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Full text of "Text-book of pediatrics"

UNIVERSITY OF CALIFORNIA 
AT LOS ANGELES 



GIFT OF 

David D. Thornton 




TEXT-BOOK 



OF 



PEDIATRICS 

EDITED BY 

PROFESSOR E. FEER 

DIRECTOR OF THE UNIVERSITY CHILDREN'S CLINIC, ZURICH 



TRANSLATED AND EDITED BY 

JULIUS PARKER SEDGWICK, B. S., M. D. 

PROFESSOR OF PEDIATRICS, UNIVERSITY OF MINNESOTA, MEDICAL SCHOOL 

AND 

CARL AHRENDT SCHERER, M.D., F.A.C.P. 

DULUTH, MINNESOTA 



262 ILLUSTRATIONS 



FIRST EDITION IN ENGLISH 




PHILADELPHIA AND LONDON 
J. B. LIPPINCOTT COMPANY 



COPYRIGHT, 1922, BY J. B. LIPPINCOTT COMPANY 



PRINTED BY J. B. LJPPINCOTT COMPANY 

AT THE WASHINGTON SQUARE PRliSS 

PHILADELPHIA, TJ. S. A. 



PREFACE 

THE introduction of this work to the physician and student is made easy 
by the widespread and favorable acquaintance it has achieved among those 
who have studied on the Continent or have read it in the original. The 
preface to the first edition sets forth the value of a text produced by the 
collaboration of a number of authors, each a master of his branch of the 
specialty. The plan of collaboration has been carried on in the translation. 
Up to the present no similar one volume work has appeared upon 
the market. 

A further distinct advantage is the concise treatment of the subject 
matter. The arrangement is such that no time is lost in referring to any one 
descriptive passage. The etiology, pathology, symptomatology and treat- 
ment are all complete, but as short as compatible with their purpose. The 
book covers the entire field of pediatrics as completely as more bulky vol- 
umes. The discussions of the individual disease conditions are absolutely 
dependable and the therapeutic measures advised are in line with the most 
recent accepted usage. 

Due to the interest of the American collaborators much has been added 
to the original subject matter and, through the kindness of numerous friends, 
who know the book in the original, a large number of illustrations have also 
been added. The editors take this opportunity to thank their associates, 
by whose help we were enabled to bring this work to completion, for their 
keen interest and their painstaking study of the sections revised by them. 
We also wish to thank Dr. R. O. Beard, Secretary of the Medical School 
of the University of Minnesota, for his careful revision of the English. 
To J. B. Lippincott Company we feel especially indebted for their patience 
and their appreciation of the problems of the translation. 

May the volume find as great a sphere of usefulness in this translation 
as it has had in the original. 

J. P. S. 
C. A. S. 
November 1st, 1922. 



PREFACE TO FIRST GERMAN EDITION 

A LARGE number of medicaltext-books,the products of the collaboration of 
a number of authors, have recently appeared. The great favor with which 
these works are received is the best indication of their value. When, there- 
fore, I was approached in 1909 by Mr. Gustaf Fisher with the suggestion 
that I edit a work of this nature, as a companion piece to the text on 
Internal Medicine by Krehl-Mering, I had no hesitancy especially since 
pediatrics is no longer a subject in which one author can have complete 
knowledge of all branches. I was able to interest a number of the most 
prominent pediatrists who were competent to write on the special subjects 
assigned to them. I believe that the work of these associates and the new 
method of presenting the subject in this volume with its numerous apt 
illustrations justify its production in spite of the great number of text-books 
on pediatrics already on the market. 

In order to give the student and general practitioner an introduction 
into the subject and an understanding of the child itself, it has been thought 
fit to make the general part very extensive. In the special part, those 
diseases not peculiar to childhood and fully described in text-books of gen- 
eral medicine were merely touched upon, in order to give space to the 
diseases that present definite peculiarities in childhood or occur only in 
children. A certain amount of duplication must of course occur, as for 
instance in those diseases classed as acute infections or " children's diseases." 
These are all considered in texts on general medicine, but belong specifically 
to this work. Special pains were taken to give full space to those diseases 
of childhood that are barely touched upon in general texts, but are of great 
importance to the podiatrist. Thus the subjects of varicella, pertussis and 
measles, given only one, two and one pages respectively in the Krehl-Mering 
text, have been accorded seven, ten and two and a half pages in this book. 

More space than is customary is devoted to early infancy. The disturb- 
ances of nutrition are discussed by the most able authors in accordance 
with most recent research. Those physicians who are accustomed to the old 
classification of dyspepsia, catarrh and enteritis, may be somewhat confused 
at first. The discussion of the disturbance of nutrition is based upon the 
study of the nutritional processes in the light of functional tests. These 
have led to a new classification and a more rational treatment. The older 
classification, though simple, is actually of little value as far as treatment is 
concerned. Those, however, who have already acquired this more recent 
view as, no doubt, all undergraduates have, will gladly recognize its great 
advances and will take advantage, clinically, of the benefits afforded by it 
in the treatment of the disturbances of nutrition, a most difficult phase of 
the practice of pediatrics. 

As far as the use of varied sizes of print is concerned, the small print 
is used for introductions and notes of a more or less general nature, not 



vi PREFACE TO SEVENTH GERMAN EDITION 

having direct bearing upon the subject under discussion, but essential for its 
understanding and to be especially brought to the reader's notice. 

The excellent ensemble of the work is due to the interest and painstaking 
care of the publisher who has spared no means to produce the best at a 
reasonable price. His efforts have further made it possible to obtain new 
illustrations that are most applicable to the text. 

May this new text-book be a reliable guide and advisor to both the 
undergraduate and practicing physician. 

E. FEER. 



PREFACE TO SEVENTH GERMAN EDITION 

THE demand for a new edition, so soon after the appearance of the last, 
has necessitated but few changes. Nevertheless, all the authors have 
revised their sections and made additions and improvements. Special pains 
have been taken to enlarge upon the therapy. By more concise handling 
of several sections, it has been possible to reduce the size of the volume 
by twenty-four pages. 

In place of our late colleague, Professor Tobler, Professor Noeggerath 
consented to take on a portion of the work and has completely revised the 
section on genito-urinary diseases, bringing out the advances made during 
the last few years in the study of the nephropathies. 

Furthermore, we must again report the loss of a colleague, Professor 
Martin Thiemich, who died February 16, 1921, following a long illness, at 
the age of fifty-one. This was a great loss not only to our text-book but also 
to the science of pediatrics and the University of Leipzig. His last work 
was the correction and revision of his section of this text. 

E. FEER. 



TEXT-BOOK OF PEDIATRICS 

EUROPEAN CONTRIBUTORS 

PEER, E., PROFESSOR DR., Zurich. 
FINKELSTEIN, H. f PROFESSOR DR., Berlin. 
IBRAHIM, J., PROFESSOR DR., Jena. 
MEYER, L. P., PRiv.-Doz. DR., Berlin. 
MORO, E., PROFESSOR DR., Heidelberg. 
NOEGGERATH, C., PROFESSOR DR., Freiburg i Br. 
THIEMICH, M. ; PROFESSOR DR., Leipzig. 
v. PFAUNDLER, M., PROFESSOR DR., Munich. 
v. PIRQUET, CL. FRH., PROFESSOR DR., Vienna. 

AMERICAN COLLABORATORS 

BRENNEMANN, JOSEPH, M.D., Chicago, 111. 

Attending Pediatrist, Children's Hospital, Chicago. 
BYFIELD, ALBERT H., M.D., Iowa City, la. 

Professor of Pediatrics, College of Medicine, State University of Iowa. 
CALHOUN, HENRIETTA M.A., M.D., Iowa City, la. 

Assistant professor of Pathology, College of Medicine, State University of Iowa. 
DE BUYS, L. R., M.D., F.A.P.C., New Orleans, La. 

Professor of Diseases of Children, School of Medicine, Tulane University of 

Louisiana; Chief of Pediatrics, Turo Infirmary. 
DIETRICH, HENRY, M.D., Los Angeles, California. 

' Attending Pediatrist, Children's Hospital, Los Angeles. 
FLEISCHNER, E. C., M.D., San Francisco, Calif. 

Clinical Professor of Pediatrics, University of California. 
HESS, JULIUS H., M.D., Chicago, 111. 

Professor and Head of the Department of Pediatrics, University of Illinois, 

College of Medicine; Chief of Pediatric Staff, Cook County Hospital. 
HOFFMANN, WALTER H. O. f M.D., Chicago, 111. 

Associate Attending Pediatrist, Children's Memorial Hospital, Chicago. 
HOOBLER, B. RAYMOND, M.D., Detroit, Mich. 

Professor of Pediatrics, Detroit College of Medicine and Surgery. 
IRVINE, HARRY GARFIELD, M.D., Minneapolis, Minn. 

Associate Professor of Dermatology and Syphilis, Medical School, University of 

Minnesota; Director of the Division of Venereal Diseases, Minnesota State 

Board of Health. 
JEANS, PHILIP C., St. Louis, Mo. 

Associate Professor of Pediatrics, Washington University School of Medicine* 
MEYER, K. F., M.D., San Francisco, Calif. 

Professor of Research Medicine, University of California. 
OTT, M. D., M.D., Minneapolis, Minn. 

Associate in Pediatrics, University of Minnesota, Medical School. 
PIERCE, NABOTH OSBORNE, M.D., Minneapolis, Minn. 

Assistant Professor of Pediatrics, University of Minnesota, Medical School, 
SCAMMON, RICHARD EVERINGHAM, M.D., Minneapolis, Minn. 

Professor of Anatomy, University of Minnesota, Medical School. 



CONTENTS 



GENERAL CONSIDERATIONS 

by 
PROFESSOR DR.' MARTIN THEIMICH, 

Director of the University Children's Clinic, Leipzig. 

PAGE 

I. ANATOMIC AND PHYSIOLOGIC PECULIARITIES 1 

Revised and Edited by 
DR. RICHARD EVERINGHAM SCAMMON, Minneapolis, Minn., 

Professor of Anatomy, University of Minnesota Medical School. 

II. CARE AND FEEDING OF THE NORMAL INFANT 36 

Revised and Edited by 
JULIUS H. HESS, M. D., Chicago, 111., 

Professor and Head of the Department of Pediatrics, University of Illinois, College of 
Medicine, Chief of Pediatrie Staff, Cook County Hospital. 

III. GENERAL SYMPTOMATOLOGY AND TECHNIC OF EXAMINATION 70 

Revised and Edited by 
L. R. DEBUYS, M. D., F. A. C. P., New Orleans, La., 

Professor of Diseases of Children, S?hool of Medicine, Tulane University of 
Louisiana; Chief of Pediatrics, Turo Infirmary. 



IV. GENERAL PATHOGENESIS, MORTALITY AND MORBIDITY 

Revised and Edited by 
B. RAYMOND HOOBLER M. D., Detroit, Mich., 

Professor of Pediatrics, Detroit College of Medicine and Surgery. 



V. GENERAL PROPHYLAXIS AND THERAPY 98 

Revised and Edited by 
ALBERT H. BYFIELD, M. D., IOWA CITY, IOWA., 

Professor of Pediatrics, College of Medicine, State University of Iowa. 

SPECIAL PART 

SECTION I. DISEASES OF THE NEW-BORN 

by 
PROFESSOR DR. MED. AND PHIL. HEINRICH FINKELSTEIN, 

Director of the Kinderkrankenhaus, Berlin, 
and 

PRIVATDOZENT DR. LUDWIG MEYER, 

Chief Pediatrist to the Orphanage and Children's Asylum of the City of Berlin. 

Revised and edited by 
NABOTH OSBORNE PIERCE, M. D., Minneapolis, Minn., 

Assistant Professor of Pediatrics, University of Minnesota, Medical School. 

DISEASES OF THE NEW-BORN 121 

ASPHYXIA 125 

BIRTH TRAUMATA 127 

EXTERNAL CEPHALHEMATOMA : 127 

INTERNAL CEPHALHEMATOMA 129 

CEREBRAL HEMORRHAGE ... . 129 



CONTENTS 

PAGE 

HEMATOMA OF THE STERNOCLEIDOMASTOID 130 

PARALYSES ,00 

DISEASES OF THE UMBILICUS 

CONGENITAL ANOMALIES 

INFECTIONS OF THE UMBILICUS 

GANGRENE OF THE STUMP .. 

BLENNORRHEA ^ - 

UMBILICAL ULCER , o Q 

UMBILICAL FUNGUS (GRANULOMA OF THE UMBILICUS) " 

OMPHALITIS (ACUTE INFLAMMATION OF THE UMBILICAL KING) i^y 

GANGRENE OF THE UMBILICUS j^l 

MIGRATORY INFECTION 

TETANUS NEONATORUM 

UMBILICAL HEMORRHAGE JT: 

SEPSIS 1 4 

MELENA NEONATORUM j|* 

ERYSIPELAS |CQ 

OPHTHALMIA NEONATORUM ***? 

SWELLING OF THE MAMMARY GLAND AND MASTITIS 101 

ICTERUS NEONATORUM J^ 

EDEMA AND SCLEREDEMA OF THE NEW-BORN 



ALBUMINURIA 

URIC ACID INFARCTS . . . 
VAGINAL HEMORRHAGE. 



154 



SECTION II. PATHOLOGICAL CHANGES OF THE BLOOD AND 
BLOOD-FORMING ORGANS 

CONSTITUTIONAL ANOMALIES AND DISEASES OF METABOLISM 

by 
PROFESSOR DR. MEINHARD VON PFAUNDLER, 

Director of the University Children's Clinic, Munich. 

Revised and Edited by 

M. D. OTT M. D., Minneapolis, Minn., 

Associate in Pediatrics, University of Minnesota, Medical School. 

INTRODUCTION 156 

PHYSIOLOGY AND PATHOLOGY OF THE BLOOD 156 

A. GROUP OF ANEMIAS (GENERAL SYMPTOMATOLOGY) 159 

ANEMIA DUE TO PRIMARY INTERFERENCE WITH ERYTHROPOIESIS 161 

ANEMIAS DUE TO Loss OF BLOOD .' 164 

HEMOCYTOLYTIC AND MYELOPATHIC ANEMIAS 165 

THE TREATMENT OF ANEMIA 172 

APPENDIX: PSEUDO-ANEMIAS 174 

B. GROUP OF LEUCEMIAS AND PSEUDOLEUCEMLAS 175 

LYMPHOCYTOMATOSES 176 

LEUCEMIC LYMPHADENOSIS OR LYMPHATIC LEUCEMIA 176 

LYMPHOSARCOMATOSES 178 

THE MYELO-CYTOMATOSES 179 

MYELOSARCOMATOSES 181 

CHOROMATA 181 

GRANULOMATOSES 182 

PATHOGENESIS OF LEUCEMIA AND PSEUDOLEUCEMIA 183 

THERAPY 183 

HEMORRHAGIC DIATHESIS OR TENDENCY TO HEMORRHAGE 184 

INFANTILE SCURVY (BARLOW'S DISEASE) 186 

RICKETS 190 

CLINICAL SYMPTOMS AND THEIR ORIGIN 196 

SKELETAL MANIFESTATIONS 196 

COURSE, COMPLICATIONS: TERMINATION 203 

DIFFERENTIAL DIAGNOSIS 203 

DIABETES MELLITUS 208 

OBESITY 210 

UNDER-NOURISHED OR FRAIL CHILDREN . . .211 



CONTENTS xi 

PAGE 

TREATMENT 213 

PECULIAR PREDISPOSITIONS TO DISEASE (DIATHESES) AND CONSTITU- 
TIONAL ANOMALIES 213 

THE INFLAMMATORY OR EXUDATIVE DIATHESIS 214 

ARTHRITISM IN CHILDHOOD 221 

APPENDIX: PATHOLOGY OP THE GLANDS OF INTERNAL SECRETION 226 

A. PATHOLOGY OF THE THYROID 226 

HYPOTHYREOSIS; ATHYREOSIS 226 

GENERAL SYMPTOMS AND THEIR CAUSES 227 

SPECIAL CLINICAL CONSIDERATIONS OF HYPOTHYREOSES 231 

INFANTILISM 233 

TREATMENT 233 

GOITRE 234 

BASEDOW'S DISEASE ; 235 

INFANTILE BASEDOWOID DISEASE 235 

B. PATHOLOGY OF THE GERMINAL ORGANS 235 

C. PATHOLOGY OF THE HYPOPHYSIS 236 

D. DISTURBANCES OF GROWTH 236 

GENERAL PHYSICAL ANOMALIES OCCURRING WITHOUT RECOGNIZED RE- 
LATION TO THE HEMIC GLANDS 236 

OSTEOGENESIS IMPERFECTA (VROLIK) 237 

OSTEOPSATHYROSIS 237 

SECTION III. DISEASES OF THE DIGESTIVE SYSTEM 

by 
PROFESSOR DR. MED. AND PHIL. HEINRICH FINKELSTEIN, 

Director of the Kinderkrankenhaus, Berlin, 
and 

PRIVATDOZENT DR. LUDWIG MEYER, 

Chief Podiatrist to the Orphanage and Children's Asylum of the City of Berlin. 

Revised and Edited by 
JOSEPH BRENNEMANN, M. D., Chicago, 111., 

Attending Podiatrist, Children's Memorial Hospital, Chicago. 

DISEASES OF THE MOUTH 242 

STOMATITIS 242 

ANOMALIES OF THE TEETH AND TEETHING 247 

DISEASES OF THE SALIVARY GLANDS 248 

DISEASES OF THE TONSILS, THE PHARYNX AND THE ESOPHAGUS 248 

ANGINA 248 

CATARRHAL ANGINA AND EXUDATIVE ANGINA 249 

HYPERPLASIA OF THE TONSIL 252 

RETROPHARYNGEAL LYMPHADENITIS AND RETROPHARYNGEAL ABSCESS. . 252 

CONGENITAL ANOMALIES OF THE ESOPHAGUS 254 

ACQUIRED DISEASES OF THE ESOPHAGUS 254 

NUTRITIONAL DISTURBANCES OF INFANTS 255 

DISTURBANCES OF NUTRITION OF THE ARTIFICIALLY-FED INFANT 256 

GENERAL ETIOLOGY AND PATHOGENESIS 256 

GENERAL SYMPTOMATOLOGY 262 

CLASSIFICATION 264 

A. NUTRITIONAL DISTURBANCES WITHOUT Toxic MANIFESTATIONS 

WITHOUT DIARRHOEA 265 

DYSTROPHY 265 

NUTRITIONAL DISTURBANCES WITHOUT Toxic MANIFESTATIONS WITH 

DIARRHOEA 273 

DECOMPOSITION (PEDATROPHY) 278 

B. NUTRITIONAL DISTURBANCES WITH Toxic MANIFESTATIONS 289 

ACUTE DYSPEPSIA 289 

INTOXICATION (ALIMENTARY TOXICOSIS, ENTERO-CATARRH, CHOLERA 

INFANTUM, ETC 291 

INFECTION AND NUTRITION 299 

THE DISTURBANCES OF NUTRITION OF BREAST-FED INFANTS 303 

DISEASES DUE TO ENDOGENOUS (CONSTITUTIONAL) CAUSES 305 



xii CONTENTS 

PAGE 

DISTURBANCES OF NUTRITION OP OLDER CHILDREN 307 

ACUTE DYSPEPSIA AND DYSPEPTIC COMA 307 

CHRONIC DYSPEPSIA 308 

SEVERE CHRONIC DIGESTIVE INSUFFICIENCY IN OLDER CHILDREN 311 

ACUTE INFECTIOUS DISEASES OF THE GASTRO-INTESTINAL TRACT 314 

DYSENTERY 316 

INTESTINAL TUBERCULOSIS 320 

INTESTINAL POLYPOSIS 321 

NERVOUS GASTRO-INTESTINAL DISEASES 322 

CONGENITAL SPASTIC PYLORIC STENOSIS 322 

HABITUAL AND UNCONTROLLABLE VOMITING OF INFANTS 325 

SIMPLE PYLOROSPASM 325 

THE PERIODIC VOMITING OF OLDER CHILDREN 326 

NERVOUS VOMITING 327 

NERVOUS ANOREXIA 328 

OBSTRUCTION OF THE INTESTINAL CANAL 329 

CONGENITAL INTESTINAL STENOSIS 329 

DILATATION AND HYPERTROPHY OF THE COLON 330 

HIRSCHSPRUNG'S DISEASE 330 

CONSTIPATION 331 

INTUSSUSCEPTION - 333 

PROLAPSE OF THE RECTUM 335 

HERNIAS 336 

ENTOZOA 337 

DISEASES OF THE LIVER 339 

CATARRHAL JAUNDICE 339 

OTHER FORMS OF ACUTE JAUNDICE 339 

CIRRHOSIS OF THE LIVER 339 

TUMORS OF THE LIVER 340 

CONGENITAL OBSTRUCTION OF THE BILE DUCTS 340 

DISEASES OF THE PERITONEUM 341 

PURULENT PERITONITIS 341 

PERITONITIS IN OLDER CHILDREN FOLLOWING APPENDICITIS 341 

OTHER FORMS OF PURULENT PERITONITIS IN OLDER CHILDREN 342 

TUBERCULOUS DISEASES OF THE PERITONEUM 34*3 

TUBERCULOSIS OF THE MESENTERIC AND RETROPERITONEAL LYMPH 

NODES 343 

FETAL PERITONITIS 345 

TUMORS 346 

SECTION IV. DISEASES OF THE RESPIRATORY ORGANS 

by 
PROFESSOR DR. CLEMENS FREIHERR VON PIRQUET, 

Director of the University Children's Clinic, Vienna. 

