diagno!(is of, 817.
oompUcttii<ms of, and their treatmeDt,
^^1
pathology of, 817.
555.
^^1
prognogii of, 818.
oontagium of, 588.
^^1
symptoms of, 817.
desquamation of, 544.
^^1
treatment of, 818.
diagnods of, 515,
^^H
Rhachitie anaemia, 368.
ear in, 586, 658.
^^H
rtisary, 1069.
effloreacenee of, 54^
^^H
Jthachititi, 10f!5.
heart in, 641.
^^H
congenital, 1071.
incubation t>f, 542.
^^1
diagnogjd of, 107S.
isolation and diJitufootion in, 549.
^^H
etiology of, 1065.
kidney in, 587, *V10
^^1
pathology of, 1006.
mtili^iuint form of, 541, 673.
^^1
pnignoeis of^ 1074,
putholo^y of, 55^4,
^^1
ayniptoma of, 10 73.
priMlhMiiata of, 542.
^^H
lr«*atnieiii of, 1074.
pn-i^no^is of, 545,
^^^1
Rhagiide-s 495.
relapfttsi of, 552,
^^H
Rheumatiiim, 11>H0,
skin in, 584.
^^H
diagnosis U'tween, and tubercular men-
symptoms of, 542.
^^1
ingiiif, 611.
thriMit in, 535, 556.
^^^
etiology of, 1080.
treatment of, 645.
^^^
pathology of, 1080.
urine in, 544.
^H
pmi^nosis of, 1081.
vjiriationi in the hcnign form of, 6fi2.
^^M
6ubcutanix>us fibr(»uB nodules, 1064.
8ehonlein'« disease, 1087.
-^^M
symptomg of, 1081.
Sdiool, 14S.
^^M
treatment of, 1081.
Sdetema naonatofum, 468, 484.
^^H
Rhinitb, acute, 80L
bhHid in, 379.
^^H
atrophic, 804.
symptoms of, 468.
^^1
hypertrophic, 804.
treatment of, 468.
^^H
purulent, 80(8,
Scleroderma, 484.
^^H
Riba, the, in the new-bom itifknt, 88.
ScleroaU, deflnitbn of, 660.
^^1
itinvemertt of, 8^,
mult) pit* oerebfONipinal, 691.
^^H
BickeU, 10U5.
1 diagnosis of, 692.
J
UTBEX. 112^ ^H
Slemum In the new-bom infant, 88.
Stomatitis gangneDosa, trcAtinent of, 789. ^^H
noroiAl development of tlie, 70.
herpetica, 779. ^^H
oniflcation of tliM^ S9, 71.
(Hioloj^y of^ 779. ^^^|
pKiimuttnij 419,
pathology of, 7@0. ^^|
sun, 249.
pn)gnoBi5 of, 780. ^^H
Stockings, 186.
symptomatology of, 780^ ^^H
8tolir's ubstervationa on the t43Q8iU, 86.
treatment of, 780. ^^H
Stomtirh, capacity of the, 79.
hyphomycetica, 785. ^^H
conge nitul mttlformutjom of tbe, 440.
diagnoeia of, 786. ^^H
contraction of the, 848.
pathology of, 785. ^^H
devek>p men till dise^aes of the^ 840.
prognofiia of, 780. ^^^^|
diiigntifiia between disenses of the, And
symptoma of^ 786. ^^H
njeningitiii, 600.
treattacDt of, 786, ^^^M
, dilatation of the, 848-
mycetogenetica, 784. ^^H
dlftgnosii of» 850.
Itnuiuatictt, 776. ^^H
pathology of, 849.
ulcerosa, 781. ^^M
ppoj^noftb of, 851.
dia^nofiU of, 783. ^^H
syiiiptutiifi of, 860.
etiology of, 781. ^^H
treatmt^nt of, 851.
{>athol(»gy of, 782. ^^^|
disease* of thp, (109, 8S6.
pmg^notiis of, 783. ^^^H
bacturi«»lnery at, 887.
symptoms of, 782. ^^^|
etiology of, 837.
trt'JttiQent of, 788. ^^|
general dia^not^ifi of, 888.
Strawberry UJDgue, 543. ^^H
patbolo|E:y of, 887.
l3trepiooo<xfua coli gracilis, 1 18. ^^H
aymptomutology of, 888.
pyogenes, 822. ^^^|
treatment of, 889,
Strumous diathesis, 1090. ^^H
eliminative diseasea of the, 840,
Study of pediatricii, importance of the, 17. ^^H
functional diaea«ea of tht% 840.
Subarachnoid 6paee, 65. ^^^|
j»'avti^<^, H46.
Sugar meofiure, 277. ^^^|
inBamtimt^rry diseafeii of the, 854.
Sun and wiudowa, 125. ^^^|
in the nt.*w-bi>rn infant, 45.
Supra-renal enpsuh^, atfbctiofia of the, 940. ^^^|
hkvage, 845.
in the new>l><ini infant, 41. ^^^|
TO ftl formations J 840.
nnnnal development of the, 78. ^^^|
malp<Jsition.«i, 840.
