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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heretofore  unpublished.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&sected  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 


I 
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=::::: 

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::::::i:::s  ::::!5-:::: 

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t         ^ 

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::::::-::±::::::::::-' 

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. 

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r- 

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£ 

1 

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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 

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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* 

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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 

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ITT" 
17  0* 

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29 

ao 
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— 

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 

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S6 

37 

38 

mI^o 

41 

43 

43 

44 

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47 

49 

0 

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njTi 

ri 

ri 

rt 

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sas* 

vn* 

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96» 
W 

ISO 
MO 

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/  / 

1- 1 

M 

■ 

h  * 

\  i 

/ 

i  ^ 

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/ 

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i/l 

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ill 

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^ 

/. 

... 

l< 

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f,  . 

•i 

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\j 

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■  (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 

1 

lOJ- 

101* 

(no* 

i 

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^^ 

/] 

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1 

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as: 

,( 

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i^ 

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— 

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.. 



„- 

^'  1/ 

/ 

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1 

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110 

»0 

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190 
TO 

_ 

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^ 

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■_ 

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 

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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 


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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  ^ 

|i 

2 

3 

4 

5 

6 

7 

a 

9 

10 

11 

12    T3 

f4 

lA 

c  , 

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 

f  1 1* 

1 
1 

1 
1 

1 

N 

r^ 

3m 

A. 

409 

1 

/ 

_J 

y 

1 

an 

4nn* 

7 

\r 

^ 

^3 

Vf 

394^ 

J 

i 

4 

i-/ 

1 

«? 

i 

ri 

r 

V 

i 

V 

V 

^flf 

/ 

/ 

V 

"  ^7  r 

99 

h 

b 

/- 

i^ 

sAI 

17^, 
HP  ' 

ay.- 
95^ 

r\\ 

1 

■—— 

— 

— 

-■ 

-- 

— 

,- 

—  - 

-- 

-,- 

--. 





^4 

s 

1^ 

in 

ee 

tf« 

3£  I* 

se* 

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>       ' 

U? 

1 

^ 

-- 

^= 

1 

g 

— ' 

— : 

^ 

J 

^ 

^ 

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 

14. 

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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 

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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 

>"/ 

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. 

Days  of  Dh^a^ 

h 

w 

U 

L2 

Ji 

11 

15 

i§ 

17  ^ 

o 

IX 
1 

m 

MM.. 

ME 

UL 

M£ 

V£ 

mi: 

ME 

MC 

416- 

40  5-    , 
40  0^ 

J 

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39.4' 

38  8- 
383" 

37.7' 

37. 2" 
37.0" 
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361' 

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1 

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y 

k 

1     ^ 

1 

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.-„, 

\   a^  1 

5r 

5-: 

1 

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&ltu. 


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 

F   ^  21  ■ 

■JiZ'  2J 

24  1  26 

fe 

27 

28 

29 

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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 

MB 

Jf  C 

MB 

MB 

HI 

MB 

MB 

MB 

MB 

MB 

MX 

MS 

MB 

MB 

urn 

^^ 

MB^ 

MK 

Mt 

MI 

o. 

41.6* 

41.  r 

40,0' 
39,4  • 
38J* 
381' 

17,  f 

37  0* 
366* 

38  1- 

355* 

35  0* 

109 

105* 

10»' 
103' 
102 
101* 

1 

1 

1 

/ 

i 

i 

1 

j 

/ 

J 

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^/ 

,// 

J\ 

J 

1 

/ 

i 

y 

100' 

/ 

/\ 

Y 

f 

y 

V 

V 

V 

-^ 

i/ 

\l 

/ 

^ 

\J 

Y 

V 

^ 

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 

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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  ^ 


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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-^;- 


fit.' 
d. 

dy 

Hi' 

an 
ar 

ri" 

el 


11 
n 


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  " 


.ii.ii 
f.\ 
\v .  I  ■ 
-\'\ 

l:i  'n, 
if  ; 
I.lT 
W  :  I 

r-  J 

r.i| 

V.  I 
!:.  -' 

1.1 ; 

•i.  • 


ll;i 


'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. 


.!...>   i. 


t  .... 
.!•■ 


I  •  :  '. 

ill-!  ■ 
!'.  .r  i.. 


'  t.<-  .-I' 
.1 1 

I*     •i'!H 

I,  ,.!    .. 
li.-    •■ 


11 


!■■•  • 
...  !i. 


:'.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-.  - 


1>< 
r:i 
en 
(•> 

r 

^i 
n 
u 
d 

ii 


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 
(li: 
yvh 
\vi 
111: 
a}, 

I1«V 

an 

car 
in 
an 
tia 

di. 

til 

a. 

vi 
\\' 

V 
V' 

ii 

f. 
ij 
1* 

I 

t 


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-. 


I'. -11 

d:v> 
mi 

^ia 
bii 

Tli 

n-i>i 
t!.. 

IT  I   ■ 

.■111 

»!!_'' 

aiit 

.•T:  i 

in 

SL'TI 


di: 

an 
ki 


111 


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&lthy,  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 

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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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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* 

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»fffir 

twi 

[ 

104^ 

103' 

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1 

k 

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l\ 

fe 

s 

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}    J 

38.3'^ 

137,7*^ 

!37,2'' 
37.0' 

iOO 

67' 

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/ 

/ 

/ 

^ 

\/ 

/ 

N 

. 

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r 

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.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 

/ 

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\ 

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^ 

1 

— 

^ 

50 
45 
40 
35 

25 

r 

'v" 

1 

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T 

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r 

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1 

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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 

/ 

/ 

/ 

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f 

/ 

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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 

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11 

1 2  1  1 3 

1'* 

15 

16 

c. 

107* 
106 

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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 

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9 

38  ST 

IV 

38.3' 

37  7" 
37.7 

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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.