Revised and Edited by 
WALTER H. O. HOFFMANN, M. D., Chicago, III., 

Associate Attending Pediatrist, Children's Memorial Hospital, Chicago. 

DISEASES OF THE NOSE 347 

RHINITIS, CORYZA ] 347 

THE CLINICAL SYMPTOMS OF ACUTE RHINITIS '. 350 

CHRONIC CORYZA 352 

ADENOID VEGETATIONS 

FOREIGN BODIES IN THE NOSE 354 

EPISTAXIS 354 

DISEASES OF THE EUSTACHIAN TUBES AND THE MIDDLE EAR . 355 

OTITIS MEDIA CATARRHALIS NEONATORUM . 356 

ACUTE OTITIS MEDIA 356 

CHRONIC OTITIS MEDIA 359 

FOREIGN BODIES IN THE EXTERNAL AUDITORY CANAL. . 360 

CONGENITAL STRIDOR 360 

ACUTE LARYNGITIS (PSEUDOCROUP) 361 

FOREIGN BODIES IN THE BRONCHIAL TUBES 363 



CONTENTS xiii 

PAGE 

PAPILLOMA OF THE LARYNX 364 

THE ACUTE TRACHEOBRONCHITIS OF OLDER CHILDREN 364 

BRONCHITIS 364 

ASTHMATIC BRONCHITIS 368 

CAPILLARY BRONCHITIS 370 

BRONCHO-PNEUMONIA 373 

LOBAR PNEUMONIA 376 

CHRONIC PNEUMONIA 381 

EMPHYSEMA 382 

BRONCHIECTASIS 382 

PLEURISY 383 

EMPYEMA 384 

SEROFIBRINOUS PLEURISY 386 

TREATMENT OF SEROUS PLEURISY 388 

SECTION V. DISEASES OF THE HEART 

by 
PROFESSOR DR. E. FEER, 

Director of the University Children's Clinic, Zurich, Switzerland. 

Revised and Edited by 
HENRIETTA CALHOUN, M. A., M. D., Iowa City, Iowa, 

Assistant Professor of Pathology, College of Medicine, State University of Iowa. 

DISEASES OF THE HEART 389 

HEART MURMURS 391 

NERVOUS DISTURBANCES 393 

CONGENITAL HEART LESIONS 394 

DEFECT OF THE INTERVENTRICULAR SEPTUM 396 

ROGER'S DISEASE 396 

PATENCY OF THE DUCTUS ARTERIOSUS (BOTALLI) 397 

PULMONARY STENOSIS 398 

AORTIC STENOSIS 399 

TRANSPOSITION OF THE GREAT VESSELS 399 

ACUTE ENDOCARDITIS 400 

CHRONIC ENDOCARDITIS AND ACQUIRED VALVULAR LESIONS 403 

ACUTE PERICARDITIS 407 

PERICARDIAL ADHESIONS 411 

MYOCARDITIS AND CARDIAC INSUFFICIENCY 413 

APPENDIX: BLOOD-VESSELS AND JUVENILE HEART 417 

SECTION VI. DISEASES OF THE GENITO-URINARY TRACT 

by 
PROFESSOR DR. C. NOEGGERATH, 

Director of the University Children's Clinic, Freiburg in Breisgau. 

INTRODUCTION 419 

UREMIA 420 

ORTHOTIC ALBUMINURIA 421 

TUBULAR NEPHROPATHY OR NEPHROSIS 428 

ACUTE DIFFUSE GLOMERULAR NEPHROPATHY, ACUTE GLOMERULAR 

NEPHRITIS 431 

GLOMERULO-TUBULAR NEPHROPATHY (MIXED FORM) 434 

KIDNEY DISEASES IN INFANTS 436 

CHRONIC KIDNEY DISEASE 436 

CHRONIC NEPHRITIS OF CHILDHOOD (PEDONEPHRITIS) 437 

NEPHRITIS WITH CONGENITAL SYPHILIS 438 

PURULENT DISEASES OF THE URINARY TRACT AND THE KIDNEYS . . . 439 

CYSTOPYELITIS; PYELONEPHRITIS AND RENAL ABCESSES 439 

DIABETES INSIPIDUS 445 

ENTJRESIS 446 

VULVO-VAGINITIS 449 

PHIMOSIS, PARAPHIMOSIS AND BALANITIS 452 



X1V CONTENTS 

PAGE 

HYDROCELE (SEROUS PERIORCHITIS) 453 

ANOMALIES IN POSITION OP THE TESTES 453 

MASTURBATION 454 

NEW GROWTHS 455 

SECTION VII. DISEASES OF THE NERVOUS SYSTEM 

by 
PROFESSOR Da. JUSSUF IBRAHIM, 

Director of the University Children's Clinic, Jena. 

ORGANIC DISEASES OF THE NERVOUS SYSTEM 457 

I. DISEASES OF THE MENINGES 

TUBERCULOUS MENINGITIS 458 

PURULENT MENINGITIS (MENINGITIS SIMPLEX) 465 

MENINGOCOCCUS MENINGITIS OR EPIDEMIC CEREBRO-SPINAL MEN- 
INGITIS i 467 

SEROUS MENINGITIS 474 

MENINGISM, HYDROCEPHALOID 476 

THE MENINGITIS OF CONGENITAL SYPHILIS 476 

SINUS THROMBOSIS 476 

II. CHRONIC HYDROCEPHALUS 477 

EXTERNAL HYDROCEPHALUS 477 

CHRONIC INTERNAL HYDROCEPHALUS 477 

HYDRENCEPHALY 483 

III. RETARDATION OF DEVELOPMENT 483 

GROSS MALFORMATIONS OF THE BRAIN 483 

MICROCEPHALY 484 

SPINA BIFIDA (RACHISCHISIS) AND CEPHALOCELE 484 

SPINA BIFIDA OCCULTA 486 

HYPERTROPHY OF THE BRAIN 487 

PYRGOCEPHALY, OXYCEPHALY 487 

CONGENITAL FUNCTIONAL DEFECTS OF THE CRANIAL MOTOR NERVES. . . . 488 
CONGENITAL APLASIA OF THE NUCLEUS; ABSCENCE OF THE NUCLEUS; 

INFANTILE NUCLEAR ATROPHY 488 

CONGENITAL MUSCULAR DEFECTS 488 

CONGENITAL M YATONIA 489 

IV. DISTURBANCE OF THE CEREBRAL CIRCULATION 489 

CONCUSSION OF THE BRAIN (COMMOTIO CEREBRI) 490 

V. ACUTE ENCEPHALITIS 491 

APPENDIX : 493 

VI. EPIDEMIC ENCEPHALITIS (LETHARGIC ENCEPHALITIS EPIDEMIC POLIOMY- 

ELO-ENCEPHALITIS, SLEEPING SlCKNESS) 494 

VII. BRAIN ABSCESS, PURULENT ENCEPHALITIS 496 

VIII. CEREBRAL TUMOR 497 

IX. CEREBRAL PARALYSIS OF CHILDREN; INFANTILE CEREBRAL PALSY 499 

SPASTIC INFANTILE HEMIPLEGIA AND DIPLEGIA 499 

SPASTIC INFANTILE HEMIPLEGIA; UNILATERAL CEREBRAL PARALYSIS 

OF CHILDREN 501 

SPASTIC INFANTILE DIPLEGIA; CEREBRAL DIPLEGIA OF CHILDREN 503 

PECULIAR TYPES OF THE DISEASE 505 

X. SCLEROSIS OF THE CENTRAL NERVOUS SYSTEM 510 

XI. ACUTE POLIOMYELITIS; SPINAL PARALYSIS OF CHILDREN 510 

HEINE-MEDIN'S DISEASE; ACUTE EPIDEMIC INFANTILE PARALYSIS... 510 

XII. DISEASES OF THE SPINAL CORD 521 

MYELITIS 521 

TABES DORSALIS 521 

TUMORS OF THE CORD 521 

XIII. ENDOGENOUS OR HEREDITO-FAMILIAL DISEASES OF THE NERVOUS AND MUS- 
CULAR SYSTEMS 522 

AMAUROTIC FAMILIAL IDIOCY (T AY-SACHS' IDIOCY) 523 

JUVENILE AMAUROTIC FAMILIAL IDIOCY 523 

FAMILIAL CEREBRAL DIPLEGIAS AND FORMS OF CEREBROSPINAL DISEASE 524 

DISEASES OF THE MYOSTATIC SYSTEM 524 

HEREDITARY ATAXIA (FRIEDREICH'S ATAXIA) 525 



CONTENTS xv 

PAGE 

MUSCULAR ATROPHIES 526 

UNCOMMON FORMS 528 

XIV. DISEASES OF THE PERIPHERAL NERVOUS SYSTEM 528 

PARALYSES 528 

NEURALGIA 529 

POLYNEURITIS 529 

XV. DISEASES OP THE MUSCLES 529 

FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM 530 

I. CONVULSIVE DISEASES . '. 530 

SPASMOPHILIA OR SPASMOPHILIC DIATHESIS 530 

LARYNGOSPASM, TETANY AND ECLAMPSIA 530 

ECLAMPSIA DUE TO NON-SPASMOPHILIC CAUSES 541 

GENERAL MUSCULAR HYPERTONIA, WITHOUT SPASMOPHILIA 543 

NUTANT AND ROTATORY SPASMS 543 

PSEUDOTETANUS 544 

EPILEPSY 545 

II. CHOREA MINOR (ST. VITUS DANCE) 549 

PARAMYOCLONUS MULTIPLEX; CHOREA ELECTRICA 553 

III. NEUROPATHIC AND PSYCHOPATHIC CONSTITUTION 553 

HEREDITARY NEUROPATHY 553 

MIGRAINE: HEMICRANIA 556 

MALADIE DBS TICS CONVULSIFS 556 

EMOTIONAL RESPIRATORY CONVULSIONS: ABSENCES 557 

PATHOLOGIC REFLEXES 558 

PAVOR NOCTURNUS 558 

NEURASTHENIA 559 

PHOBIAS; UNCONTROLLABLE IDEAS AND ACTS 561 

DISTURBANCES OF PSYCHICAL IMPULSES 562 

HYSTERIA 562 

IV. PSYCHOSES 567 

CONGENITAL AND EARLY ACQUIRED DEFECT PSYCHOSES (FEEBLE MIND- 

EDNESS, IDIOCY; IMBECILITY, MENTAL DEBILITY) .... 567 

ACQUIRED DEFECT PSYCHOSES 569 

HEBEPHRENIA: CATATONIA OR DEMENTIA Pn^cox 570 

PSYCHOSES WITHOUT DEFECTS OF INTELLIGENCE 570 

SECTION VIII. THE ACUTE INFECTIOUS DISEASES 

by 
PROFESSOR DR. E. FEER, 

Director of the University Children's Clinic, Zurich. 

Revised and Edited by 
E. C. FLEISCHNER, M. D., San Francisco, Calif., 

Clinical Professor of Pediatrics, University of California, 

and 
K. F. MEYER, M. D., San Francisco, Calif., 

Professor of Research Medicine, University of California. 

GENERAL CONSIDERATION 571 

SCARLET FEVER 579 

PECULIARITIES, SEQUELAE AND COMPLICATIONS OF SCARLET FEVER 588 

MEASLES (MORBILLI) 598 

RUBELLA (GERMAN MEASLES ROTELN) 616 

INFECTIOUS ERYTHEMA 620 

DUKE'S "FOURTH" DISEASE 622 

VARICELLA (CHICKEN-POX) 623 

PECULIARITIES OF THE EXANTKEM 626 

VACCINATION (Cow-pox) 630 

PECULIARITIES OF COURSE AND COMPLICATIONS 634 

DIPHTHERIA 637 

PATHOGENESIS AND PATHOLOGIC ANATOMY 641 

THE GENERAL DISEASE-PICTURE 642 

MILD FORMS 644 

SEVERE FORMS . . 645 



xvi CONTENTS 

PAGE 

SPECIAL LOCALIZATIONS OF DIPHTHERITIC MEMBRANES 646 

NASAL DIPHTHERIA 647 

AURAL DIPHTHERIA 648 

DIPHTHERIA OF THE LARYNX, TRACHEA AND BRONCHI 648 

RARE LOCALIZATIONS OF DIPHTHERIA 651 

PECULIARITIES OF DIPHTHERITIC MEMBRANES 652 

THE EFFECT OF DIPHTHERIA ON VARIOUS ORGANS 653 

COMPLICATIONS AND SEQUELS 653 

THE DIAGNOSIS OF DIPHTHERIA 656 

DIFFERENTIAL DIAGNOSIS 656 

DIFFERENTIAL DIAGNOSIS OF AFFECTIONS OF THE LARYNX 657 

PERTUSSIS OR WHOOPING-COUGH 672 

VARIATIONS IN COURSE 675 

SPECIAL SYMPTOMS AND COMPLICATIONS 676 

MUMPS (EPIDEMIC PAROTITIS) 684 

TYPHOID FEVER 688 

PECULIARITIES OF COURSE; COMPLICATIONS 692 

PARATYPHOID 698 

INFLUENZA AND GRIPPAL DISEASES 699 

ACUTE ARTICULAR RHEUMATISM (POLYARTHRITIS ACUTA) 706 

PECULIARITIES OF THE COURSE WITH IMPLICATIONS OF VARIOUS ORGANS . 708 

CHRONIC RHEUMATISM 711 

ERYSIPELAS 713 

GENERAL SEPSIS 715 

SECTION IX. TUBERCULOSIS 

by 

PROFESSOR DR. CLEMENS FREIHERR VON PIRQUET, , 

Director of the University Children's Clinic, Vienna. 

Revised and Edited by 
HENRY DIETRICH, M. D., Los Angeles, Calif. 

Attending Pediatrician, Children's Hospital, Los Angeles. 

TUBERCULOSIS 720 

CLINICAL MANIFESTATIONS 725 

PRIMARY STAGE 725 

TUBERCULOSIS OF THE BRONCHIAL LYMPH NODES 726 

PRIMARY TUBERCULOSIS OF THE LUNGS 727 

THE SECONDARY STAGES; OR THE GENERAL SPREAD OF TUBERCULOSIS. 728 

SCROFULA 739 

CHRONIC PULMONARY TUBERCULOSIS; THE TERTIARY STAGE 735 

SECTION X. SYPHILIS 

by 
PROFESSOR DR. ERNST MORO, 

Director of the University Children's Clinic, Heidelberg. 

Revised and Edited by 
PHILIP C. JEANS, M. D., St. Louis, Mo., 

Associate Professor of Pediatrics, Washington University School of Medicine. 

ETIOLOGY AND NATURE 750 

MODES OF INFECTION 752 

CONGENITAL SYPHILIS . 754 

FETAL SYPHILIS 755 

INFANTILE SYPHILIS \ 757 

RECURRENCES IN EARLY CHILDHOOD . 774 

LATE CONGENITAL SYPHILIS: 775 

THE DIAGNOSIS OF CONGENITAL SYPHILIS .... 777 

PROGNOSIS [ 781 

THE TREATMENT OF CONGENITAL SYPHILIS '. 782 

ACQUIRED SYPHILIS IN CHILDREN 785 



CONTENTS xvii 

PAGE 

SECTION XI. DISEASES OF THE SKIN 

by 
PROFESSOR DR. ERNST MORO, 

Director of the University Children's Clinic, Heidelberg. 

Revised and Edited by 
HARRY GARFIELD IRVINE, M. D., Minneapolis, Minn. 

INTRODUCTION. 787 

ECZEMA 791 

INTERTRIGINOUS ECZEMA 793 

ERYTHRODERMIA 795 

CONSTITUTIONAL ECZEMA OF INFANTS 796 

URTICARIA 803 

SIMPLE URTICARIA 804 

ACUTE CIRCUMSCRIBED EDEMA OF THE SKIN (GIANT URTICARIA) 805 

STROPHULUS 805 

PRURIGO 807 

MULTIPLE ERYTHEMA (ERYTHEMA MULTIFORME) 809 

IMPETIGO 811 

IMPETIGO CONTAGIOSA 811 

PEMPHIGUS NEONATORUM 812 

DERMATITIS EXFOLIATIVA 813 

FURUNCULOSIS 814 

PARASITIC SKIN DISEASES 815 

PEDICULOSIS 815 

SCABIES 816 

TUBERCULOSIS 818 

LUPUS 819 

SCROFULODERMA 821 

LICHEN, ACNE, ECZEMA 822 

THE SMALL PAPULAR TUBERCULIDE OF INFANCY 824 

THE PAPULO-NECROTIC TUBERCULIDE 824 

SUPPLEMENT 

EXUDATIVE DERMATOSIS 825 

URTICARIA PIGMENTOSA (XANTHELASMOIDEA) 825 

HERPES SIMPLEX (HERPES FEBRILIS, HERPES LABIALIS, COLD SORES, 

FEVER BLISTERS) 826 

HERPES ZOSTER (ZONA SHINGLES) 827 

PEMPHIGUS 827 

PEMPHIGUS ACUTUS 828 

PEMPHIGUS FOLIACEUS 828 

PEMPHIGUS VEGETANS 828 

PEMPHIGUS VULGARIS 828 

EPIDERMOLYSIS BULLOSA 829 

HYDROA VACCINIFORME 829 

INFLAMMATIONS OF THE SKIN 830 

DERMATITIS VENENATA 830 

DRY SCALY INFLAMMATORY DERMATOSES 831 

PlTYRIASIS ROSEA (HERPES TONSURANS MACULOSUS, PlTYRIASIS 

CIRCINATA) 831 

PSORIASIS 832 

INFECTIOUS DISEASES OF THE SKIN 834 

GRANULOMA PYOGENICUM 834 

FAVUS (TINEA FAVOSA) 834 

TINEA TRICHOPHYTINA (RINGWORM, TRYCHOPHYTOSIS) 835 

TINEA TRICHOPHYTINA CORPORIS (TINEA CIRCINATA: RINGWORM 

OF THE BODY; TRICHOPHYTOSIS CORPORIS.) 835 

TINEA TRICHOPHYTINA CRURIS (TINEA CRURIS; ECZEMA MARGI- 

NATUM; DHOBIE ITCH) 836 

ONYCHOMYCOSIS (RINGWORM OF THE NAILS) 837 

TINEA TRICHOPHYTON CAPITIS (TINEA CAPITIS: TINEA TONSURANS: 
RINGWORM OP THE SCALP) 837 



xviii CONTENTS 

PAGE 

DISEASES OP THE APPENDAGES OF THE SKIN 839 

MILIARIA 839 

MILIUM (STROPHULUS ALBIDUS, ACNE ALBIDA) 840 

COMEDO 840 

GROUPED COMEDONES IN CHILDREN 840 

ACNE NEONATORUM - 840 

ACNE VULGARIS 840 

ALOPECIA AREATA 841 

BENIGN EPITHELIAL GROWTHS 842 

ADENOMA SEBACEUM 842 

HYPERTROPHIES 843 

VERRUCA VULGARIS 843 

VERRUCA PLAN^E JUVENILIS 843 

KERATODERMIA PALMARIS ET PLANTARTS (SYMMETRICAL KERATO- 
DERMIA OF THE EXTREMITIES, CONGENITAL KERATOMA OF THE 

PALMS AND SOLES, ICHTHYOSIS, PALMARIS ET PLANTARIS) 844 

ICHTHYOSIS (XERODERMA, FISHSKIN DISEASE) 844 

ATROPHIES 847 

XERODERMA PIGMENTOSUM 847 

DEGENERATIVE NEOPLASMATA 848 

MOLLUSCUM CONTAGIOSUM (MOLLUSCUM SEBACEUM, EPITHELIOMA 

CONTAGIOSUM) 848 

XANTHOMA (FIBROMA LIPOMATODES, XANTHELASMA) 849 

NEVUS (BIRTH-MARK) : 849 

NEVUS PlGMENTOSUS (PlGMENTED MOLE) 849 

NEVUS VASCTTLOSUS (NEVUS SANGUINEUS, NEVUS FLAMMEUS, MOTHS 

MARK, BIRTH-MARK, PORT-WINE-MARK) 851 

TELANGIECTASIS . 852 



GENERAL CONSIDERATIONS 

BY 
MARTIN THIEMICH, LEIPZIG. 



I. ANATOMIC AND PHYSIOLOGIC PECULIARITIES 

REVISED BY 
Dr. RICHARD EVERINGHAM SCAMMON, 

Professor of Anatomy, University of Minnesota Medical School, Minneapolis. 

THE new-born infant is, by no means, to be considered a miniature of the 
adult. While obvious differences are shown externally in the relatively 
large head and small face, the short extremities, the notable arching of the 
thoracic walls, the undeveloped genitalia, etc; numerous other differences in 
anatomic and histologic structure and in the physiologic functions of the 
various organs and systems of organs are discoverable by careful study. 
Certain of these, of especial interest to the physician, will be described. 
Those which are merely of anatomic interest, or useful in the study of cases 
which come to autopsy will be specifically noted in Chapter III. 

The body of the child contains more water than that of the adult; the 
largest percentage is found in the fetus; the proportion decreases rapidly 
toward puberty. The body of the new-born contains about 25 per cent, 
of solids and that of the adult about 33 per cent. Under normal conditions, 
an increased water content of the infant body causes a correspondingly 
increased turgor or sense of resistance of the skin and subcutaneous tissues. 