Surface anatomy of the «pine, 58. ^^^|
ner\'ous diseases of the, 840.
Suture^ petro-«<}uiimmal, 38. ^^^|
now fjpiwths of the, 8«>4.
Sweat-glanda in the nt?w-boni infant, 61. ^^^H
non-intlainmator}' diseimes of the, 848.
normal development of the, 110, ^^^|
nonnat develi>pmi'nt of the, 79.
of premature infanta, 292. ^^H
of the premature infiint, 298.
Sweet whey, 282. ^^M
orjjanic disieHiit^ of tho, 848.
SyphitiK, 487. ^H
rvflex of the, 752.
acquired, 487. ^^H
liieern of the, 853.
adenopathy, 493. ^^B
wiwhint? *mt the, 845.
alopei:-iu, 493. ^^H
Stoin neb -tube, 847.
bcuies, tuWrcHitiei cm, 606^ ^^H
Sti'iJiatiti.H I'utarrbalii', 776,
conc;onital, with enlufed ftpleen, 867* ^^H
patholoij^y of, 777.
dactytitiH, 496. ^^M
prngii(j«is of, 777,
deafneM, 606. ^^H
^yniptnnintology of, 777.
dentition in, 498, ^^U
treatrnenl of, 778,
dkgnoab hetween, and nioiilngitii«>, 61 L ^^H
eryth»-«nmtf>u», 776.
diagnoaia of, 497. ^H
exaiithi'niatiea. 776.
of hetrditary, 496, ^^M
ganj^neixj^H, 788.
dlgMtiva di<*ttir?mrir«*« in, 493. ^^H
diAgnoiiis of, 78a
«arly niio -^f bt'r«^itaiy, 491. ^^H
etioloiry of, 788,
hflimorrhii:: u to ram, 494* ^^^H
prolan CM id of, 781*.
heart in, 490. ^^H
fivio|;>ti>io>4 *if. 7h9.
herieditAry, 487. ^^H
1130
11^
Syphilis, insomnia in, 494.
intra-cranial| 668.
diagnosis of, 669.
pathology of, 668.
prognosis of, 670.
symptoms of, 669.
treatment of, 670.
iritis, 498.
keratitis, 50C.
kidney in, 490.
later manifestations of hereditary, 604.
liver in, 489.
lungs in, 490.
miscarriage caused by, 608.
mouth in, 494.
nose in, 494, 606.
of the new-bo]:n, 487.
onychia, 498, 606.
osseous system in, 490, 606.
osteochondritis, 496.
pancreas in, 490.
pathology of, 489.
post-conceptional, 488.
prognosis, 497.
retarded, 487.
retro-infection, 488.
secondary, with enlarged spleen, 867.
spleen in, 489.
teeth in, 606.
testicle in, 490.
thniftt in, 490.
thymus gland in, 490.
treatment of, 498.
of later symptoms of, 606.
upper air- passages in, 490.
Syringomyelia, 690.
Syringo-myelocele, 420.
T.
Tabes mesenterica, 1090.
Tables showing management of food an'
increase in weight, 264.
Tache c^rebrale, 690.
Taenia mediocanellata, 911.
solium, 911.
Tapeworms, 911.
Tamier's incubator, 306.
Taste in the new-born infant, 61.
Teeth, difficult dentition, 795.
effect of syphilis on the, 493, 606.
first dentition, 69.
in the new-born infant, 37.
normal development of the, 68.
second dentition, 70.
syphilitic, 608.
INDEX.
1131
Tongue-tie, 414.
Tonsil, 86.
fiftucial, 85.
hypertrophy of the, 806.
diagnosis of, 806.
etiology of, 806.
pathology of, 806.
prognosis of, 808.
symptoms of, 806.
treatment of, 809.
Killian's observations on the, 86.
Luschka's, 806.
pharyngeal, 86, 66.
Tonsillitis, 809.
acute, 809.
diagnosis of, 811.
prognosis of, 811.
symptoms of, 810.
treatment of, 811.
chronic, 812.
pathology of, 812.
prognosis of, 818.
symptoms of, 81 3.
treatment of, 818.
follicular, 810.
simple, 810.
Topographical anatomy of early life, 120.
Torticollis accompanying eczema universale,
474.
acute rheumatic, 1086.
Touch in the new-bom infant, 51.
Toys, 128.
Trachea, diseases of the, 968.
Transportation-box at milk-laboratory, 268.
Tremor, 762.
Tricophyton tonsurans, 460.
Trismus nascentium, 462.
Trunk, diseases of the, in early life, 418.
Tub, 129.
Tubercle bacillus, 994.
Tubercular dactylitis, 602.
disease of the testicle, 946.
meningitis, 608.
infantile, 612.
peritonitis, 921.
ulcer of the caecum, 908.
Tuberculosis, 1089.
acute miliary, 1090.
bl<K)d in miliary, 374.
chn)nic diffuKo, 1090.
chronic, of the lung, 996.
diagnosis of, 996.
prognosis of, 997.
symptoms of, 996.
treatment of, 997.
communicated by kissing, 142, 604.