Among the differences described in the chemical composition of the 
entire organism, special attention may be called to one item. In the last 
months of fetal life, a considerable deposit of iron salts is gathered in the 
liver, enabling the infant to exist for a varying length of tune upon a diet as 
poor in iron as mother's or cow's milk, without lack of this essential material 
for the purpose of blood metabolism. 

The Anatomic and Hemodynamic Relations of the Heart. These show 
great departures from adult life. The absolute weight of the heart in the 
new-born averages about 20-25 grams, about one-twelfth the adult weight of 
the organ. At birth the organ forms about 0.7 per cent, of the body-weight 
compared to about 0.4 to 0.6 per cent, of the body-weight in the nursling. 
The relative or percentage weight of the heart usually falls to about 0.5 per 
cent, during the first year. The weights of the musculature of the right 
and the left ventricle is usually about equal at birth, but the left ventricle is 
double the weight of the right by the close of the first six months. The wall 
of the left ventricle is only slightly thicker than that of the right; and the 
heart, with its large, wide ventricles, has a much lower resistance to work 

1 



2 TEXT-BOOK OF PEDIATRICS 

against because of the relatively large lumen and the larger sectional area 
of the arteries. This is shown by the systolic pressure, which is 80-90 mm. 
of mercury in the infant and 110-120 mm. in the adult. The pulse is more 
frequent, ranging from 134 during the first year of life, and gradually de- 
creasing in rate to about 90 during the eighth or ninth years. It is more 
elastic and compressible. The complete circuit of the blood is more rapid 
than in the adult. When one considers that neither the heart muscle nor 
the arterial walls have been injured by the insidious poisoning of tobacco 
and alcohol, or by chronic and recurring infections, and that arterio- 
sclerosis is a condition almost unknown in childhood, it may be readily 
understood that the vascular system can withstand the severest demands 
upon it and can compensate serious obstructions to the circulation for a 
long time. However, for a time, during the development of puberty, 
the heart does not keep pace with the rapid growth of the body 
and changes in its anatomic relations may cause functional lesions or 
cardiac insufficiencies. 

During the first few days of life, the period in which the physiologic 
loss of weight, due to the output of large quantities of fluid occurs, the 
blood has a relatively higher percentage of haemoglobin, an increased num- 
ber of cells and a higher specific gravity. This concentration disappears 
during the first month, and after that a very gradual decrease in the per- 
centage of haemoglobin, in the relative number of erythocytes and in the 
slight leucocytosis continues, until, by the end of the second year, the 
blood of the child is the same as that of the adult. It may be questioned 
whether the concentration of the blood through the loss of fluids from the 
body is the main cause of the natal leucocytosis since the number of cells 
drops rapidly in the second and third days after birth while the body is still 
losing in weight. A slight secondary rise in the white cell count is often 
noted in the second week coincident with the detachment of the umbilical 
cord. In general the total leucocyte count after this time is little higher in 
the infant than in the adult. The lymphocytes form from 30 to 40 per cent. 
of all leucocytes in the first year and the polymorphonuclear neutrophiles 
form 50 to 60 per cent. From this time on the neutrophiles increase and 
the lymphocytes decrease in relative numbers. Their percentages are about 
equal (at about 45 per cent.) at five to six years. The counts of eosino- 
philic and basophilic leucocytes and of transitional cells are about the same 
in infancy, childhood and maturity. The blood does not assume its normal 
adult picture until about the time of puberty. During the years of infancy, 
however, the leucocytes remain slightly increased and a peculiarity in the 
percentage of their various forms is maintained to the end of childhood; the 
lymphocytes representing 50 per cent., while, later, they decrease to about 
25 per cent. During the first two weeks of life, the normal hoemoglobin 
content is about 36 per cent, greater than in the adult. From these high 
values, the percentage begins to diminish at once and, after two weeks, the 
fall is very rapid. By the fifth month the value reaches very nearly the 
minimum and is far below the value of adult life. 

The respiratory apparatus and its mechanics present important differ- 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 3 

ences. The thorax of the new-born, with its high arch and its lesser length, 
is always in the phase of almost extreme inspiration, the ribs forming 
nearly a right angle with the vertebral column. As a result, the breathing 
is almost entirely abdominal or diaphragmatic. To compensate for the 
shallowness of the respiration, its frequency is increased and every added 
demand upon the respiratory function of pathologic origin produces an 
increase in the number of respirations. As the child grows older and is not 
continuously recumbent, the upright position causes a gradual change in the 
form of the chest which makes thoracic breathing possible. The weight of 
the abdominal organs and of the thoracic walls in the vertical position tend 
to draw down the anterior wall of the thorax. The larger air passages, 
larynx, trachea and bronchi, are also affected by the downward stress. 
The ribs, which were initially transverse to the vertebral column, not only 
take an obliquely downward position but also change shape by the formation 
of a distinct angle, which increases the thoracic space and gives more room 
for the lungs, both anteroposteriorly and laterally. The ultimate results of 
these anatomic changes upon functional activity are seen in the gradual 
assumption of the mixed type of breathing (thoracic and diaphragmatic) 
in the increased volume of the respiration and in the reduced frequency of 
its rhythm. 

These changes are completed at about the end of the first year, at which 
time the number of the respirations has been reduced from 40 or 45 per 
minute, at birth, to 25. The respiratory volume ranges from 27 to 42 c.c. 
during the first six months of life; while it increases to 78 c.c. during the 
second six months and to 135 c.c. by the end of the first year (Gregor). 

Later, the number of respirations is reduced very gradually, so that the 
average, during rest and sleep, at two years of age, is about 24 per minute, 
at five years about 20 per minute, and at ten years about 18 per minute. 
The individual respirations grow deeper, the mechanism works more eco- 
nomically and is readily able to overcome temporary demands for 
increased activity by its. greater elasticity, indicated both in frequency 
and volume. 

Attention should also be called to the fact that the respiratory rhythm, 
during the first months of life, and, at times, even up to the third year, is 
not always regular. In the young infant, pauses of varying length may 
occur (Czerny). The differences in respiration, dependent upon sex, the 
thoracic type of the female and the abdominal type of the male, do not 
make their appearance until after the tenth year. More or less permanent 
malformations of the thoracic wall may occur in infants as a result of 
pathologic conditions, such as forced respiration and an abnormal softness 
of the ribs. These may be due in part to an incurvation of the thoracic 
wall at the attachment of the diaphragm. 

THE PHYSIOLOGY OF NUTRITION 

The knowledge of the physiology of nutrition is of great importance in 
the understanding of the pathology of childhood. Because milk is the chief 
article of diet, during the first year we incline to classify the descrip- 



4 TEXT-BOOK OF PEDIATRICS 

tion of the digestive processes according to the kinds of milk in common 
use. Practically, it is necessary to consider, in addition to the human milk, 
only that of the cow and goat. Asses' milk, with its very low fat content, 
is hard to get and not indispensable. 

In the following table 1 the more important constituents and peculiar- 
ities of woman's, cow's and goat's milk are arranged for ready comparison 
and as a basis for discussion. 

PERCENTAGE COMPOSITION AND PECULIARITIES OF MILK. 





Woman's 


Cow's 


Goat's 


Water 


87 


88 


87 


Solids 


13 


12 


13 


Total nitrogen 


0.15-0.30 


0.55 


0.56 


Nitrogen in protein 


0.12-0.17 


0.5 


0.43 


Total protein 


1.0 -1.5 


3.0-4.0 


3.5 


Caseinogen 


0.6 -1.0 


3.0 


3.8 


Lactalbumin and globulin 


0.5 


0.3 


1.2 


Lactose 


7.0 


4.0-4.5 


4.4 


Fat 


4.0 


3.0-4.0 


4.0 


Total ash 


(1.3-9.0) 
0.14-0.28 


0.7 


0.7-1.0 


Calcium oxide 


0.03 


0.2 


0.2 


Phosphorus pentoxide 


0.05 


0.24 


0.28 


Iron oxide . 


0.0005 


0.001* 


0.003 


Chlorine 


0.043 


0.1 


0.1 


Heat value (calories per litre) 


650-750 


650-750 




Reaction to htm us 


alkalin 


amphoteric 


amphoteric 


Combining power (acidity), per litre 
with blue litmus in N/10 acid. 


85 


320-550 





* According to more recent estimations, only a part of this iron is actually a constit- 
uent of cow's milk. The greater part comes from the utensils of transportation, etc. 

The total nitrogen consists largely of the nitrogen of the caseinogen, 
lactalbumins and lactoglobulins. A small fraction is found in ammonia and 
in extractives, which are probably excretion products of the lacteal gland; 
some may also be found in the questionable lactomucins. The caseinogen, 
or more properly the caseinogens, because we have to deal with different 
substances in the various kinds of milk, are acid protein bodies containing 
phosphorus. They are insoluble in water, but dissolve in acids, bases and 
salt solutions; and are held in solution or in an ultramicroscopically fine 
colloidal suspension in the milk by alkalis or, more properly, by alkalin 
earths. The lactalbumins and lactoglobulins are usually called soluble pro- 
teins, in contradistinction to the caseinogen which is called an insoluble 
protein. Clinically, great stress has been laid for a long while upon this 
difference, because the less digestible cow's milk actually and relatively 
contains more caseinogen than human milk. At first, it appeared that the 
greater digestibility of human milk was due to the presence of larger amounts 



1 This, table, with a few minor changes, is taken from the chapter on milk by 
Raudnitz, in Pfaundler and Schlossmann's Treatise of Pediatrics. 2nd Edition, 1910, 
Vol. 1., pp. 133. 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 5 

of the soluble protein, as well as to the demonstrated differences in the two 
caseins. When coagulated by acid or by the action of ferments, to the oper- 
ation of which the presence of calcium salts is necessary, the caseinogen of 
cow's milk forms a more solid and a coarser curd than that of human milk; 
and, upon digestion in vitro with pepsin and hydrochloric acid, leaves a 
residue of " pseudonuclein, " sparingly soluble and digested only after a 
long time and with great difficulty. This is not found in human milk. 
The facts, later to be discussed more fully, that the direct absorption of 
lactalbumin and lactoglobulin, formerly accepted as a fact, has been proved 
an error, and that the appearance in the intestine of this undigested 
"pseudonuclein" has no pathogenic significance, have limited the value 
of these findings. 

Milk-sugar, of which human milk contains a larger percentage than 
either cow's or goat's milk, is chemically the same substance in the 
three varieties. 

This is not true of the milk fats which represent complicated mixtures 
of various glycerin esters and free fatty acids. They are inconstant in 
their composition and are dependent, to a certain extent, upon the fats 
of the food digested by the milk-producer. Cow's milk contains, in round 
numbers, four times as much volatile fatty acid as does human milk. 

The fat content (see table) shows greater minimal and maximal vari- 
ations than any other constituent. Apart from individual differences, 
found alike in human and in animal milk, we note that in both the first 
portion of the milk extracted from the organ contains a smaller percentage 
of fat than does the later output, and that the fat content increases pro- 
portionately and gradually as the gland is emptied; showing the most 
gradual increase in breasts which secrete large quantities. The average 
percentage of fat content is therefore smaller in milk obtained from a freely 
secreting organ than from one which secretes less. 

The various mineral constituents shown in the ash receive much atten- 
tion at present. In part, these constituents are found in the organic com- 
ponents of the milk and especially in the protein bodies, in the molecules of 
which they are incorporated with greater or less stability; and, in part, they 
are found as certain preformed salts in diffusible and more or less ionized 
state in solution in the whey. 

The quantity of mineral constituents is much greater in animal milk 
than in human milk, corresponding to the greater demand which the more 
rapid growth of the young animal makes. This is especially true of calcium 
and phosphorus, the two important inorganic constituents of bone. It is 
interesting to note that both human and animal milk are comparatively 
poor in chlorine. The mineral content of the ash of human milk has not the 
same relation to the body-ash of the new-born, as von Bunge has found to 
be true of the milk and body-ash of several very rapidly growing animals. 
It is adequate, however, with probably the single exception of its iron con- 
tent, to the normal nutritive demands of growth and repair and of functional 
development in all the infantile organs. 

The reaction of fresh milk to litmus is amphoteric or alkalin. Upon 



6 TEXT-BOOK OF PEDIATRICS 

standing, the ensuing bacterial action ferments the milk-sugar and pro- 
duces acid. This is of great importance in milk intended for infant feeding 
and will, therefore, be discussed further in the chapter upon that subject. 

The tendency of cow's milk to sour is twice as great as that of human 
milk. This is of major importance in the process of gastric digestion, for 
with cow's milk a much greater proportion of the hydrochloric acid secreted 
by the stomach is changed into combined form and the appearance of free 
hydrochloric acid may be greatly delayed or may entirely fail. While 
acid cells are found in the gastric glands both of the fetus and the 
new-born it is approximately two years before they reach their full develop- 
ment. The gastric mucosa of the infant is relatively thick and the mus- 
cular coat relatively thin, although all the layers of the latter are present. 
The elastic tissue of the stomach is limited to the walls of the arteries of the 
organ for some time after birth. 

To the constant constituents of milk belong, in varying quantity, 
various ferments and certain immune bodies. The former have long been 
considered important to the process of digestion in the gastro-intestinal 
tract, while the latter have been supposed to be important factors in the 
development of the high grades of immunity which appear with the use of 
certain kinds of food. This view, on first consideration a very essential 
one, and chiefly because the usual practice of boiling milk for a short time, 
kills these ferments and immune bodies, but without affecting the food- 
value of the milk, does not seem tenable today. 

Neither human milk nor cow's milk has the same composition at the 
beginning of lactation as it has when the function is fully established, save 
for relatively minor changes, it then becomes constant and remains so 
throughout the period. 

The colostrum is the initial secretion of the functionating mammary 
gland; it is, at first, small in quantity, but gradually increases. It is a 
yellow fluid, viscid because of its high protein and globulin content, and 
coagulates upon heating. It contains about 3 to 5 per cent, of milk 
sugar; its fat content varies within wide limits. The fat is not chemically 
identical with the fat of the later milk of the same animal. In the woman, 
the transition from colostrum to milk is normally complete by the end of the 
first week. 

The best evidence of the colostral condition of the milk is the discovery 
of colostral corpuscles (see Fig. 1) that is, of leucocytes loaded with coarse 
and fine fat droplets, which are, at first, very numerous in each microscopic 
field, but later are few and require careful search. Czerny has shown that 
they are leucocytes and, according to more recent investigation upon the 
human subject, are lymphocytes which take care of the unchanged, non- 
absorbable fat, present in the temporary hypersecretion of the mammary 
gland, by emulsifying it and removing it through the lymph channels, 
They are found whenever there is congestion of the gland and to this fact 
attaches their clinical interest. 

Since the milk of animals is not used directly from the udder, but is 
usually pasteurized or sterilized and is variably diluted for infant use, it is 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 7 

necessary to consider, from the viewpoint of clinical interest, the physical 
and chemical changes which follow. 

Dilution produces a slower coagulation and a finer curd. Heating, 
and the effect is the same whether milk be heated to 70-80 C. (150-180 F.), 
for a long time, or brought to the boiling point for a short time causes a 
partial precipitation of the phosphates or alkalin earths and the formation 
of insoluble tri calcium citrate, which delays clotting, a process dependent 
upon the presence of soluble calcium salts, and thus forms a finer curd. 
Lactalbumin is partially coagulated at 55 C. (140 F.) but is not completely 
precipitated by boiling, a part being held in solution by the caseinogen and 
alkalin salts. A portion of the caseinogen is dissociated into casein and its 




FIG. I. Fat globules; above, in mother's milk; below, in colostrum. 

base, which causes the formation of the skin or pellicle upon the surface of 
boiled milk. The milk-sugar is changed into caramel by continued boiling 
and the brown color of commercial preparations which have been excessively 
sterilized is due to a reaction between the milk-sugar and the caseinogen. 
Similarly, long continued heating causes a coalescence of the fat globules. 
The inorganic constituents are greatly changed upon boiling by the breaking 
up of their organic combinations, but nothing definite is known about the 
import of these changes in the physiology of nutrition. The ferments and 
the most of the immune bodies are destroyed at 60-80 C. (140-180 F.). 

As the child develops, it is finally able to utilize the mixed diet of the 
adult, the discussion of which is not essential here. 

During the first year of life, the child takes nourishment entirely by 
suckling and swallowing. It is only towards the end of the second year, when 
the premolars have developed, that the child learns to masticate his food. 



8 TEXT-BOOK OF PEDIATRICS 

In suckling from the mother's breast, even the new-born may develop 
considerable negative pressure. But this negative pressure of the oral 
cavity is by no means the only factor in the extraction of the milk. Besides 
this the closure of the jaws and the pressure upon the musculature of the 
areola cause a reflex relaxation of the sphincter muscles. Psychic influence 
also plays some part in the relaxation of the breast. From the very com- 
plexity of these reflex reactions, we may anticipate that there are wide 
individual differences in the ease with which the breast may be emptied, 
even though the suckling powers of the children be equal. This proves 
especially true when the milk is expressed or pumped out. 

The liquid nourishment passes the comparatively small mouth of the 
infant rapidly. According to Tobler's observations on a four-year-old boy, 
3-5 c.c. of saliva are added to 100 c.c. of milk. In children during the first 
four months, in whom the mouth is comparatively dry and the secretion 
of saliva scant, there is probably even less admixture. By the fourth to the 
sixth month, the secretion is much more abundant and until the child 
learns to swallow the saliva it may run from the mouth. 

Attention may be called to certain anatomical peculiarities of the 
infant's mouth which fit it for the mechanics of suckling. The inner mar- 
gin of the lips is studded with numerous papilla? (the pars villosa) and the 
middle portion of the upper lip is prolonged in a median labial tubercle. 
These structures with a series of marked transverse ridges or rugce on the 
hard palate aid in holding the nipple. The collapse of the lateral parts of 
the cheeks in the suckling act is prevented by the presence of the sucking 
pads, specialized masses of fat which lie below the superficial fascia and 
are pressed against the gums when a negative pressure is produced in the 
oral cavity. Hasse has pointed out that in sucking, the milk passes the 
mouth by way of two functional passages the median salivary cavity, 
between the tongue and soft palate, and the lateral salivary cavity between 
the cheeks and gums. In either case the .fluid is discharged into the pharynx 
through narrow posterior apertures lying between the soft palate and 
larynx medially and the posterior pillars of the fauces laterally. As the 
larynx lies at a relatively high level it is possible for fluids to pass through 
these openings into the lower part of the pharynx without entering the 
cavity of the larynx even when this structure is open. 

Ptyalin is certainly found in the saliva of the new-born, although in 
small quantities, but there is nothing in the milk upon which it can act. 
When gruels or flour are added to the diet, its function is required. 

The stomach of the young infant is but slightly developed as to the fun- 
dus; the lesser curvature, because of the fulness of the intestine, is more 
horizontal and its concavity is directed backward instead of to the right, as 
in the adult. This peculiarity changes as soon as the child begins to stand 
and to walk, when the vertical position of the organ develops. The capacity 
of the stomach is at first very small ; varying in individuals and according 
to diet; it increases rapidly in size as the child grows older. Exact figures 
can hardly be given because the capacity and the distensibility are not 
identical under varying conditions of feeding. Such conclusions as may be 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 9 

drawn from the quantities of food that the healthy child spontaneously 
takes are noted in the second chapter. It is an established fact, however, 
that the healthy breast-fed babe occasionally takes much greater quantities 
of food at one time than would seem possible, according to the capacity of 
the stomach, and it has been shown that part of the milk passes unchanged 
from the stomach into the intestine while the child is nursing. 2 

The histologic structure of the stomach wall evidently shows no great 
differences from that of the adult. The hydrochloric acid and all the 
digestive ferments are present in the stomach of the new-born. 

The casein formation in the stomach occurs rapidly with cow's milk, 
after it has become acid in reaction. With human milk the process is 
slower. In the former larger flakes of curd are formed than in the latter. 
The whey, which is separated after coagulation and which contains the 
greater part of the salts, the milk-sugar, the so-called soluble milk proteins, 
and other constituents about which little is known, is soon acted upon suffi- 
ciently by the pepsin and hydrochloric acid to permit its passage, in frac- 
tional quantities, into the intestine for its further digestion by trypsin and 
erepsin. The casein in the stomach content, which gradually becomes 
more solid, is digested more slowly but in an analogous manner, the fer- 
ments attacking the outer surface and digesting it. If more cow's milk be 
put into the stomach before this dense mass of cheese is completely dis- 
solved, the new milk spreads itself between the stomach wall and the outer 
surface of its older content and prevents its further digestion by taking up 
the hydrochloric acid and the ferments. It is possible that abnormal changes 
in the direction of decomposition may develop in this central mass. 

The presence of free hydrochloric acid is dependent not only upon the 
total quantity secreted, but also and directly upon the power of the food to 
combine with it. For this reason it is present in the stomach of the breast- 
fed infant after one to one and a half hours, and in the child fed with cow's 
milk only after two and a half to three hours. This is important, because 
the free hydrochloric acid has an antiseptic action which the combined acid 
does not possess. 

N 

The total acidity, varying from 20-60 c.c. acidity per 100 c.c. of con- 
tent is due to the organic acids and acid salts, and especially the acid phos- 
phates present, rather than to the hydrochloric acid. The organic acMs 
arise partly from the action of the ferment lipase upon the fats, which 
occurs in small measure in the stomach, and partly from bacterial action. 

Flour or gruels, given with or without additions of milk, are not only 

2 The stomach of the new-born infant is usually almost vertical in position with the 
greater curvature to the left. The transverse type of stomach characteristic of infancy 
is established with the distention of the viscus at birth either with injected fluid or with 
air and mucus. Until this distention has taken place the anterior surface of the organ 
lies entirely under the cover of the liver and is usually covered in part by the gastric 
surface of the spleen. The average anatomic capacity of the stomach is about 1 ounce 
(33 c.c.) at birth. This is doubled in the first ten days, tripled in the first month and 
increased over 6-fold by the end of the first six months. After the first four or five days 
the size of the average feeding is about a fifth to a quarter more than the anatomic 
capacity of the stomach at the same age. 



10 TEXT-BOOK OF PEDIATRICS 

changed digestively by the long continued action of the p.tyalin of the saliva, 
but are split further by bacteria mixed with them, inducing a fermenta- 
tion, the products of which are usually, in part, low fatty acids. 

The duration of gastric digestion in the healthy child depends upon the 
kind and quantity of the food. After an abundant feeding of breast-milk, 
the stomach is empty at the end of two hours, and after the same quantity 
of cow's milk it is emptied in three hours. Smaller feedings leave the stom- 
ach in a correspondingly shorter time. These digestive periods obtain 
only in healthy children; even the slightest disturbance may influence the 
motility of the stomach so greatly that the food may remain for an hour or 
so longer. 

The rapidity with which the stomach empties is regulated by the closure 
of the pylorus which is stimulated reflexly by the content both of the 
stomach and of the duodenum. According to Tobler's investigations, food 
rich in fat delays its emptying. 

Small quantities of salt and sugar solutions and of albumoses are 
absorbed by the gastric mucosa. The larger part of the food mass passes 
into the intestine. 

The acidity of the gastric contents is reduced in the duodenum by the 
addition of sodium carbonate, of which the pancreatic juice contains a 
large percentage. This causes a withdrawal of alkali from the body. 

The digestive changes in the intestinal tract apparently occur in the 
same manner as in the adult. All the ferments of the intestine and the 
contiguous glands, even including the prosecretin and the hormone se- 
cretin, which are found in the adult, are present in the new-born, and, for the 
most part, have been identified in the fetus. 

A more detailed description of the digestive function is hardly neces- 
sary here; but a few special points may be emphasized. As we have said, 
the absorption of the so-called soluble milk proteins unchanged was 
formerly accepted as a fact. This, however, has been disproved. They, 
as well as the casein, are split, in part even in the stomach, to the finer 
divisions of the protein molecule (amino-acids, and peptids) and, if they 
are not oxidized, are used in the intermediate metabolism of the synthesized 
body protein. This is true even of the proteins of the human milk. 

Milk-sugar (lactose) if not given in quantities beyond the limits of 
digestion and absorption, is split by the ferment lactase into dextrose and 
galactose. If this enzymic action is not complete and if the remaining 
portion is not fermented by bacteria in the intestine, the milk-sugar may 
be absorbed unchanged and is then excreted in the urine, as it is if paren- 
terally formed. This incident plays a part in pathologic conditions. 

For the clear understanding of many of the metabolic processes which 
are to be described later, attention must be called to the fact that not only 
are the products of the digested food absorbed during the whole course of 
gastro-intestinal digestion, but that there is, also, a secretion of a very con- 
siderable quantity of fluids containing proteins and salts into the tract. It 
should be noted, further, that the colon, in which no actual digestion occurs, 
is an organ of absorption, as well as of excretion, and especially for the 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 11 

earthy and fixed alkalis and for iron and phosphorus. The tune necessary 
for the passage of food through the intestine varies, normally, from twelve 
to thirty-six hours. 

The feces, consisting of particles of undigested food and remnants of 
the secretions of the intestinal tract and of the glands accessory to it, 
together with a considerable number of bacteria, naturally vary in consist- 
ency, color, odor and mass with the kind and quantity of food ingested, 
with the intensity of the various secretory influences, and with the rapidity 
of the peristalsis. 

The first evacuations of the new-born consist partly of epithelial debris 
and of the secretions of the fetal intestinal tract and its adjacent glands 
and, in part, of the constituents of the ingested amnionic fluid and of sub- 
stances found in it, e. g., lanugo, epidermal cells, etc. Its dark green color 
and viscid quality, giving to it the name of meconium, disappear so soon as 
the results of milk digestion appear in the stool. This usually occurs 
between the second and fifth day. 

Under normal conditions the stool of the breast-fed infant has a salve- 
like consistency, is egg-yellow in color, and has an aromatic and acid odor. 
The bowel movements should occur once or twice in twenty-four hours. 
More frequent bowel movements, generally regarded as signs of chronic 
dyspepsia, occur with surprising readiness in children who are developing 
normally. They are thin or watery, non-homogeneous and lumpy, or con- 
tain shreds, and are full of minute particles of greenish mucoid material in 
which traces of fecal matter are imbedded. The odor alone is like that of 
the normal breast-milk stool; it may be of stronger quality, but it never has 
the offensive character of putrefactive feces. According to the researches 
of Gregor, we are justified in the belief that the appearance of such stools, 
which are usually poor in substance, is due to a relative reduction of the 
amount of fat in the breast-milk, although an increased irritability of 
the secretory and motor functions of the intestine must be presumed as a 
causative factor. 

Attention must be called to the fact that stools which are yellow when 
passed may change to a green color when left exposed to the air for a time. 
While the conditions necessary for the oxidation of bilirubin to biliverdin, 
in the intestine or after evacuation, are not fully understood, it must be 
stated emphatically that the condition is not in itself pathologic. 

In artificial feeding with dilutions of cow's milk, or with mixtures of 
cow's milk and gruels or flour, the stool is usually better formed, is lighter 
in color than the breast-milk stool, and has a slightly unpleasant or even a 
putrefactive odor. Its reaction to litmus is alkalin. Every deviation 
from type in the artificially-fed must be taken much more seriously than 
variations in the stools of the breast-fed infant and must be regarded as a 
possible symptom of disturbance of nutrition. 

As the change to a mixed diet, with only moderate quantities of milk, is 
made, the normal bowel movements take on the characteristic consistency 
of the evacuations of the adult. 

The entire digestive tract, from mouth to anus, offers a suitable soil for 



12 TEXT-BOOK OF PEDIATRICS 

the growth of numerous varieties and strains of bacterial flora. It may be 
readily understood that, even during the first few hours after birth, the 
gastro-intestinal tract becomes infected, both by way of the mouth and 
the anus, with numerous micro-organisms from its immediate surroundings. 
All do not enter in the same manner, nor do all find an equally fertile soil. 
It is manifestly true that the bacteria found in the stool of the breast-fed 
child are of other varieties and of lesser number than those seen in the stool 
of the artificially-fed infant. 

In the bowel of the breast-fed infant, the number of the anaerobic 
bacillus, bifidus communis (Tissier) greatly exceeds that of the aerobic 
bacilli, coli communis and the bacillus lactis aerogenes (Escherich). 
Besides these, streptococci, the bacillus acidophilus, the bacillus butyricus 
immobilis (the bacillus perfringens of the French authors), the "Koepfchen 
bacteria," (Escherich) the anaerobic bacillus, butyricus mobilis, and the 
bacillus putrificans coli (Bienstock) which causes putrefaction, and several 
others, are commonly found. In the artificially-fed infant, the colon 
bacillus and the intestinal cocci are most common, but many of those named 
above are also present and usually in larger number than in the stool of the 
breast-fed child. 

From the clinical point of view, and for several reasons, the intestinal 
bacteria are interesting. From experimental researches upon new-born 
animals, which die when a sterile gastro-intestinal tract is maintained, 3 it 
seems possible that an irreplaceable physiologic function is performed by 
them in the human infant. The fact that a continual germicidal activity 
is exhibited throughout the small intestine, especially in the intervals 
between the digestive acts, and that rapid bacterial growth occurs only 
in the colon, where the actual digestive process is completed, makes the 
problem a difficult one to solve. Nevertheless, the influence of the intesti- 
nal flora upon the reactions of the intestinal content has been established. 
These producers of fermentation and putrefaction exist in constant antag- 
onism to each other and determine an acid or alkalin reaction of the feces, 
according to the predominance of each type. Of course, the kind of food, 
apart from the general condition of the organism, has an influence in deter- 
mining this predominance. 

Finally another point not to be overlooked is the possibility that 
under certain circumstances, with an increase of the usually harmless 
saprophitic bacteria, they may acquire a virulence which makes them 
pathogenic to the particular infant. 

While the kidneys, relatively large in the new-born and during infancy, 
show normally some degree of fetal lobulation, they generally resemble 
those of the adult; so, also, does the urinary tract. The urine, during the 
first few days of life, is scanty and concentrated, tallying with the small 
quantity of fluid ingested and the large water output from the lungs. It 
contains a relatively large quantity of uric acid in an amorphous or crys- 
talline form. The explanation of the cause of albuminuria in the new-born, 

3 Schottelius vs. Thierfelder, Nuttel, etc. 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 13 

the subject of much discussion, an event common only during the first and 
second weeks of life and but rarely of longer duration, is no more definite 
than that of the occurrence of uric acid infarcts. Without going deeper into 
these questions, amply and critically discussed by Czerny and Keller, it 
may be asserted with confidence that this albuminuria and these infarcts, 
while probably non-physiologic, are, at most, conditions not particularly 
harmful to the individual. 

The kidneys weigh about 25 grams in the new-born and increase in 
weight between 19- and 14-fold between birth and maturity. They double 
their weight in the first year and triple it by three years. They form about 
.6 per cent, of the body-weight in the new-born as compared with 0.2 to 0.3 
per cent, in the adult. They occupy a relatively larger proportion of the 
posterior abdominal wall in infancy than in later life, their lower poles 
generally lying below the iliac crests and their upper poles extending to the 
eleventh or even the tenth ribs. Their adult skeletal relations are estab- 
lished as the child habitually assumes the erect posture and the lumbar 
region elongates. 

The bladder is almost entirely an abdominal structure at birth and in 
early infancy. In the contracted state its apex lies about midway between 
the umbilicus and pubis on the anterior abdominal wall and its base lies 
behind the middle third of the symphysis pubis. When filled the fundus 
may lie above the level of the umbilicus 

So soon as the course of nutrition is normally established a close relation 
between the quantity of water taken and the quantity of urine excreted 
becomes clear; from 60 to 70 per cent, of the ingested water reappearing 
in the urine. Of course this is true only under perfectly normal conditions. 
The urine is voided about three times as frequently as food is taken and, if 
water be given between meals, micturition may occur twenty or twenty-five 
times in the twenty-four hours. We are not justified in speaking of phys- 
iologic incontinence in the infant; for there is no continuous flow of urine. 

The infantile penis varies greatly in size in different individuals. Nor- 
mally there is more or less complete phimosis and usually but a pinhead 
opening, with complete adhesion between the glans and the inner surface of 
the prepuce. Neither this, nor the presence of epithelial concretions in the 
region of the coronary sulcus, should be, under any circumstances, an 
excuse for superfluous and disfiguring operations for phimosis. At the 
present time it is necessary to lay special stress upon this point. 

The vulva of the female infant gapes because of the slight development 
of the labise. This physiologic prolapse is favorable to the entrance of 
fecal particles into the urethra and the resulting occurrence of cystitis. 
This etiology of cystitis is more fully discussed in the chapter on 
Genito-urinary Diseases. 

The skin of the infant, because of the thinness of the epithelial layer and 
the greater vascularity of the papillary layer, is more tender, softer and 
more intensely colored than in later years. These differences are most 
marked in the new-born, whose skin is so vascular during the first few days 
that a physiologic erythema neonatorum is described. In all diseased con- 



14 TEXT-BOOK OF PEDIATRICS 

ditions and, especially in disturbances of nutrition, a distinct pallor rapidly 
takes the place of the blush of health, or, a more serious symptom, a slate- 
gray coloring may appear. 

The subcutaneous fat is present and, in normal conditions, fairly well 
developed over the whole body and even over the extensor surfaces of the 
joints where it is absent later in life. When the watery and saline constit- 
uents of the organism are normal, the fat gives to the skin of the infant a 
tensity and elasticity "turgor" which, with its fresh color, is a distinct 
indication of health. 

The anatomic development of the sweat glands is slight, while the 
opposite is true of the sebaceous glands which are well formed. The func- 
tional scantiness of the perspiration and the abundance of the secretion of 
sebum in the new-born tally with these facts. 

Finally, the mammary glands, which are modified cutaneous organs, 
should be mentioned. In both sexes the body of the gland represents a 
flat disc, not more than one centimeter in thickness. It is usually sur- 
mounted by a pale, indistinct areola, in the centre of which is the mammilla 
about the size of a pinhead. An increase in the volume and an active 
functioning of the gland during the third or fourth day of life is quite a 
common rule. This is probably due to the action of the same hormone, 
circulating in the blood of the babe, which stimulates lactation in the 
mother. Since the secretion ("witch's milk") is not normally excreted 
and congestion results, the fluid has the consistency of colostrum. During 
the first few days of the first month, the secretion completely disappears. 
Histologic evidences of milk secretion, in the form of dilated ducts and 
alveoli containing remains of secretion, may be found six months or more 
after birth. 

The body temperature 4 of the infant depends upon the temperature 
of its surroundings to a greater extent than that of the adult. This is 
especially noticeable in premature infants and in those who are congeni- 
tally weak, so that we may speak of a poikilothermia in these cases. This 
condition may also appear, however, in normally strong children. Its cause 
is in part found in the thinner epithelial layers and the greater vascularity 
of the skin. On the other hand, the low water output from the skin of the 
new-born and the relative excess of the body surface to its actual volume. 5 
are material factors. Slight irregularities in heat distribution, which is 
largely a function of the body surface, may cause, therefore, slight variations 
of body temperature the more readily because the relatively small body 
mass is less able to equalize them by rapid changes in heat production. 

It is not necessary to discuss, in this connection, the inadequacy of 
thermal regulation due to the non-development of thermotaxic and thermo- 
inhibitory centres, since analogies in other nerve functions, as in the motor 
field of the new-born, justify the assumption. However this may be, clinical 

4 See technic of examination. 

5 In the new-born we have, for each kilo of body- weight, approximately 810 square 
centimeters of surface; at six months, 620 square centimeters; at twelve months, 530 
square centimeters; at four years, we still have 500 square centimeters; while the adult 
has only 300 square centimeters. 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 15 

observation has proved that young infants may be cooled or overheated by 
external influences much more readily than older children. There is, at 
least, a reduced range of physiologic heat regulation. Within these limits, 
it is nevertheless very exact. The healthy infant, surrounded by non-con- 
ducting substances, maintains a temperature between 36.8 and 37.2 C. 
(98.2-99 F.) almost continuously without the aid of external heat. 
These figures mark the slight morning and evening range of temperature by 
rectum. This practical monothermia, according to the careful studies of 
Jundell and Goffer je, who took temperatures every two to four hours by 
rectum, is found only during the first few weeks of life. By the second 
month, the temperatures similarly taken, revealed variations up to 1 C. 
(1.8 F.) a range in which, under regular conditions of sleep and growth, 
may be recognized a nightly fall and a daily plateau. Irregular variations 
and increases over 37.5 C. (100 F.) in children who have not been 
artificially warmed by hot-water bottles or similar agencies, must be 
considered pathologic. 

THE PHYSIOLOGY OF METABOLISM 

Attention has already been called to the great importance of the role 
which the nutrition and allied phenomena assume in the life of the infant 
an importance which will be emphasized in other portions of the work. 
It seems necessary, therefore, to devote a special chapter, in addition 
to the subsequent detail of the process of digestion, to the physiology 
of metabolism. 

a. NITROGEN 

Nitrogen is present in milk almost entirely in the form of protein. The 
researches of Bahrdt and Langstein upon new-born animals have demon- 
strated that even the protein materials of the milk of the mother animal 
undergo very complete metabolism into amino acid and amino acid com- 
plexes (peptids). There is no reason why the results of these researches 
may not be transferred to the human new-born. If this were done, the 
hypotheses based upon the differing effects of feeding homologous and 
heterologous proteins, as represented in natural and artificial feeding 
would lose support, unless we also assume that their comparatively simple 
cleavage products (amino-acids, etc.), retain the identical characteristics 
of the protein from which they are derived. In support of this latter posi- 
tion, however, no definite proof has as yet been advanced. Recently various 
researches tend to show that foreign protein (egg) may be absorbed un- 
changed in certain nutritional disturbances. These proteins may be 
found in the blood and urine; the quantities depend upon the severity of 
the disturbance. 

The nitrogen requirement of the infant is evidently small, as indicated 
by the low nitrogen content of human milk. This should be remembered 
in studying the requirements of the nutrition and the period of the greatest 
relative growth, for it shows how little an excessive protein diet can be 
justified by the indications of the demands of natural growth. Certain 



16 TEXT-BOOK OF PEDIATRICS 

authors claim that the protein need of the growing infant is fully supplied 
when 7 per cent, of its caloric need is supplied in protein. The first few days 
of life only, the period of the so-called physiologic loss of weight, present an 
exception to this, for if the child be nourished during this period with milk 
of an established lactation there is a distinct loss of body nitrogen, which is 
avoided if colostrum, which contains much more nitrogen than does the 
fuU milk (Birk) be fed. 

In the healthy child the absorption and retention of nitrogen is very 
complete. The dried feces contain only 4-4^2 per cent, of nitrogen, and even 
this small amount consists only in part of the nitrogen of the food which 
has escaped absorption. At least an equal share comes from the nitrogen 
containing secretions of the intestine and its auxiliary glands and from the 
bacteria present. The retention is represented by the difference between 
the intake and the excretion in the feces and urine, but it may be said that 
a positive N. balance is not necessarily indicative of growth or, rather, of 
tissue building. Nitrogen retention may occur temporarily during periods 
of weight loss. 

The end products of nitrogen metabolism in the urine are the same as in 
the adult, excepting that the amount of ammonia is normally somewhat 
greater. This will be more fully discussed in the chapter on Disturbances 
of Nutrition. 

As in the adult, the addition of carbohydrate to the protein food leads 
to an increased N. retention, in spite of a poorer N. resorption, while fat 
reduces the N. absorption as well as the N. retention very slightly. This, 
however, is of no practical importance under normal conditions, since the 
nitrogen intake always exceeds the minimal requirements. It may become 
important in pathologic conditions. 

6. FAT 

The fat taken in milk feeding consists of neutral fats and contains only 
small amounts of free fatty acids. 

As already stated, a slight fat-splitting by lipase occurs in the stomach 
of the infant. It is probably much less than takes place in the stomach of 
the adult, where the strong lipolytic secretions of the small intestine nor- 
mally flow back into the stomach and initiate a more complete breaking up 
of the fats. The purpose of this is probably to facilitate the emulsification 
of the coarser fat droplets by the alkalin carbonate of the pancreatic juice, 
which is dependent upon the presence of free fatty acids. In the infant 
whose fatty food is taken in the form of a fine emulsion this is unnecessary. 

The amount of fat taken with the food varies greatly in the breast-fed 
child, not only from day to day, but also in the several feedings; doubling 
in quantity, in some instances, with the increase of the volume and the fat 
content of the different meals. This is readily understood when we recall 
the variations of the fat content of the human milk stated above. In the 
artificially-fed child these variations do not usually occur, since in children 
fed with milk mixtures, of closely similar quality at each feeding, the total 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 17 

amount of fat ingested, e\en when cream is added, is far less than the 
breast-fed babe receives. 

More than nine-tenths of the fat ingested is absorbed from the intestine 
of the healthy infant. Part of the fat recovered from the feces probably 
comes from the intestinal secretions and a small portion of the volatile 
fatty acids may originate from the breaking down of the carbohydrates. 
The fat of the feces consists of neutral fats, free fatty acids, and the earthy 
alkalin and fixed alkalin salts of the fatty acids (soaps). It is found in 
varying quantity. This is shown, without further examination, by the con- 
sistency, the reaction and the odor of the evacuations, in so far as the fatty 
acids are in excess in the acid stools; while in the dry alkalin feces the 
earthy alkalin soaps are in excess, only a minor part (about 10 per cent.) 
consisting of neutral fat which shows very slight variation. 

The role of soap formation in the metabolism of the fixed and alkalin 
earths is evidently a very complicated one and, up to the present time, is not 
fully understood. As these are of special importance in pathologic con- 
ditions we dispense with their full discussion here. 

The absorbed fat is required by the body partly for combustion and in 
part as a reserve of storage food. 

c. CARBOHYDRATE 

Only one carbohydrate, milk-sugar (lactose) is contained in human milk 
and in the milk of animals. It is a disaccharide and splits into one mole- 
cule of glucose (dextrose, grape sugar) and one molecule of galactose. These 
two monosaccharides are combined with a loss of one molecule of water. 

Other disaccharides used in the artificial feeding of healthy infants are 
cane-sugar (saccharose = dextrose + levulose or fructose) ; and maltose 
( = dextrose + dextrose) the latter being either an important constituent of 
the commercial malt extracts, or a product of enzymic action upon starch. 

Preformed monosaftcharides are not contained in the nutriment of the 
infant. Only when the child is able to take honey and fruit does it receive 
levulose and glucose, as such. 