Tuberculosis, infection of, 142.
of the liver, 915.
of the lung, 998.
etiology of, 993.
pathology of, 998.
of the skin, 486.
treatment of, 486.
Tuberculous cows, 228.
Tubular disease of the intestines, 861.
Tumors, intra-cranial, 662.
diagnosis of, 664.
pathology of, 662.
prognosis of, 664.
symptoms of, 668.
treatment of, 664.
of the kidney, 989.
of the testicle, 482, 946.
Typhoid fever, bacillus of, 900.
blood in, 870.
diagnosis of, 902.
between, and meningitis, 610.
pathology of, 901.
prognosis of, 908.
symptoms of, 901.
treatment of, 908.
U.
Ulcers of the stomach, 868.
Umbilical arteries in the foetus, 20.
post-natal change in the, 21.
cord, hemorrhage from the, 64.
normal condition of the, 24, 64.
normal development of the, 110.
hernia, 426.
congenital, into the cord, 426.
vein, post-natal change in the, 21.
Umbilicus, 64.
arteritis umbilicalis, 425.
fungus of the, 425.
Meckel's diverticulum, 426.
Uranopla.«sty, 413.
Uric acid infarction in the new-bom infant,
44, 113.
Urine, anuria, 946.
chyluria, 941.
hiL'inuturiu. 940.
ha;ni(>i^lol)inuria, 940.
incHjntinence of, 946.
in scarlet fever, 644.
in the new-bom infant, 63.
normal development of the, 111.
of adolescence, 114.
physiological albuminuria, 927.
Urticaria, 4<>7.
treatment of, 467.
1132 INDEX.
Urticaria, giant, 484.
Uterus in the new-bom in&nt, 48.
Uvula, elongation of the, 816
V.
Yaocination, abnormal effects of, 162.
efflorescence of, 528.
evolution of, 161.
method of, 160.
sUtistics of, 147.
Vaccine virus, 149.
Vaccinia, 162, 528.
Vagina, gonococcus of Neisser, 948.
occlusion of the, 485.
presence of oxyuris, 946.
reflex of the, 762.
Vaginitis, 948.
Valves in the veins, 48.
Varicella, 624.
complications of, 626.
diagnosis of, 627.
efflorescence of, 625.
gangrenous, 525, 526.
incubation of, 525.
pathology of, 525.
prodromata of, 525^
prognosis of, 526.
symptoms of, 525.
treatment of, 581.
Variola, 617, 618.
blood in, 871.
complications of, 622.
confluent, 621.
contagiuni of, 624.
desquamation (»f, 621.
diagnosis of, 622.
discrete, 620.
disinfection of, 621.
efflorescence of, 621.
hemorrliagic, 621.
incubation of, 620.
modified form of, 622.
mortality of the vaccinated and of the
un vaccinated, 148.
pathology of, 618.
prodromata of, 620.
symptoms of, 520.
treatment of, 624.
Veins in the new-born infant, 48.
Ventilation of the nursery, 127.
Ventilator in milk-laboratory, 248.
window, 127, 180.
Ventricular septum, absence of the, 19.
Vermiform appendix, inflammation of the,
888.
Vermiform appendix, nopinal development
of the, 92.
Vernix caseosa, description of, 28.
Verrucae, 480.
Vertebra, position of, in the new-born in-
&nt, 87.
Vertigo, 748.
Vitality in the new-born infant, 49.
Voice in the new-bom infant, 51.
normal development of the, 110.
Volvulus, 876.
Vomiting, 840.
diagnosis of, 842.
etiology of, 841.
prognosis of, 842.
symptoms of, 841.
treatment of, 842.
Von Jaksch, anaamia of, 869.
Vulvo-vaginitis, 948.
caused by oxyuris, 909.
pathology of, 948.
prognosis of, 944.
symptoms of, 944.
treatment of, 944.
W.
Walker-Gordon laboratory, 246, 276.
Walking, 120.
Walls in the nursery, 126.
Wandering rash, 798.
Warts, 480.
Wash-room at milk-laboratory, 268.
Weaning, 206, 284.
Weighing of infants, systematic, 99.
of premature infants, 301.
Weight in the new-born infant, 49.
loss of, an important symptom, 97.
normal development of, 97, 128.
normal gain of, 101.
of premature infant, 290.
physiological loss of, 99.
Wet-nurses, 209, 211, 212.
Wheat, 282.
Whey, sweet, 282.
White corpuscles at birth, 62.
Whooping-cough, 998.
Wlnckel's disease, 443.
Window ventilator, 127.
Windows, sun and, in the nursery, 126.
Worcester, Dr. Alfred, incubator, 806.
Writing, mirror, 678.
Yellow atrophy, acute, of the liver, 916.
f
pat Totoh, T.Y.
F84? Pt-'i.- trier.
NAltB
DATE DUB
j^iS A.a.?AirS.