Among the polysaccharides, starch and cellulose must be considered. 
The former is a constituent of the pure flours, partially dextrinized in 
toast (Zwieback) and found in several of the so-called infant foods; and the 
latter is a constituent of vegetables and fruits. 

It is generally understood that only the monosaccharides are directly 
absorbed; other varieties of sugar being absorbed only after they have been 
split by the action of enzymes and, probably, by bacterial action as well. 
Only if greater quantities are ingested than can be broken up by the 
enzymes or fermented by bacteria, does the direct absorption of disaccharides 
occur; and then they are excreted unchanged in the urine, even as they are 
after parenteral absorption. It may be said, in this event, that the limit of 
assimilation has been exceeded. The polysaccharides undergo a compli- 
cated splitting before absorption. 

It has been stated already that the various ferments necessary to carbo- 
hydrate digestion are found in the new-born, even though in very small 
2 



18 TEXT-BOOK OF PEDIATRICS 

quantities. This is true both of the diastase of the saliva and the amylo- 
lytic secretion of the pancreas. In view of their scanty presence, it is prob- 
ably true that a relatively large part of the carbohydrate, the exact 
quantity not being determined, is split by bacterial action (fermentation) 
with the formation of the acid products of this decomposition. 

The limit of assimilation for milk-sugar and maltose is higher in the 
infant than in the adult. 

The carbohydrates of the food serve in the infant, even as in the adult, 
not only as material for combustion and as a source of energy, but they 
facilitate or even actualize the normal potential combustion of the fats. If 
they are absent, a disturbance of fat metabolism results, recognized by the 
appearance of acetone bodies in the urine. This is more readily developed 
in the infant than in the adult. It has been determined that a moderate 
amount of lactose in the diet increases the nitrogen retention, but that large 
amounts cause a negative N. balance. Also the complete withdrawal of 
carbohydrates causes a negative N. balance. 

The amounts of blood sugar, as recently determined by Goetzky using 
the method of Bang, are 0.085 per cent, average for infants of twelve days; 
0.095 per cent, for one month; and 0.102 per cent, at one year. In older 
children other authors have obtained an average of 0.072 to 0.113 per cent, 
which are approximately the same as the variations in the adult. 

d. MINERAL CONSTITUENTS 

Human milk contains all the minerals necessary for the life and growth 
of the infant. In the milk of the domestic animals they are present in much 
larger quantity, corresponding to the more rapid growth of their young. 
So plentiful are they, in fact, that in the feeding of the healthy infant with 
the usual milk dilutions their quantity is ample, with the probable excep- 
tion of iron which is very scanty in both human and animal milk. 

The close relationship of inorganic to organic metabolism, and the rel- 
ative independence of individual kations and anions in their migration 
through the organism, make it plain that one mineral substance can act 
vicariously for another in only limited measure. In fact, the continued 
absence of even one certain ion is incompatible with growth and life. The 
danger of its lack may be overcome for a time by the ability of the tissues 
when subjected to "salt hunger" to retain their mineral substances with 
great tenacity; but this temporary protection is broken down after awhile. 
These inorganic ingredients have a great influence, also, upon the water 
content of the organism. 

e. WATER 

Water plays an important part in the life of the infant because the child 
takes more than double the quantity of water with his food per kilo of body- 
weight, than does the adult. His body, in fact, contains relatively more 
fluid. As with other tissue components, the organism regulates this water 
content, not according to the quantity obtainable, but according to its 
necessities, By the figures of Camerer it is shown that in the healthy 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 19 

breast-fed child about two-thirds of the water ingested is excreted in the 
urine, and only 1 to 2 per cent, remains in the body; the remainder leaving 
the body by way of the lungs, the skin and the intestines. 

The ingestion of larger quantities of water does not increase the storage 
but the excretion, especially by the kidneys; and since always it takes with 
it soluble substances (urea, salts, etc.) this probably leads to a partial 
leaching of the tissues. In order to increase the water content of the body, 
we must give salts or other substances, e. g., carbohydrates, favorable to 
water retention, in addition to sufficiently large quantities of water. On 
the contrary, a reduction of the water retention can be accomplished only 
by restricting the intake of salts or carbohydrates, or by a pathologic 
increase of the secretion of water and salts. The simple reduction of the 
water intake has the ordinary result of reducing its excretion. These con- 
ditions probably play some part in the etiology and pathogenesis of the 
various disturbances of nutrition. It seems, at times, that the possibility 
of regulating the water balance in the infant is less developed than in later 
life. Perhaps on the other hand the amount of water excreted from the 
body by the way of the intestine and the power of water retention play a 
most important role. 

/. ACCESSORY FOOD SUBSTANCES 

It has recently been recognized by experiments on animals and by 
observation on the human that there must be other food elements which by 
their presence in the diet promote normal growth in the young and prevent 
so-called " deficiency diseases" in the adult. To these Funk has applied the 
name of "vitamins," but Hofmeister's term of "accessory food substances" 
seems preferable because it is more noncommittal. Their chemical and 
biological study still offers a large field for research, but it is generally recog- 
nized that they occur in small quantities in certain food, and that they are 
not of animal origin, but are transmitted through milk and meat from vege- 
table food. Their importance as an etiologic factor of beriberi and the 
analogous polyneuritis of chickens, of scurvy, and of keratomalacia has 
been proved. In rickets, however, it is apparently only a factor. The anti- 
neuritic principle is contained in most vegetable foods and the form of 
polyneuritis known as beriberi is produced only by a continued one-sided 
diet with polished rice. The antiscorbutic principle is found in fresh green 
vegetables and certain fruits (lemons, oranges, raspberries and tomatoes), 
and in small amounts in milk and meat. It is quite resistant to heat, 
drying and preserving. The antirickitic element is found in green leaf vege- 
tables and in animal oils (butter, cod-liver oil, yolk of egg). Friese was able 
to cure the keratitis produced by the specific Hopkins diet by adding a small 
amount of fresh milk. The solution of the innumerable problems arising 
from the study of the accessory food substances is of great importance to 
the podiatrist. 

g. THE TOTAL METABOLISM 

The total metabolism of the child demands a greater intake of food than 
in the adult because of the added requirements of normal growth. If the 



20 TEXT-BOOK OF PEDIATRICS 

larger output, through the several channels does not counteract this intake, 
the margin of increase will be very slight, since even in the period of most 
rapid growth the greater part of the gain in weight consists of water. 

Thus Camerer estimates that in a child ten weeks old, weighing five 
kilos, taking 800 gms. of breast-milk per day, and showing an average 
daily gain of 25 gms., the increase consists of 18 gms. of water, 0.7 gms. 
mineral substance, 3.0 gms. of protein and 3.3 gms. of fat. 

Actually, a greater intake is counterbalanced by a notably increased 
physiologic output. In the resting infant, this output is the larger on 
account of its relatively greater heat radiation. Attention has been called 
to the fact that the body surface of the infant, as compared to his weight or 
mass, is two or three times greater than that of the adult. And since the 
heat radiation runs parallel, in definite degree, to the surface area, the out- 
put of the metabolism of the infant would be two to three times as great 
as in the adult and the intake, in order to maintain a positive balance, 
would have to be that much greater. As an actual fact Rubner has deter- 
mined experimentally, in his researches upon adult dogs of various sizes, 
that their carbon dioxide excretion is proportionate to their body surface, 
other things being equal ; and that it does not rise or fall in proportion to 
their body-weight. Since the carbon dioxide excretion may serve as a 
measure of the combustion of organic substances, in accordance with 
demonstrated physiologic principles, a close relationship is thus established 
between surface area and food requirement. This food requirement may 
now be measured by its caloric value, and the experimentally established 
values of the different food substances may be rated as follows: for 1 gm. of 
protein 4.1 calories; 6 for 1 gm. of fat 9.3 calories; and for one gm. of sugar 
4.1 calories. The salts do not present a calculable caloric value. 

Putting the clinical conception of food requirement aside, in favor of the 
energy requirement or rather the caloric index, which lends itself readily to 
physical and chemical investigation, the latter has gained recognition in 
scientific pediatrics by the epoch-making work and studies of the elder 
Camerer, of Rubner and Heubner; and is both lauded as an important 
advance and condemned as unscientific and contrary to clinical experi- 
ence. It may be acknowledged at once, that in considering food as an 
entity, basing its value upon its heat-producing power, we must accept 
as a premise that its component substances are capable of far-reaching 
physiologic interchange. This is based upon the idea of isodynamia, 
that is, that a calorie of one food component can be freely substituted 
for a calorie of another food component in the metabolism. At the same 
time, we must acknowledge that this premise is true only to a limited 
degree in the healthy infant, and is entirely untrue when applied to the 
child with disturbances of nutrition. Heubner, to whom the study of the 
problem of energy requirement in infant feeding owes its greatest advance, 
has replied to objections raised by Czerny and Keller, when they feared 

6 Protein gives 5.6 calories in the calorimeter, but of this only 4.1 calories are physi- 
ologically available as useful calories in the organism, while 1.5 calories are lost in nitro- 
genous excretions (urea, etc.)- 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 21 

that the physical viewpoint in the teaching of infant feeding would wholly 
supersede the physiologic-chemical view, by emphasizing that this is not 
the purpose of the proponents of the method, but that the aim is to give a 
better quantitative standard of the food requirement of the infant than 
was given by any former methods in determining the volume or weight of 
the food. He further asserts that with this common standard it is possible 
to obtain the most favorable quantitative variations in which the different 
food substances may and must be put together. The energy quotient fur- 
nishes us with a unifying principle and, whatever the choice or qualitative 
composition of the infant's food, informs us of the essential quantities, 
which, under all the variances in age and condition the infant demands. 

Apart from the minor fact of the broad interchangeability of various 
food substances in infant feeding, the adoption by the clinic of the caloric 
method of treating the feeding problem meets with two other sources of 
error, which, while reflecting upon its absolute exactness, do not impair its 
approximate usefulness. 

It should be noted, first, that a part of the raw calories taken in as food 
are lost to the metabolism, in that organic substances of definite caloric 
value are excreted unused in the urine and feces. The sum of the raw 
calories is, therefore, greater than that of the net calories which serve as 
the physiologic units of energy for growth and repair. A part of this error 
in reckoning the raw calories has been already noted (see footnote 6). 
The remainder because it is small and, in the healthy child at least, of 
slight variability is a negligible quantity. 

In the second place, a further error is incident to the fact that the 
caloric requirement is estimated by body-weight rather than as the theory 
strictly demands by body surface. 7 This really important error is dis- 
counted in clinical practice by the fact that a gradual reduction of the 
caloric requirement is adopted corresponding to the decrease of surface as 
weight increases. 

Attention is called to these limitations in order to protect the caloric 
method of determining food requirements, on the one hand, from the exces- 
sive enthusiasm of its advocates and from its indiscriminate application, 
and, on the other hand, from the unjust objections of its critics. Within 
these limitations, the method permits us to determine empirically a definite 
relation between body-weight and the total food requirement of the healthy 
child. Heubner has designated the number of calories which a normally 
growing child requires during the successive divisions of its first year of 
life, for every kilo of body-weight, as the energy quotient. The first figures 
given by Heubner were based upon a few observations only; but as experi- 
ence has added to the sum of knowledge these figures have been, again and 
again, corrected; and today we use, in round numbers, 100 calories, or a 
little more, in the first quarter year of life; 90 calories in the second; 80 in 

7 The measurement of the body surface is an extremely difficult task; it takes a long 
time and is not applicable even in hospitals, to say nothing of private practice. The 
calculation of the surface area from body-weight, according to the formula of Meeh, 
demands a mathematical facility which is hardly to be expected of the physician and, 
therefore, it has not come into common use. 



22 TEXT-BOOK OF PEDIATRICS 

the third and 70 in the fourth, per kilogram of body-weight. For human 
milk, a caloric value of 700 (650-750) calories per litre has been adopted. 
The value for undiluted cow's milk is as great. The caloric value of various 
other milk mixtures will be given later in the chapter on Artificial Feeding. 

The caloric requirement of the healthy, artificially-fed infant does not 
differ greatly from that of the breast-fed child. From various studies it 
appears that its demand is somewhat larger and these findings have been 
explained by the fact that the digestive labor is greater upon artificial food 
and that this necessitates an increased supply of food. Results recently 
reported by Engel and Samelson do not agree with this conclusion and it is 
a question whether other factors did not enter into the earlier observations; 
as, for instance, the greater loss of useful, but unused calories in the feces 
and urine; or, still more probably the less favorable nutritive balance 
induced by the greater restlessness of the artificially-fed child. 

While the fact that the total metabolism of the child is more rapid than 
that of the adult has been incontrovertibly established, the rule of Rubner 
that metabolism and food requirement are, other things being equal, pro- 
portionate to surface area has not gone uncontradicted. 

Several physiologists, Magnus-Levy, Sonden and Tigerstedt, and A. 
Loewy, have drawn the conclusion from their researches that a special 
increased energy is present in the infant because of his youth, which causes 
a peculiar excitability of the heat-producing agencies and, therefore, an 
excessive metabolism. Schlossmann and Murschhauser have gone over 
these results in very complete metabolic experiments in the calorimeter, 
but have found that they could not confirm them with the material used. 
They maintain that deviations from the rule laid down by Rubner are due 
to stiU another item, that of less economical muscular activity in the infant. 

In the study of heat production in approximately normal infants from 19 
days to 18 months of age, Benedict and Talbot found an average resting 
heat production of 65 calories per kilogram of body-weight. They state 
that "aside from a slight tendency for the total metabolism to be larger 
with increasing weight, no regular relationship exists with infants between 
the total heat production and the body weight, regardless of whether the 
body-weight was actually found, computed from statistics of average 
values for normal infants, or was the expected body- weight based on the 
birth weight." They conclude that the extent of metabolism is deter- 
mined neither by weight nor by surface area, but by the mass of active 
protoplasmic tissue. The varying amount of fat, comparatively inactive 
tissue, may influence the variations of caloric requirement. 

The requirements of the child for specific materials are similar to those 
of the adult. Water, salts and protein serve for purposes of growth and 
repair; fats and carbohydrates are used for fat deposits and, especially, for 
combustion. It is not immaterial to the organism whether this necessary 
energy is supplied exclusively or predominantly by fat or by carbohydrate. 
In the total absence of carbohydrates, as already shown, disturbances of the 
internal metabolism arise, because an interaction between the digestive 
products of the carbohydrates and of the fats is necessary to complete the 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 23 

combustion of the latter. If these products of carbohydrate digestion are 
wanting, the acetone bodies remain as incombustible end-products. If, 
however, fat is absent, the integrity of the chemical composition of the 
body is endangered, as is shown in the retention of abnormally large 
quantities of water in the tissues. The cause of this water-retention is not 
known. The fact that the glycogen deposited in the body holds two to three 
tunes its weight of water is not a sufficient explanation, since the amount of 
glycogen is so small. The harmful influence of a disproportionately fatty 
or carbohydrate diet is important clinically only when it has continued 
unchangingly for some time. 

Corresponding to its more active metabolism, the infant uses more 
oxygen and excretes more carbon dioxide, although the difference is very 
small when the exchange is calculated not in ratio to body-weight, but to 
body surface. The figures, obtained by Schlossmann and his assistants, 
of 12.85 gms. of oxygen used and 15.75 gms. of carbon dioxide excreted, 
per hour, per square meter of surface area in the resting infant, agree with 
the average quantities determined by Rubner in the resting adult. 

A very considerable part of the gaseous metabolism is represented in 
excretion through the lungs with the aqueous vapor. The so-called insen- 
sible perspiration, according to a table by Camerer, Jr., is about 1.3 to 1.7 
grams per kilo per hour during the first half-year; about twice that in the 
adult. These averages, however, have been obtained from greatly varying 
individual determinations. Thus, for instance, an infant when at rest may 
lose only 2 to 3 grams per kilo per hour, but when extremely restless it 
may lose from 10 to 15 grams per hour. 

GROWTH 

In the preceding pages so much stress has been laid upon growth as a 
visible phenomenon in the life of the infant organism that it seems neces- 
sary to treat the principle of growth more fully. Aside from minor 
indices of growth, of interest only from a clinical standpoint, as, for instance, 
the increase of the circumference of the head and chest, to be discussed in a 
later chapter, growth may be determined by measurement in two ways: 
first, as weight and, second, as total body length. 

The figures cited at the close of the preceding section concerning the 
volume of the insensible perspiration, as well as those which bear upon the 
capacity of the stomach, suggest that to be of value for comparison the 
child's weight must be taken always at the same hour. This is also true 
for the measurements of length, since it is well known that a slight decrease 
(1-3 cm.) occurs after the body has been in an upright position during the 
day. The disturbing factor of variance in the amount of the stomach- 
content is best avoided by weighing the child immediately before the first 
or second feeding of the day. 

The average birth weight of healthy children is 3400 gms. (l l /2 pounds) 
for boys, and 3200 gms. (7^ pounds) for girls. Great variations from these 
averages are possible under entirely physiologic conditions. Usually the 



24 



TEXT-BOOK OF PEDIATRICS 



first-born children are smaller than those of later birth. 8 The size and 
weight of the mother do not always determine the size of the new-born child 
at full term and great variations, in both directions, often occur. This is 
also true in the degree of development of the subcutaneous fat. 

The average weight of the American new-born (white) is about 3.45 
kilos for boys and about 3.35 kilos for girls, being slightly above the 
European average usually quoted. Among the factors affecting the weight 
of the new-born are sex, activity of the mother in the last weeks of preg- 
nancy, age of the mother, parity and race. Most of these factors apparently 
influence the new-born weight through their effect on the duration of preg- 
nancy rather than through any direct influence on the rate of growth. 
There is no scientific evidence to show that changes in the nutrition of 



Gervlcht 



7Z 15 20 ^t f 28 



Jff W 



f.8 5Z. 



9000 



8000 



7000 



6000 



5000 



WOO 



3000 



FIG. 2. Average weight of breast-infants weighing more than 2750 grams (6| pounds) at birth. 
(After Camerer, Sr.) 

the human mother, within ordinary limits, has any constant effect on the 
weight of the offspring. 

During the first two, three, or more days, all new-born infants show a 
physiologic loss of weight in varying amount, 9 which is equalized again, 
in breast-fed infants, by the eighth to the tenth day. Then follows, under 
normal conditions, a continuous gain, which may be interrupted, as shown 
hi the daily weighings, by pauses or even by slight losses, but which, com- 
paring one week with another, indicate an almost regular rise. 

This regularity is, of course, definite only in individuals of undisturbed 
development. As soon as an average of any large number of children, who 
are not always weighed at the same interval, is taken, it is lost. The fol- 

8 To this is supposedly due, in part, the fact that the material of lying-in hospitals 
which consists largely of first-born children, shows a small average of weight. 

9 This physiologic loss amounts to 200 gms. (7 ounces) or more, especially in chil- 
dren of heavy weight at birth. 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 



25 



lowing tables were obtained by the elder Camerer from the study of 119 
breast-fed and 84 artificially-fed infants, of more than 2750 gms. (6 pounds) 
birth weight, without consideration of sex. The table for breast-fed 
infants is presented in the form of a curve, so that it may be the more 
readily studied. 

TABLE I. 

Average weight during the first year of children weighing more than 2780 gms. 
(6.12 pounds) at birth. 

Abbreviated from the table of Camerer, Sr. in the Jahrbuch fur Kinderheilkunde, 
Vol. LIII, pp. 409. 



End of Week 


Breast-fed Infants 


Artificially-fed Infants 


Grams 


Pounds 


Grams 


Pounds 


Birth 


3433 
3408 
3567 
3781 
4008 
4907 
5600 
5693 
6294 
6824 
7289 
7505 
7774 
8175 
8655 
8674 
8855 
9232 
9589 
10141 


7.55 

7.49 
7.85 
8.33 
8.83 
10.80 
12.33 
12.54 
13.63 
15.00 
16.05 
16.53 
17.12 
18.00 
19.06 
19.10 
19.50 
20.33 
21.12 
22.33 


3467 
3314 
3384 
3557 
3683 
4303 
4911 
5093 
5532 
6181 
6836 
7278 
7207 
7783 
8161 
8470 
8306 
8782 
9192 
9624 


7.64 
7.30 
7.45 
7.83 
8.15 
9.48 
10.82 
11.22 
12.18 
13.61 
15.05 
16.03 
15.87 
17.14 
17.97 
18.65 
18.29 
19.34 
20.25 
21.19 


1st 


2nd 


3rd 


4th 


8th 


12th . . 


13th . 


16th 


20th 


24th 


26th 


28th 


32nd 


36th 


39th 


40th 


44th 


48th . 


52nd 





These figures of Camerer's may be considered rather high in their 
absolute values and indicative of a stronger tendency to growth than the 
average in these children. Every physician who has the opportunity to 
observe different types of children frequently meets with infants who, in 
spite of continuously undisturbed health and regular development, will not 
come up to these figures. Nor is the curve the same in all cases. In some, 
the greater increase occurs at the beginning, while a gradual flattening of 
the curve is evidenced by the sixth or seventh month; in others, an almost 
regular advance occurs during the entire first year. Between these 
extremes all possible transitional forms may exist. Further, attention must 
be called to cases in whom no actual increase occurs, during the first weeks, 
because of a slow increase in the quantities of breast-milk, but in whom the 
delay is fully equalized by the more rapid growth of following months. This 
is the best of evidence that a long continuance of even scant feeding at the 
breast has caused no lasting injury to the child. 

From these figures it may be seen that the birth weight is about 
doubled by the beginning of the fifth month and is trebled by the close of 



26 



TEXT-BOOK OF PEDIATRICS 



the first year. The differences in weight between boys and girls, which are 
not shown in the table, gradually become greater, being from 200 grams 
(7 ounces) to 500 grams (18 ounces) in favor of the boys by the end 
of the twelfth month. 

After the second year, the weight increase is markedly slower. The fol- 
lowing table gives in round numbers the yearly averages and also the sex 
differences of weight. 

A number of formulae have been developed for expressing the growth 
in height and weight during childhood, but most of these are too complex 
for immediate practical application. The following simple rules give 

TABLE II. 
Increase in Weight. 



End of the Year 


Boys 


Girls 


Body- Weight 


Annual Increase 


Body-Weight 


Annual Increase 


Kilos 


Pounds 


Kilos 


Pounds 


Kilos 


Pounds 


Kilos 


Pounds 


Birth 


3.4 
10.2 
12.7 
14.7 
16.5 
18.0 
20.5 
23.0 
25.0 
27.5 
30.0 
32.5 
35.0 
37.5 
41.0 
45.0 
50.0 
56.0 


7.48 
22.44 
27.94 
32.34 
36.30 
39.60 
45.10 
50.60 
55.00 
60.50 
60.00 
71.50 
77.00 
82.50 
90.20 
99.00 
110.00 
123.20 


6.8 
2.5 

2.0 
1.8 
1.5 
2.5 
2.5 
2.0 
2.5 
2.5 
2.5 
2.5 
2.5 
3.5 
4.0 
6.0 
6.0 


14.96 
5.50 
4.40 
3.96 
3.30 
5.50 
5.50 
4.40 
5.50 
5.50 
5.50 
5.50 
5.50 
7.70 
8.80 
13.20 
13.20 


3.2 
9.7 
12.2 
14.2 
15.7 
17.0 
19.0 
21.0 
23.0 
25.0 
27.0 
29.0 
32.0 
37.0 
43.0 
48.0 
52.0 


7.04 
21.34 
26.84 
31.24 
34.54 
37.40 
41.80 
48.20 
50.60 
55.00 
59.40 
63.80 
70.40 
81.40 
94.60 
105.60 
114.40 


6.5 

2.5 
2.0 
1.5 
1.3 
2.0 
2.0 
2.0 
2.0 
2.0 
2.0 
3.0 
5.0 
6.0 
5.0 
4.0 


14.30 
5.50 
4.40 
3.30 
2.86 
4.40 
4.40 
4.40 
4.40 
4.40 
4.40 
6.60 
11.00 
13.20 
11.00 
8.80 


1st 


2nd . 


3rd 


4th 


5th 


6th 


7th 


8th 


9th ... 


10th 


llth 


12th 


13th . . 


14th . 


15th 


16th 


17th .... 





weights and heights which fall within the range of normal variation from 
the average for American children. 

Height (in inches) equals twice the age (in years) plus 32 inches (good 
from 3 to about 14 years). 

Weight (in pounds) equals seven times age in years minus 2 pounds for 
each year under seven (good from 3 to 7 years). 

Weight (in pounds) equals seven times age in years plus 4 pounds for 
each year over seven (good from 7 to 12 years). 

A more rapid increase of weight during the years of adolescence is very 
plainly indicated in this table and a corresponding rise is shown in the table 
of body lengths. Since puberty occurs earlier in girls, their increases during 
the thirteenth to the fifteenth years exceed those of the boys, not only 
relatively but absolutely. During the succeeding years the increase is 
always less. 



27. 

The growth in length corresponds to the weight increase, in so far as it is 
greatest during the first year of life and becomes more gradual with 
advancing age. The following table gives the yearly averages in 
round numbers: 



TABLE III. 
Growth in Height. 


End of the Year 


Boys 


Girls 


Height 


Annual 
increase 


Height 


Annual 
Increase 


Cm. 


Inches 


Cm. 


Inches 


Cm. 


Inches 


Cm. 


Inches 


Birth 


50 
75 
85 
93 
99 
104 
109 
115 
120 
125 
130 
135 
140 
145 
151 
157 
164 
168 
170 


20.0 
30.0 
34.0 
37.2 
39.6 
41.6 
43.6 
46.0 
48.0 
50.0 
52.0 
54.0 
56.0 
58.0 
60.4 
62.8 
65.6 
67.2 
68.0 


25 
10 

8 
6 
5 
5 
6 
5 
5 
5 
5 
5 
5 
6 
6 
7 
4 
2 


10.0 
4.0 
3.2 
2.4 
2.0 
2.0 
2.4 
2.0 
2.0 
2.0 
2.0 
2.0 
2.0 
2.4 
2.8 
1.6 
0.8 


49 
74 
84 
92 
98 
103 
107 
113 
118 
123 
128 
133 
139 
146 
153 
158 
160 
161 


19.6 
29.6 
33.6 
36.8 
39.2 
41.2 
42.8 
45.2 
47.2 
49.2 
51.2 
53.2 
55.6 
58.4 
61.2 
63.2 
64.0 
64.4 


25 
10 
8 
6 
5 
4 
6 
5 
5 
5 
5 
6 
7 
7 
5 
2 
1 


10.0 
4.0 

3.2 
2.4 
2.0 
1.6 
2.4 
2.0 
2.0 
2.0 
2.0 
2.4 
2.8 
2.8 
2.0 
0.8 
0.4 


1st : 


2nd 


3rd 


4th 


5th 


6th 


7th 


8th 


9th 


10th 


llth. . 


12th 


13th 


14th 


15th . 


16th 


17th 


18th 





Attention should be called to the fact that these measurements taken 
absolutely are, as already stated of the table of weights, rather high and 
that measurements which do not come up to them are still within the 
limits of normal individual variance. 

A more rapid increase in girls, both relatively and absolutely, during 
the years immediately preceding early puberty is recognized. During the 
periods of sharply accelerated growth the child is commonly said to "shoot 
up." We distinguish such a period during the first year, which may be 
looked upon as a continuance of the rapid fetal growth; a second stage 
appears at about the same time in both sexes, in or near the seventh year; 
and a third acceleration, dependent upon the climax of puberty, sets in 
with boys from the fourteenth, to the sixteenth year, and in girls from the 
twelfth to the fourteenth. 

Besides these variations in the rate of increase, alike in weight and 
length, dependent upon the factor of age in children after infancy, Mailing- 
Hanson first observed variations dependent upon seasonal change. These 
were confirmed later by the elder Camerer and by Schmid-Monnard. Three 
seasonal periods may be distinguished. 



28 TEXT-BOOK OF PEDIATRICS 

1. The period from the middle of August to the end of November or 
middle of December, the last third of the year, showing the greatest increase 
in weight and the least increase in length. 

2. The period from November or December to the end of March, or the 
first part of April, the first third of the year, showing a moderate increase 
in weight and length. 

3. The period from the end of March or the beginning of April to the 
middle of August, the second third of the year, exhibiting the greatest 
increase in length, with loss of weight. 

It is probable that different modes of life and varying activities of 
children in the several seasons cause these altered relations in the factors 
of growth. Whether the sedentary habits and the long continued in- 
door life incident to attendance at school play an important part is not en- 
tirely clear. 

The unfavorable influence of improper food and unhygienic surround- 
ings, as indicated by the greater morbidity and the greater frequency of 
the severer forms of rickets among the poorer classes, is suggested also by 
the fact, established in many tables of statistics, that, as a rule, the children 
of the well-to-do exceed those of the poor both in weight and in height. 
This general observation does not, of course, exclude far-reaching individ- 
ual differences. 

The relations of age, weight and height which obtain in healthy children 
have been presented very clearly in von Pirquet in the form of the "meas- 
uring tape. " 

To these considerations of general growth should be added some em- 
phasis upon the incidents of special growth. 

The Brain. The average weight of the brain at birth is 370 grams in 
male and 350 grams in female infants, while the adult brain weighs from 
1260 to 1400 grams. One-third of this increase (300-350 grams) takes 
place in the first 9 or 10 months and the rest of the increase is attained by 
the middle of the third year. Roughly, the weight of the brain is doubled 
by the end of the first year and tripled at two and one-half years. The 
growth is completed by the 16th to 20th years. The sexual difference in 
weight of 10-15 grams at birth becomes greater, so that in adult life the 
brain of the male weighs 120 grams more than that of the female. Normal 
average weights for various ages are approximately as follows: 

Grams 

New-born 370 

At 2 mos 460 

At 4-6 mos 600 

At 11-12" mos 850 

At 2nd year 970 

At 3rd year 1100 

At 4th year 1190 

At 5-8th year 1220 

At 9-14th year 1300 

At 15-20th year 1400 

The variations in normal subjects are great and even during the first 
year may be 100-200 grams. There is no noticeable parallel between men- 
tal development and size of brain. 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 29 

Skeletal Growth. The centres of ossification may be studied in the liv- 
ing by the radiograph and are of clinical interest. 

The ossification of the bones of the wrist is of particular interest ag 
indicating the physiologic age of the child. All of the bones of the wrist 
are commonly cartilaginous at birth although one and sometimes two small 
ossification centres may be seen in particularly well-developed new-born 
children. Two centres are usually present at 1 year, 3 at 2 years, 4 at 3 
years, 5 at 4 or 5 years, and 6 at 5 or 6 years. The ossification of the wrist 
proceeds more rapidly in girls than in boys, the former being a full year in 
advance of the latter at 6 years. 

The centres appear normally in regular order, subject to little vari- 
ation. The time of appearance is not so constant that the exact age of the 
child can be determined by their appearance. Any pronounced delay in 
the development of the ossification centres, however, must be considered 
pathologic and, under certain circumstances, as pathognomonic. It is not 
infrequently combined with a general delay of the growth in height. 

Of the fontanelles, only the greater or anterior is normally open, that is 
closed only by a membrane, at birth. If the smaller or posterior fontanelle 
at the juncture of the sagittal with the lambdoid suture, or the parietal 
fontanelles between the temporal, parietal and occipital bones are still 
palpable as openings, these, as well as the open condition of the sutures, 
may be taken as evidence of retarded ossification. From birth to its com- 
plete closure, which occurs during the first half of the second year, the 
greater fontanelle decreases in size continuously. Any increase in area is to 
be considered pathologic and due either to rickets or to abnormal growth of 
the head. Complete bony occlusion before the end of the first year is found 
only in conditions where the growth of the entire head is abnormally 
retarded (microcephaly). There is great variation in the time of the com- 
plete closure of the anterior fontanelle, even in normal children. Collected 
statistics show that the structure undergoes but little change in size in the 
first 3 or 4 months after birth. It is closed in about 15 per cent, of all cases 
at one year and in about 50 per cent, at 15 months. 

Dentition. 'The physiology of dentition has always been of great interest 
to the physician. For hundreds of years, 10 this interest was inspired entirely 
by the fact that the causation of all imaginable diseases of the first years was 
ascribed to dentition. If this theory which, in its extreme conclusions has 
led to much useless interference and senseless prescribing and in its actual 
disregard of disease present has resulted in the death of uncounted numbers 
of children, could be completely erased from the minds of all physicians of 
today, it would be as unnecessary to discuss the course of dentition as it is 
to discuss growth changes in the bones or in other parts of the body. Since 
this is not yet true, the following statement may be presented. 

The cutting of the teeth has been erroneously considered a mechanical 
process and this one-sided consideration of the growth of the teeth has led 



10 We must thank Ludwig Fleischmann, Clinic of Pediatrics, Vol. II, Vienna, 1877, 
and Kassowitz, Diseases During the Age of Dentition, Leipzig and Vienna, 1892, for 
interesting clinical and historical presentations of this subject. 



30 TEXT-BOOK OF PEDIATRICS 

to the complete oversight of the coincident growth of the jaw. Today, 
however, we know that most marked and rapid changes take place shortly 
after birth and that, running parallel with the development of the dental 
germ, there is an enlargement of the jaw and a gradual resorption of the 
tissues lying above and beside the growing tooth. This, curiously enough, 
is true not only during the later stages of development when the tooth has 
become hard, but, also, in the earlier phases when the tooth is but a soft 
sack which is capable of exerting only slight pressure. 

The erupting tooth does not rupture the alveolus any more than the 
growing epiphysis ruptures the articular cartilage which covers it. It is 
rather a process of the spreading of the alveolus for the tooth, the opening 
out without force of a passage for it under the gum. The soft gum tissue 
then forms its only barrier, and this too is doubtless overcome, in an anal- 
ogous manner, by the gradual resorption of the soft parts without no- 
ticeable pain and, at least in the nervously normal child, without any 
disturbance either of a local or a general nature. 

This does away with any physiologic basis for the teaching of difficult 
dentition. In its place, we are gaining an increasing knowledge of the 
pathology of infancy and a clearer comprehension of the nature of all those 
disturbances and diseases which were formerly ascribed to it. 

A knowledge of the normal course of dentition is of importance for 
another reason; that is, in regard to the time of the successive appearance 
of the several groups of teeth. First, between the sixth and the ninth 
months, the lower central incisors appear; a few weeks later, the upper 
middle incisors; and, in rapid succession, the upper lateral incisors. The 
lower lateral incisors appear somewhat later; so that by the end of the 
first year, at least, all of the eight incisors have erupted. Usually several 
weeks or several months after, the premolars appear, first above, then 
below, and but very rarely in the reverse order; and, by the end of the 
second year of life, the cuspids come through. In the third year of life, 
the first molars finally appear and with these twenty teeth the temporary 
dentition is complete. The following method may be used in writing the 
tooth formula of a child, the horizontal line representing the buccal opening 
and the vertical the median line. 



c' 





b 


a' 


a 


a 


a' 


1) 


B 


c' 


c' 


c 


b 


a' 


a 


B 


a' 


b 


C 


c' 



Any notable extension of the period of dentition marked by longer 
pauses between the eruption of the several teeth, or any great variation 
from the natural order in which the teeth appear must be considered as an 
evidence of rickets. 

The second dentition begins with the eruption, in both the upper and 
the lower jaw, of the third pair of molars (six-year molar) ; then the milk 
teeth gradually drop out, in about the order of their appearance, and are 
replaced by the teeth of the permanent set. Just before the beginning of 
puberty the fourth molars erupt and finally the fifth pair, called the wisdom 
teeth, because they usually appear sometime after puberty. 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 31 

The Nervous System. The central nervous system of the new-born and 
the young infant has practically the same form as that of the adult. When 
we consider that the brain of the new-born is remarkably heavy, even in 
comparison to the total body- weight (about 1 : 8 at birth; in the adult about 
1 : 40), we may readily understand that man brings into the world with him 
a brain which is laid out in external outlines and form upon a remarkably 
large scale, but the interior may be compared to an unfinished house. The 
interior is not hollow or empty, nor are its ventricles larger than in later 
life; but the greater part of its mass consists of unfinished tissue which 
apparently serves only for scaffolding and framework and which, in the 
course of later development, is gradually replaced by specific nerve tis- 
sue ganglion cells and nerve fibres. This development involves not 
only a quantitative increase but also a qualitative change from the 
simpler forms resembling embryonic types to the higher differentiations 
which mark the adult. The most noticeable difference in the macroscopic 
comparison of the infantile and the adult brain and spinal cord is found in 
the development of the myelin sheaths. 

In the cord of the infant born at term this is complete, excepting for a 
small remnant. Only the directed and crossed pyramidal tracts are almost 
wholly unmedullated. The cauda equina, the medulla and the cerebellum 
contain numerous medullated tracts even at birth; while only a few fibres 
or bundles of fibres, in the cerebellum and preponderantly in the projection 
system, are medullated. Because of this, the entire white portion of the 
brain appears gray upon section, being only slightly differentiated from the 
gray of the cortex. Further development continues progressively, with 
slight variations of rapidity and order in different individuals, one bundle 
of fibres after the other becoming medullated. 

At about nine months, most of the long association tracts, with the 
exception of the projection fibres, are medullated, while the shorter fibres, 
connecting closely neighboring regions, and the radiation fibres are much 
slower of medullation and are probably not completely covered and 
definitely developed by the end of childhood or the period of com- 
pleted growth. 

The brain has acquired nearly one-third of its adult weight at the time 
of birth and the spinal cord about one-seventh, whereas the body increases 
twenty-fold in weight between birth and maturity. Approximately two- 
thirds of the postnatal growth of the brain takes place in the first 18 
months and over 90 per cent, is accomplished by 6 years. The different 
parts of the brain grow at somewhat different rates, the cerebellum and 
brain stem increasing more in postnatal life than the cerebrum. The 
primary and secondary fissures of the cerebrum are all present at the time of 
birth although some of the tertiary ones are formed during the first month 
after birth. It is probable that all of the nerve cells of the cerebrum and 
cerebellum are formed at birth. 

The peripheral nerves of the new-born are very poor in covering and 
where neurilemma can be distinguished it is thin, unequally developed and 
frequently interrupted by non-medullated areas. The medullation proceeds 



32 TEXT-BOOK OF PEDIATRICS 

rapidly during the first few weeks; later more slowly, and is completed by 
the end of the first year. Other histological peculiarities of the peripheral 
nervous system of infants, which need not be specifically mentioned here, 
also disappear by the end of this period. 

Of the cranial nerves, the optic nerve is only partly medullated at birth 
and in the region of the cribriform plate is entirely unmedullated. The 
medullation proceeds from the central to the peripheral end, that is in the 
reverse of the direction of the transmission of impulses through the fibres. 
The auditory nerve, on the contrary, is completely covered at birth. 

The anatomical differences in the sense organs to which attention should 
be called, are first, the eye, which is hyperopic in the new-born, and second 
the middle ear, which is filled with mucous fluid, at least during the first 
few hours after birth and sometimes for a longer period. This probably 
comes from the amniotic fluid. The condition of the middle chamber might 
lead us to suspect a temporary deafness, especially when we consider, as 
already mentioned, that the auditory nerve is completely formed at birth. 

To attempt a description of the psychic development of the child from 
birth to puberty, even though but the chief points were to be touched, would 
seem an impossible task. It is better that we refer to the works of Preyer, 
Compayre, Ament and others, where many references to the literature may 
be found. We can give only the following points: 

At the age of three months, after the so-called stupid quarter of the 
year, the infant is so completely in control of all his senses that the move- 
ments of the eyes, incoordinate at first, have become completely balanced 
and objects which are not too small and lie in the line of direction of the 
vision will be fixed and followed. Frequently, images which the child has 
seen before, as for instance, the faces of his parents, are recognized and 
greeted with a smile. Similarly, there appears a tendency to turn toward 
the location of a noise, at first by turning the head and later by turning the 
eyes also. 

Articles which the infant sees or which are laid in the palm of the hand 
are grasped. However, even up to the fourth month, the closing of the 
hand is accomplished by a palmar flexion of the hand as a whole. But 
shortly after, as evidence of purposeful central coordination, the closure 
of the hand occurs with a synchronous dorsal flexion. During the fourth 
or fifth month, active grasping motions are made. 

The sense of smell, temperature and pain are soon much better devel- 
oped than they are at birth. 

Among coordinated muscular movements, the lifting of the head is the 
first to appear when the child is laid upon its abdomen; and this position 
may be maintained for several minutes. At a slightly later period, when the 
child sits with some support, the head is held erect and is freely turned from 
side to side; while unsupported, sitting is not usually possible before the 
sixth month. This is more constant in its date of development than the 
power of standing, which shows great individual differences. With sup- 
port under the arms, strong children will stand for several minutes during 
the fourth or fifth month, and by the seventh or eighth month they will 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 33 

stand if they can hold fast to something with the hands. However, they 
sometimes let go suddenly and fall down. Shortly after this children, with 
well-developed static function begin to take their first steps, while they hold 
by or lean against the furniture. Children remain at this stage for a longer 
or shorter time, according to their temperament, before they dare to walk 
without support. This is usually accomplished between the tenth and the 
fifteenth month. 

Delays may be caused by disease, especially by long-continued illnesses 
which disturb the entire development. More frequently, rickets may post- 
pone the date of any of these periods of progressively acquired function. 
Even the simple muscular stretching and the power of standing upon the 
feet which normal children attempt very early may be absent until late in 
the second year. These children, recognized for other reasons as back- 
ward rickitics, draw the legs up to the abdomen when they are lifted by the 
arms. Standing and walking, with them, may be delayed until the third 
or fourth year. 

Marked delay in the development of coordinated motor function, even 
in the matter of holding up the head, is under certain circumstances to be 
considered an early symptom of imbecility. It doubtless depends, in the 
first place, upon the lack of attention and interest in the surroundings and 
is, therefore, to be considered an intra-psychic rather than a psychomotor 
defect. This is further shown in other respects, as in the reduction of the 
pain and taste senses phenomena of absence which can be demonstrated at 
one and the same time and can be explained in no other way. 

The first motions of the new-born are in part automatic and in part 
reflex. This is true, not only of the complicated coordinated motions, such 
as suckling, but also of the mimic motions of expression. 

It is a well-known fact that the new-born infant reacts to stimulation 
of the taste organs, by placing upon the tongue sweet, sour, salty or acid 
substances, by corresponding facial expressions. That these responses are 
brought about by reflex (subcortical) action, without psychical correlation 
is shown by the fact that hemi- and anencephalic infants in whom the cere- 
brum, the entire organ for psychic function, is absent, show the same re- 
sponsive power. 

It is very interesting to note how the subcortical reflexes disappear in 
the course of the first year or are rather replaced by cortical action. This 
explains the fact that the facial mimicry is often absent in older idiots. 
Their subcortical reflex is lost, but the cortical action has not developed 
because of the central defect. 

The same condition is seen in the sucking reflex. In the first weeks, it 
appears unconditionally every time the lips or the neighboring region re- 
ceive a sufficient stimulus, but later it occurs only when the child is hungry 
or is waiting for a feeding or the like, and then as a conditional reflex. 

The light reflex and the corneal reflex are completely developed in the 
new-born, while the reaction of the pupil for accommodation appears in the 
second month. The blinking reflex, excited by the rapid approach of an 
object to the eye, first appears in the second or third month. 
3 



34 TEXT-BOOK OF PEDIATRICS 

It must be noted that Babinski 's phenomenon (the dorsal flexion of the 
toes, and especially of the great toe, and the spreading of the toes when the 
sole of the foot is tickled) is physiologic even to the second year. 

The skin reflexes, frequently absent in the new-born, are usually very 
active in older infants. 

The lachrymal secretion is absent during the first few months. The 
tendon reflexes are active in the new-born, as well as in older infants, and are 
easily brought out when the limbs are relaxed as during the act of nursing. 
At other times they are masked more or less completely by the physiologic 
hypertonia of the muscles. It is not easy to explain the condition upon 
which this "hypertonia," a distinctly increased resistance to passive mo- 
tion, depends. It is a readily recognized stiffness and awkwardness of all 
active movements in the extremities of the new-born which exceeds the 
hypertonia of later infancy. That the muscle of the new-born animal does 
not respond to a nervous stimulus with lightning-like rapidity, but reacts 
with a more gradual and more or less tonic contraction a fact discovered 
by Soltmann, has probably something to do with it, but the mechanism of 
the fact is far from clear. 

Physiologic spasmophilia, in the sense of an increased excitability of the 
reflexes (Soltmann) exists neither in the new-born nor in older infants. 
Nor is the remarkably frequent occurrence of clonic and tonic convulsions 
at a definite period of infancy, chiefly during the second and third semesters 
of life, dependent so much upon any physiologic peculiarities of the infan- 
tile nervous system as upon special disturbances of metabolism incident to 
that age. (See chapter on Spasmophilia.) 

The acquirement of speech, to which a certain degree of intellectual 
development is necessary, is timed rather closely. The child shows an 
understanding of words and simple sentences at about one year of age and 
soon after, say at about one year and three months, begins to speak. Even 
earlier, usually between the sixth and eighth months, the child exercises 
the mechanism of articulation with easy syllables, preparing for the func- 
tion of speech. Such periods, however, are subject to great variations, in 
part due to the inherent conditions of the child itself and in part to its 
environment. They may be markedly delayed without the presence of 
any mental defect. Such defect should be suspected only when the attain- 
ment of speech is delayed until the third or fourth year. 

The further development of speech and the exercise of the mental 
faculties varies so greatly, even in children of similar or nearly similar 
intrinsic quality, under differing environment, that it is not as yet possible 
to establish any definite criterion which would be useful in judging the 
milder grades of mental deficiency. Long continued disease, conditions of 
exhaustion, and especially defect of sense organs, may delay the acquire- 
ment of speech and the exercise of mentality, but a definite prognosis of 
future development is entirely impossible. In the healthy child differences 
in temperament are often noticeable at an early period, even in the first or 
second year, but in these, even, the influence of intentional and unconscious 
training is very great. 



ANATOMIC AND PHYSIOLOGIC PECULIARITIES 



35 



The sleep of the infant is normally sound and long continued. Healthy 
infants, during the first few months, sleep nearly all day, excepting when 
being fed or bathed or changed, and 
when asleep assume the position 
shown in Fig. 3, which is evidently 
a continuation of intra-uterine pos- 
ture. It is usually an indication that 
the child is ill when the arms sink 
to the sides. The length of time 
spent in sleep is gradually decreased, 
from about twenty hours, by occa- 
sional periods of wakefulness, but 
even during the third to the sixth 
year the child still sleeps twelve to 
fifteen hours and at school age from 
nine to eleven hours. 

FIG. 3. Position of healthy infant during sleep. 

Puberty, the period of the de- 
velopment* of the genital functions and of the secondary sexual char- 
acteristics, gradually leads up to maturity and does not actually belong 
to childhood. 




II. CARE AND FEEDING OF THE NORMAL INFANT 

REVISED BY 

JULIUS HESS, M.D., 

Professor and Head of the Department of Pediatrics, University of Illinois, College 

of Medicine, Chicago. 

THE science of the feeding of children and especially of infants, the 
differentiation of normal from pathological conditions, and a strict discrim- 
ination of what should be considered normal is more important in this 
than in any other division of pediatrics. The indefinite understanding of 
normality, the recognition or non-recognition, for instance, of constitutional 
anomalies even in the infant, the designation of nutritive results as satisfac- 
tory when we have only succeeded in causing a great increase in weight and 
large deposits of fat, have proved to be sources of serious error prejudicial to 
the science of pediatrics. In their Manual, Czerny and Keller define a 
new-born child as healthy, "when it is born of healthy parents in the inid- 
productive period, when it is carried to full term, is free from essential 
malformities, and is able, with the protection of non-conducting clothing, to 
maintain a normal body temperature." They further designate that 
method of feeding as suitable for a healthy child "by which the child devel- 
ops normally in body and, so far as this depends upon food, psychically, 
and remains free from disturbances of metabolism, as well as of those 
diseases the occurrence of which is influenced by disorders of nutrition." 
Only a strict adherence to these definitions has put an end to the former 
chaos in the teaching of infant-feeding. 

In the future, whoever tries a favorite infant-food upon a number of 
children, without considering whether, in the strict sense, they are well or 
ill; and who attempts to draw conclusions of the values or non- value of a 
feeding method by such means, shows that the entire progress of modern 
pediatrics has passed him by without leaving any impression. 

a. NATURAL FEEDING 

The only natural food for the infant, during the first half year, at least, 
is the mother 's milk. To what extent this may be replaced by the milk of 
other women will be stated later. It is sufficient here to call attention to the 
fact that so-called artificial feeding should never be considered natural 
feeding for children of this age. 

OBSTACLES TO NURSING 

Before we describe breast feeding, the following question must be 
settled. Can all new-born children be nursed by the mother? This must be 
answered in the negative. There are doubtless obstacles to nursing upon 
the part of the mother and upon the part of the child, but they are much 
more rare than is generally believed, even by physicians. 
36 



CARE AND FEEDING OF THE NORMAL INFANT 37 

All diseases of the mother, whether they are connected with the process 
of giving birth to the child, or whether they be of an infectious or constitu- 
tional nature, are only conditional obstacles. Since the feeding of the 
child, at least during the first period of life, requires only small quantities of 
mother's milk, the supply makes no special demand upon the physical 
strength of the mother. Further, lactation is in many respects necessary to 
her own health. The physician should not always look upon severe acute 
diseases, as eclampsia and nephritis or pneumonia, as reason to discontinue 
nursing. Especially is nursing not contraindicated under conditions, 
involving even large loss of blood in parturition, which give promise of the 
comparatively rapid recovery of the mother. On the other hand, marked 
puerperal sepsis, typhoid fever, severe erysipelas, and the like, make nursing 
impossible because they mean danger to the child. Similarly, malignant 
diabetes and epilepsy, with numerous crises, are contraindications. 

For want of experience unimpeachably beyond the contradiction of 
critics, views are divided as to the propriety of a tuberculous mother nursing 
her child. While formerly nursing was absolutely forbidden in every 
definite case of tuberculosis, a view Czerny and Keller take, this is con- 
tradicted by Schlossmann, who bases his argument upon the favorable 
influence of lactation upon the health and weight increase of the mother, as 
well as upon the greater resistance of the breast-fed child to tuberculous 
infection. This claim seems to be supported by several clinical observations. 
Still later (Deutsch, Tuberculosis and Nursing, Munchner, Medizinische 
Wochenschrift 1910, page 1335) facts have been reported on the other side, 
under rather meagre observations, which indicate that the mother with 
distinct tuberculous pulmonary disease should be absolutely prohibited 
from nursing, for her own benefit as well as for that of the child ; while in 
mothers with suspicious changes it may be permitted only as an experiment 
under the observation of a physician. A positive von Pirquet reaction 
without physical lung findings, has never seemed to us sufficient reason to 
discontinue nursing or to interrupt it without mature consideration. 

General weakness, anemia and emaciation, extreme youth, and in most 
cases, even a neuropathic constitution, are not adequate causes for the 
initial prohibition of nursing. 

The majority of such women not only bear the added strain of nursing, 
but receive undeniable benefit to their own health which is not confined to 
the better and more complete involution of the puerperal organs a well- 
known result, but manifests itself in the rarity with which carcinoma of the 
breast occurs in women who have nursed. No prediction can be made in the 
individual case as to whether the woman will lose or gain in weight while 
nursing. More usually the mother gains in weight, and hand in hand with 
this gain comes more blooming health, an increase of strength and an im- 
provement in her general well-being. Loss of weight is not in itself a cause 
for anxiety, for the mother may be placed under treatment and the child 
may be weaned at any time. 

Bearing-down pains in the breast or back, sometimes present at the 
beginning of lactation, or appearing after getting up are usually dissipated 



38 TEXT-BOOK OF PEDIATRICS 

by suggestive treatment, as, is my experience, is the rare tenderness of 
the nipples in neuropathic women. 

More serious difficulties are presented by fissures in the region of the 
nipples because of the severe pain which some women suffer and because 
of the danger of mastitis. Their appearance is not always preventable, 
even by the massage of the nipples with spiritous solutions which is 
frequently recommended during the last months of pregnancy. 

Skill in placing the child to the breast, so that it sucks from the entire 
areola and not from the nipple alone and the avoidance of too long periods 
of feeding are probably the most successful preventatives. 

The milder cases of fissured nipple are relieved by various methods of 
treatment. Glycerin, or glycero-tannin (5-10 per cent.) ; or the so-called 
"black salve" (silver nitrate 0.1, Balsam Peru 1.0, petrolatum 10.0), or 
napthalin ointment; or an antiseptic drying powder (bismuth subgallate, 
or the like), applied between feedings and removed before putting the child 
to the breast, give opportunity for the reformation of epithelium. Anesthesin 
ointment (5 per cent.), may be used to allay pain or, better still, a solution 
of silver nitrate (3-5 per cent.), may be used. The latter causes an anes- 
thesia of long duration after the short initial pain and repair occurs rapidly 
under the crust. In addition to these methods, it will be found necessary 
to bind, up the breasts and to empty them frequently by nursing or ex- 
pression. This may be done either completely, three or four times daily 
or by removing small quantities frequently. A nipple-shield of glass 
with rubber nipple may be used in exceptional cases, but the abuse of 
this device will be treated later. Only rarely do these methods fail to give 
relief, -so that in few cases, and especially in hypersensitive women, nursing 
has to be discontinued. 

Cases of mastitis should be treated surgically with ice-bags, or with 
warm moist applications, or by carefully applied hyperemia. Later, radial 
incisions which do not enter the mammilla, may be made as soon as the pus 
is localized, followed by expression from the incisions. 

With this treatment we must provide for the same satisfactory emptying 
of the breast as in fissures, both for its beneficial effect by reduction of 
pressure upon the circulation and to prevent the arrest of the secretion. 
This emptying may be accomplished by putting the child to the breast 
without hesitation, since, supported by numerous experiences, the admix- 
ture of even large amounts of infected pus with human milk is not dan- 
gerous to the healthy infant. 

By this means it is possible, in most instances, if the inflammation is not 
of a phlegmonous type and inclusive of the entire breast, to combine the 
recovery from the inflammatory process with the preservation of function. 
The secretion of the unaffected breast does not suffer and in case of necessity 
may be increased to such a degree that its output will be sufficient for 
many months of lactation. 

The form of the breast and nipple makes the first attempt at nursing 
difficult or easy. Distinctly retracted nipples, rather rare, but which 
may occasionally occur on both sides, may be an absolute obstacle to 



CARE AND FEEDING OF THE NORMAL INFANT 



39 



nursing. 1 Very flat, short nipples increase the difficulty of nursing, but do 
not make it impossible. 

The only absolute and continuing obstacle to nursing upon the part of 
the child is a cleft palate. In children who are born weak or who have suf- 
fered considerably in the process of birth and have passed the first few days 
in a sort of comatose condition, nursing may be very difficult and, in certain 
cases and for the first few days, at least, may be impossible. In such cases, 
where suckling is temporarily precluded, the breast must be emptied arti- 
ficially and normal nursing delayed. The expressed or pumped mother's 
milk may be given the child by teaspoon or by means of a pipette through 
the mouth or nose. 

In severe coryza, with marked swelling of the mucous membrane, the 




FIG. 4. First position. FIG. 5. Second position. 

Direct expression of milk. 

application of epinephrin solution (1 : 3000) may relieve the difficulty. Con- 
genital syphilis, frequently the cause of such snuffles, is never a reason for 
prohibiting the nursing of the child by its own mother since infection from 
infant to mother is impossible. 

THE ABILITY OF THE MOTHER TO NURSE 

Up to this point, we have not raised the question whether there is always 
milk in the mother's breast. This question of the physical ability of the 
mother to nurse her infant is of general interest. 

Comparing the reports of the large lying-in hospitals, according to which 
almost 100 per cent, of all women confined there are able to feed their 
children adequately, at least during the first nine to eleven days of the 

1 In this case the milk secretion is to be maintained by regular expression which 
can be accomplished throughout the period of lactation. 



40 TEXT-BOOK OF PEDIATRICS 

puerperium, with the experiences of private practice, in which a certain 
per cent, of all women either do not attempt to nurse or give up the attempt 
after a short time, because of the alleged lack of milk, we might arrive at 
the conclusion that the ability to nurse differs widely in the various social 
strata. Whether this is actually so or not cannot be determined, because 
the ability or the lack of ability to nurse is not a definite and unchanging 
fact, but rather a relative condition dependent upon many other factors 
besides the anatomic and physiologic structure of the gland. This has been 
often shown by the experience of many institutions when, as a result of a 
change in medical direction, the ability to nurse has enormously increased, 
a fact which teaches us to recognize the influence of their surroundings upon 
young mothers. Anxiety for the health of the mother and doubt of her 
ability to nurse may, from the first, weaken her desire to overcome the 
difficulties which present themselves. To strive by personal influence over 
the mother and, as a teacher of midwives and nurses, for the increase 
of nursing-power among all classes of the women offers a grateful task to 
every physician. 

Cases in which the breast of the puerperal woman altogether fails of 
secretion are so extremely rare that they are of no practical importance. The 
real question to be met is whether we may expect an adequate secretion. 
Frequently, this can be determined neither before nor shortly after 
delivery, for the rapidity with which lactation commences differs widely in 
individuals. As a rule, it is slower in primiparse than in women who have 
nursed before. Often it is impossible to express even a drop from the 
breast for the first two days and yet the milk secretion shortly becomes suf- 
ficient if the child is placed to the breast regularly and suckles strongly. 
We must admit that there are women whose breasts do not functionate nor- 
mally and whose power of lactation remains inadequate, especially if the 
child does not nurse energetically and does not empty the breast completely. 

The physiologic increase of lactation power, which may drag along for 
weeks in women whose breasts do not secrete freely, should be remembered in 
attempting to judge the value or the non-value of the various galactagogues. 
Up to the present time all the preparations which have been praised, with 
more or less clamorous advertising, as "milk producers " (somatose, 
sanatogen, malt-tropon, lactagol, etc.), are no more specific for the mam- 
mary gland than are excessive amounts of liquid (soups, milk, etc.), or 
solid foods. The inefficiency of such agents is shown in the fact that while 
in some cases no physiologic increase of the lactation power occurs or 
becomes adequate under forced feeding for a considerable period of time, 
yet in these very cases a continued and complete emptying of the breast 
gradually accomplishes its desired result. The recommendations given in 
good faith by physicians concerning the results obtained by the use of 
various galactagogues given them for trial, are not testimonials to the 
scientific knowledge of such men. Galactagogues should be used only for 
the psychic support they may add to other means advised by the physician. 

The fact, which may now be considered firmly established, that the 
relation between the mammary gland and the reproductive organs, in- 



CARE AND FEEDING OF THE NORMAL INFANT 41 

eluding the placenta, is not a nervous one, but rather one of chemically 
active substances of the hormone type, present in the blood, suggests that 
the time is approaching when specific galactagogues will be isolated and 
adapted to therapeutic use. Very suggestive experiments in this direction 
have been reported by Basch. 

Spontaneous failure of lactation is certainly extremely rare and prob- 
ably always occurs in consequence of an incomplete emptying and an 
insufficient stimulation of the breast, as in cases where the child is weak and 
does not nurse properly. This is shown by the fact that this failure, fre- 
quently reported by the laity in private practice, is never, or hardly ever 
seen in institutions conducted by physicians. In spite of the reappearance 
of the menses, the normal duration of a well established lactation is almost 
unlimited and may, if a new conception does not occur, continue for several 
years in women of our race as well as in those of uncivilized peoples. 

Eppstein 's interesting case, in which a wet-nurse after a continued lac- 
tation of over a year, undertook the nursing of the next child of the same 
family without interruption and with the best results is by no means unique. 
It shows that the milk of so "old" a nurse may be used for anew-born 
babe. This fact of the theoretically unlimited duration of lactation is but 
rarely made use of in practice, because we have to recommend complete 
weaning by the ninth month or, at least, by the end of the first year, for 
reasons which will be discussed later. 

THE HYGIENE OF THE NURSING MOTHER 

The nursing woman should change her mode of living as little as possible, 
avoiding only harmful excesses both of work and idleness. Special atten- 
tion should be directed to this with women of the well-to-do classes and with 
wet-nurses. So far as work is concerned, observations among the poor have 
shown that even a large amount of daily work in house or factory is borne 
without injury to the health, or to the secretion of milk of the constitu- 
tionally healthy nursing mother. 

Psychic excitement, especially anger, pain, sorrow, etc., have no influ- 
ence upon the qualitative or quantitative condition of woman 's milk. The 
sudden stopping of the flow of milk, supposedly suffered under such con- 
ditions in especially sensitive women, is a psychic reflex and probably 
depends mainly upon the closure of the sphincter of the mammilla, which 
temporarily prevents the flow or makes the emptying of the breast more 
difficult. It may be gradually overcome, in every instance, by putting the 
hungry child to the breast at regular intervals. The idea of the so-called 
toxic effect of milk supposed to be sensitized by such circumstances should 
be relegated to the realm of the fable. 

The nursing woman should take a sufficient amount of suitable nourish- 
ment, but should not limit herself to any particular diet. Nothing should be 
prohibited that agrees with her. She may eat, without fear for the con- 
sistency of her milk, not only spices and sour foods, but also lettuce, raw 
fruits, etc., with freedom, because in these foods the elements essential to 
the physiologic growth of the child are contained in larger quantities than 



42 TEXT-BOOK OF PEDIATRICS 

in many others. In women with small appetites as variable a diet as 
possible is to be recommended, while for those having a tendency to con- 
stipation it is well to give, instead of a largely milk and soup diet, foods 
yielding a large bulk of debris. 

The quality of the milk, especially as to its fat content, varies in only 
slight and practically unimportant degree in any individual and cannot 
be influenced by the diet of the mother. Particular exceptions (Moll) 
are not proof against the argument for this view, when we consider that 
the child itself can regulate the quantity of food which it gets from the 
breast (Gregor). 

Excessive eating and drinking, especially of such foods as milk and rich 
soups, do not lead to an increase in milk production, but merely cause the 
nursing woman to put on useless fat. Such excesses are not only useless 
but should be especially avoided in women who tend to corpulency and to 
insufficient physical exercise. 

After lactation has been fully established, hunger is similarly without 
immediate effect upon the quality and quantity of the milk. Only after 
a long sustained and severe degree of starvation, when the bodily strength 
itself wanes and emaciation ensues, is a decrease in the quantity and proba- 
bly, also, unfavorable changes in the quality of the secretion to be noted. 

The fluid requirement of the mother is naturally increased during 
nursing. This may be met by drinking large quantities of water, if the food 
contains sufficient nutriment. The use of large quantities of rich soup has 
no more effect upon the volume of the secretion than has alcohol in the 
form of beer or wine. Nothing can be said against the use of beer or wine in 
temperate quantity. Traces of alcohol are to be found in the milk only 
when it is taken in very large amount. 

The general hygiene of the nursing woman should be the best that her 
environment will permit. The drawing pains in the back which so com- 
monly occur when the child is put to the breast may be relieved in many 
cases by supporting a pendulous abdomen or by taking a comfortable 
position while nursing the infant. 

The breast, and especially the nipples, should be kept clean by fre- 
quent washing, for esthetic if not for hygienic reasons, even though the 
rough surface of the mammilla cannot be completely disinfected by ordi- 
nary measures. 

Of the medicinal agents which it may be necessary to give internally 
to the nursing mother, only iodine, bromine and salicylic acid are excreted 
in the milk and these in absolutely harmless quantities. In animals, opium, 
morphine and atropine also pass through. Mercury, in event that the 
mother is treated by inunction, is excreted in the milk, but in such minute 
quantities that it is impossible to expect therapeutic results from it in the 
child. It may also be said that chloroform anesthesia in the mother is 
entirely without importance to the nursing babe. 

After the confinement the menses do not appear at all, or only once 
some five to six weeks after, and then remain absent for months or until 
the end of lactation. Occasionally, they appear regularly during the entire 



CARE AND FEEDING OF THE NORMAL INFANT 43 

period of nursing. The occurrence of the menses has in itself no influence 
upon the quantity or quality of the milk, nor does it cause restlessness or 
digestive disturbances in the child. When the breast is functionating 
indifferently and the mother is much affected by the menstruation, an 
increased difficulty in emptying the breast may be experienced, together 
with an increased nervous irritability. This should never be considered 
cause for additional feeding. 

To a certain extent pregnancy is more infrequent in nursing women 
than in others and doubtless the women who are amenorrhceic during the 
lactation period 2 do not conceive as readily as those who menstruate 
regularly. Neither the maintenance of lactation nor amenorrhcea give 
absolute assurance that conception may not occur during their course, 
but it is very probable that immunity from conception is present for several 
months of lactation and in nursing women a dangerously rapid sequence 
of conceptions is not seen as commonly as in those who do not nurse their 
children. The claim of some mothers that they have had to wean a nursing 
child because of a new pregnancy is often due to the error of regarding 
the absence of the menses as an indication of conception. Immediately 
upon weaning the infant, they conceive at the next ovulation. Other 
women, on the contrary, discover a pregnancy only after several months 
have passed, without either mother, nursing child or fetus suffering any 
harm from the continued lactation. This proves that pregnancy of several 
months' duration does not necessarily cause the secretion to dry up. The 
child, therefore, should never be weaned suddenly though pregnancy is 
suspected and even when it is definitely determined, the weaning should 
occur gradually. 

All these facts tend to show that obstacles to nursing or legitimate 
causes for its interruption occur much less frequently than has been sup- 
posed both by the laity and the profession. The knowledge of this and the 
avoidance of those numerous rules and limitations with which the nursing 
mother has been unreasonably surrounded, have produced a gratifying 
increase in the number of mothers among the educated classes who are 
willing to nurse their children. It is knowledge, however, that must be 
brought home to all classes of people by the physician, and its spread will add 
greatly toward making mothers more ready and more able to nurse. Then, 
too, those social conditions which force the mother to seek employment 
will no longer necessarily rob the child of the food provided for it by nature. 
The value of this to the individual and to the nation is to be considered. 
(See Section IV.) 

THE TECHNIC OF BREAST FEEDING. 

The new-born should be put to the breast of the mother only after 24 
hours. If the child seems hungry before this time has elapsed, it may be 
given, from a spoon, a little water sweetened with benzosulphinidum 
(saccharin). If the infant sleeps for a still longer time, the sleep should not 

1 This physiologic amenorrhoea depends upon a more complete puerperal involution 
of the reproductive organs, in consequence of which ovulation is arrested. 



44 TEXT-BOOK OF PEDIATRICS 

be interrupted. Quite a few children require no nourishment for 36 to 48 
hours after birth. 

Infants act differently in their first attempts at nursing. Some im- 
mediately suckle well and with much force ; others will not take the nipple 
or let go after a few attempts. Nothing is to be gained by force. The child 
is to be put back into its crib and the attempt repeated after an interval. 
With patience and continued application to the breast every normal child 
will learn to nurse. If the breast is very tense and difficult to empty it may 




FIG. 6. Method of holding baby during nursing. 

be made more responsive to the effort of the child by expressing or pumping 
off small quantities of milk. 

Emphasis should be put upon the fact, from the very first, that the 
child must take not the nipple only, but also almost the entire areola into its 
mouth; for the greater the portion of the breast included, the greater is the 
area affected by the stimulus of suckling and the greater is the reflex 
response. This practice is also less liable to tear the nipple and to pro- 
duce fissures. 

The nipple shields or protectors, consisting of a glass to cover the 
mammilla and a rubber nipple for the child to suckle, which are in common 



CARE AND FEEDING OF THE NORMAL INFANT 



45 



use and are intended to make the first application of the infant to the breast 
easier, or are used out of an excessive fear of mastitis, are dangerous. Their 
harmfulness lies in the fact that while they may make the work of suckling 
easier for the child, the unphysiologic stimulus makes the emptying of the 
breast much more difficult. The continued use of such an apparatus almost 
always leads to the drying up of the secretion and the under-nourishment of 
the child. 

Conical breasts are more easily emptied by milking movements which 
make slight rhythmic pressure upon the areola; flat breasts are best 
emptied by pumping apparatus. Of pumping devices there are numerous 
types. The teterelle biaspiratrice, which was formerly in common use, 
consists of a glass bell placed over the nipple and supplied with two pieces 
of tubing, from the one of which the mother draws the air, while from the 
other the child takes the milk. In this form, 
the saliva of the mother easily flows into the 
apparatus, which does not seem to be very 
desirable. Of the various models in which 
a negative pressure is produced by a rubber 
bulb, the pattern designed by Ibrahim 
(Fig. 7) is easily handled and readily 
cleaned. With rhythmic compression and 
release of the heavy walled bulb, the action 
of the normal suckling apparatus may be 
imitated to some extent; but here also the 
rhythmic massage of the areola is lacking 
and the breast is never emptied as com- 
pletely as by the suckling of a strong child. 

It is not only necessary to empty the 
breast completely in order to obtain suffi- 
cient milk for the child, but also because 
this is the only method which stimulates and increases the initial secretion 
and prevents congestion. If the breast is not completely emptied, the irre- 
parable result, an unavoidable one during the first few weeks and often 
within a few days, is the complete failure of the secretion. 

The colostrum secreted during the first few days is very small in quantity 
and often measures only a few cubic centimeters. Usually, after the third 
or fourth day, but often not until the fifth or sixth, a rapid increase of the 
secretion ensues, which in many women is accompanied by the subjective 
feeling of the " shooting-in " of the milk. At the same time, the number of 
colostrum corpuscles rapidly sinks to a minimum. 

The further increase of the quantity of the milk is dependent on the one 
hand, upon the amount of glandular tissue in the breast and, on the other 
hand, upon the demand made upon it. These two factors determine the 
total production of the secretion, as well as the time at which the function is 
fully established. 

The question whether the child should be put to one or both breasts at 
each feeding can be answered only in a general way by saying that the 




Fio. 7. Breast pump (Ibrahim) 



46 TEXT-BOOK OF PEDIATRICS 

object of the nursing should be to empty the breasts as completely as 
possible and that congestion must be avoided. Other things being equal, this 
occurs to a greater extent in small breasts than in large ones. It is per- 
missible at times, therefore, to apply the child to both breasts after an inter- 
val of at least three hours, taking care only that the child receives the 
second breast after it has emptied the first one sufficiently. By beginning 
alternately with the breast from which the child has nursed last, all these 
demands are fulfilled in the best manner. It is only with very well 
developed breasts that we may persist in giving only one breast from 
the beginning. 

The ease with which the breast may be emptied, whether artificially or 
by the nursing infant, varies greatly in individuals in whom the quantity 
of secretion may be the same. It often happens that while the child is 
nursing from one breast, the milk drops or even spurts from the other. 3 The 
number of feedings which the healthy infant will take spontaneously from a 
freely secreting breast varies between five and six in 24 hours; but it may 
occasionally fall to four or be increased to seven. It is recommended and is 
generally accepted, to-day, that three-hour intervals should be allowed be- 
tween the feedings during the day and that during the night two longer in- 
tervals are most satisfactory to the favorable development of the child. 

A large experience with new-born and older infants has shown, and the 
method has been generally adopted by numerous pediatrists, that an 
interval of four hours is even more satisfactory. This is true both from the 
standpoint of the child and of the mother. The editors have used the four- 
hour feeding for a number of years. The schedule is placed in force 24 to 
48 hours after birth. On the part of the child, less digestive disturbances are 
encountered and on the part of the mother, the great advantage lies in the 
fact that she is given more freedom for work or social duties. Even pre- 
matures are more successfully fed on this schedule. The hours for nursing 
most frequently recommended are 6 A. M.; 10 A. M.; 2 P. M.; 6 P. M.; 10 p. M. 
and one night feeding at 2 A. M., if necessary. 

It is usually superfluous to prescribe the length of the individual period 
of nursing for the healthy infant, .because when satisfied it stops suckling, 
often falling asleep at the breast. Some children suckle for a moment and 
then stop, and when the attempt is made to remove them from the breast 
grasp it greedily, to suckle again for a moment. In such children the time 
of nursing should be limited to fifteen or twenty minutes at the most. 

It may be shown, by weighing the child at equal intervals of about 
five minutes, that the quantities taken during successive periods of nursing 
decrease very rapidly and that only a few grams are taken after the first 

3 After long intervals between nursings, and especially at night, is this apt to occur. 
In many women, some milk flows from the breast after long intervals in nursing and 
more especially after the night interval. This becomes annoying and disturbing only 
when it occurs immediately after putting the child to the breast and when because of an ab- 
normally low tone of the sphincter mammillae, a sort of incontinence or galactorrhea results. 
Obstinate eczema of the areola and of the skin over the breast may ensue. The treatment 
of this anomaly, which usually appears to be of neuropathic origin, is generally quite use- 
less and must confine itself to the application of dressings to absorb the milk and to the 
treatment of the eczema with ichthyol or with silver nitrate solution (2-3 per cent). 



CARE AND FEEDING OF THE NORMAL INFANT 47 

twenty minutes. The long-drawn-out nursing period not only wastes the 
mother's time and strength but is actually dangerous because of the 
maceration of the nipple and the consequent liability to fissures. 

The quantity of milk taken at each nursing, determined by weighing the 
child before and after putting it to the breast, varies within wide limits. 
Usually the secretion is most abundant at the first morning feeding and is 
often two to three times as great as that of the smallest output which is 
usually had late in the afternoon. This is most definitely observed after an 
interval of the whole night especially in breasts of large capacity. 

The total quantity of the twenty-hour hours' secretion is of greater 
import to the physician. It will be seen from the above statement that 
this total can never be obtained by multiplying the amount secured at one 
nursing by the number of feedings, but must be determined by weighing the 
child before and after each nursing. The quantity of milk which the infant 
receives within the 24 hours varies also from day to day; the variance 
running at times from 200-300 c.c., so that the knowledge of the quantity of 
any one day's feeding permits only indefinite conclusions upon the total 
amounts regularly taken. On this account, Czerny and Keller have 
adopted as a standard the average of the total output of five days. Except- 
ing from this estimate the first 8 or 10 days, when great irregularities occur, 
it has been determined that the amount of nourishment taken during the 
first few weeks equals about one-fifth of the body-weight. This quantity is 
gradually reduced to about one-sixth or one-seventh, between the first to the 
fourth month, and at the end of the first six months it equals about one- 
eighth of the body-weight. This gradual reduction of the relative quantities 
of food stands in close relation to the conditions described on page 22. 
When the quantities of food taken and the body-weight are represented by 
curves a marked divergence appears, in that the weight curve continually 
rises while the food curve, representing food quantities, becomes more and 
more flattened. It must be said, however, that cases have been observed in 
which the two curves ran parallel for months. 

Under normal circumstances both breasts commonly secrete like quanti- 
ties, but it is not exceptional to find women in whom one breast secretes 
more freely than the other throughout lactation. Similarly, women are 
quite often found in whom one breast has been depreciated by a former 
mastitis, but are able, for many months, to produce sufficient milk with the 
remaining gland which has become structurally and functionally hyper- 
trophied. This is especially interesting when there are twins, in which case 
each child usually suckles one breast. 

When the quantities of food fall markedly below the average given and 
still produce satisfactory increases in weight, we are justified in the suppo- 
sition that this depends upon a higher fat-content of the particular secretion. 
This has been proved in a case reported by Heubner. The occurrence of 
such individual differences, uninfluenced by the mode of life of the nursing 
mother, has been established by careful observations made under due pre- 
cautions. It would seem, generally speaking, that the fat-content of milk 
from breasts giving small total quantities is relatively much greater than in 



48 



TEXT-BOOK OF PEDIATRICS 



breasts which secrete greatly in excess of the quantities required by any 
one child. Wet-nurses, for instance, are found in institutions, who give 
two to three litres per day of such milk. When several children are put 
to the same breast in succession, the first child to nurse receives milk 
containing the lowest percentage of fat. 

The weight increase is looked upon as the chief index to the results of 
feeding. This view is probably justified by the large consideration to be 
given to the congenital tendency to growth and the many-sided import of 




FIG. 8. 

weight increase, but it should not be permitted to overshadow such other 
signs of general well-being in the child as its color, turgor, disposition and 
sleep, the development of its static functions and its reaction to infections. 
The normal condition of the child in all these respects is more important 
than the rapid increase of weight. 

In healthy children who develop well, the weekly increase varies in the 
second and third quarters of the first year between 150 and 250 grams and 
occasionally even 300 grams; and in such a regulated manner that especially 
large increases of one week will be equalized by smaller increases in the next, 
and vice versa. 

If the increase in weight remains for a considerable period below what 
would naturally be expected, the cause should not be laid unconditionally 



CARE AND FEEDING OF THE NORMAL INFANT 49 

to underfeeding. We should rather seek to determine, by the methods 
already cited, whether the quantity of food is actually too small and if so 
whether the fault lies in a positive lack of milk, in a weakness of suckling, 
or in anorexia hi the child due, for instance, to parenteral infection. The 
last of these alternatives is much more common than is generally believed. 
To avoid serious errors, every other cause of disturbance upon the part of 
the child should be certainly excluded before means are taken to increase the 
food artificially. 

As we have already said, the time of the "coming in" of the milk and 
the rapidity of its increase in quantity stimulated by the suckling of the 
child and by the measure of its food requirement varies greatly in dif- 
ferent individuals and is usually slower in primiparse than after repeated 
lactations. This possibility and the axiomatic fact that even scant nour- 
ishment at the breast for a certain period does not injure the child, justifies 
the physician in keeping the patient under careful observation and waiting, 
as long as possible, for the full establishment of lactation in these cases of 
delayed beginning, or slowly increasing output. As a guide, it may be 
stated that after the physiologic loss of weight has occurred (see page 24), 
a lesser loss of 5 to 10 grams a day may occur and that such loss may be 
permitted to continue for one or two weeks, giving the child only a little 
water sweetened with benzosulphinidum (saccharin). If no increase in 
milk secretion or in the body-weight of the child occurs by this time, 
it becomes necessary to supplement the insufficient breast-feeding and us- 
ually with some artificial mixture. 

It may be possible, in rare cases, to give the child who does not receive 
sufficient milk from its mother, several adequate feedings a day at the 
breast of a wet-nurse. It may be stated emphatically, that in case of 
necessity, the child may receive each feeding from a different wet-nurse, 
as has been done in certain institutions, and it may still develop ex- 
ceptionally well. 

The addition of artificial food to the breast feeding, a method to which 
the French term allaitement mixte, or mixed feeding, has been applied, 
serves much more favorably for the development of the child than arti- 
ficial feeding alone, and it should be recommended more frequently by 
physicians than it is. Since the once deep-rooted prejudice against this 
mixed feeding, or the alternation of natural and artificial food, has proven 
entirely without foundation, the lack of sufficient secretion by the mother 's 
breast should never be an occasion for weaning, but always an indication for 
the addition of other food. In such cases, it may be well to give the bottle 
once or twice daily, or later, at the most, three tunes during the 24 hours, in 
place of the breast; or instead of this to the scanty breast feeding, the 
artificial food may be immediately added once, or several times, a day in 
sufficient quantity to satisfy the infant. 

Each of these two methods has been successfully used and has been 
recommended ; either is justified in suitable cases. It is of prime importance, 
whichever method is followed, to prevent the child from being weaned. 
Further, preference may be lent to the easier way of giving the added nour- 



60 TEXT-BOOK OF PEDIATRICS 

ishment. The surest avoidance of weaning is found in the first form of 
mixed feeding, that is, by the alternate feeding at the breast and from the 
bottle. This type of mixed feeding is, too, the only possible one when the 
mother is hindered by outside demands from nursing the infant regularly. 
Either method, however, should be carried out under strict observation, 




FIG. 9. 

giving the child only such quantity of artificial food as is absolutely 
required, so that it will continue to empty the breast completely and so 
prevent congestion and the arrest of the secretion. Otherwise a result, 
frequently seen in practice, soon obtains in the infant 's refusal to nurse the 
scantily secreting breast, thus "weaning itself," because "it does not care 
for the breast any more." The choice of the food to be used in mixed 
feeding depends upon the accepted standards of artificial supply. 

If the occasion for mixed feeding disappears, it may be possible to dis- 



CARE AND FEEDING OF THE NORMAL INFANT 51 

continue it in favor of exclusive breast feeding. Thus, with an initially 
scanty secretion, the continued strong suckling of the infant may stimulate 
the breast to the point of sufficiency; or, in event of hitherto enforced 
absence, it may become no longer necessary for the mother to be away from 
the child for hours at a time. Since the secretory capacity of the mammary 
gland is dependent within wide limits upon the demands made upon it, the 
quantity of the secretion usually becomes sufficient in amount within a few 
days after the abandonment of mixed feeding. It is even possible to bring 
a breast which has almost entirely dried up back to full function again. This 
so-called re-lactation, however, occurs only when the colostrum formation 
has not advanced too far. 

WEANING 

In spite of the fact that the period of lactation itself, as already said, is 
almost unlimited and that the secretion itself may be adequate to produce 
satisfactory and normal gains in weight even beyond the first year, it is 
neither customary nor advisable to continue breast feeding exclusively for 
so long a time. In the first place, the normally developed breast-fed child 
will indicate its desire for other food much earlier; often, at about the sixth 
or eighth month taking bread and the like in its mouth and eating it. In 
the second place, the additional food given at this time acts in a clearly 
favorable manner, maintaining the natural fresh color and sound turgor, 
promoting the development of the bones and the exercise of static functions. 

Whether this beneficial action of the additional food is due to the added 
carbohydrate supply or to the increase of inorganic salts, particularly cal- 
cium and iron, both of which are present in relatively small amounts in 
human milk, is beside the question. It is certain that the natural transition 
to the mixed dietary of adult life is satisfactorily made in this manner. 

The time as well as the methods of the transition show great variation in 
accord with the customs of the country and it is not always made in a 
proper manner The error of too early feeding, so early indeed as the third 
or fourth month with large quantities of sweet or starchy foods and breads 
or with animal milk, is much more common than the error of too long 
exclusive feeding with breast-milk 

We recommend the method of Czerny, now very generally accepted by 
podiatrists, of beginning at the sixth or seventh month to substitute for the 
noon-meal of breast-milk some 5 to 7 ounces of farinaceous soup prepared 
with meat broth. The soup-stock should be prepared from a quarter of a 
pound of meat and should contain the same condiments (salt and vege- 
tables) as may be used for adults, but the fat should be completely skimmed 
off and it should not contain so large quantities of lime salts as may be found 
in broths made from calves' feet or young fowls, because these will produce 
diarrhoea in some children. 

After several weeks, or even after several months, if perfectly safe milk 
cannot be obtained, as may be true during the summer months, a second 
breast feeding is replaced by an artificial feeding consisting of cow's milk 
and flour soup, or milk and toast. These feedings should be in accord in 



52 TEXT-BOOK OF PEDIATRICS 

quantity with those recommended for a child of given age and weight. 
Gradually, with intervals of at least several days, the remaining breast 
feedings are replaced in a similar manner. During the process, however, the 
breast and the artificial feedings should alternate, in order to prevent 
marked congestion of the milk in the breast. When the weaning is com- 
plete, the child's menu may be varied by the addition of any one of the 
large variety of soups (rice, sago, potato, legumens, etc.), or of one or two 
tablespoonfuls of mashed vegetables (carrots, spinach, cauliflower, etc.), 
or by replacing the milk and flour soup, or the milk and toast by a more 
nourishing milk pap, made with cereals, rice, etc. 

Stewed or raw, scraped vegetables should, for pedagogic reasons, be 
given only after the child has acquired the taste for several of the mashed 
vegetables, otherwise it may be difficult to teach the child to eat the latter. 
Even with the greatest variety of food, care should be taken to prevent the 
child from being " spoiled" and capriciously selecting its own food. When 
vegetables are given, it is well to warn the mother to expect the appearance 
of undigested shreds in the stool, for if this is not done she may become 
frightened and discontinue their use in the belief that they are indigestible. 

Even large and strong children should not be given more than one quart 
of milk daily at the end of the first year. The milk other than contained in 
gruels, etc., should not be fed from the bottle. It is better, even if somewhat 
more troublesome, to teach the child to take the food from a cup or mug 
after it has learned to take soup from a spoon, because this is the natural 
mode of drinking. 

The unpleasant custom, a widespread one in some countries, of allowing 
children, who are running about or even of school age, to take their milk 
from a bottle, because they will drink more by this means, is not only irra- 
tional and unesthetic but is a practice harmful, as all long-continued suck- 
ing is, to the process of dentition. 

WET-NURSING 

The only perfect substitute 4 for mother's milk is the milk of a wet-nurse. 
The only prerequisites are that the wet-nurse be healthy and that she 
have sufficient milk. The qualitative differences that may obtain in the 
milk of different women play no part in the nourishment of a healthy 
infant. As an actual fact, everything that has been reported concerning 
the unfitness of the milk of certain mothers is due to the improper inter- 
pretation of superficial observations. 

Even though difficulties in the establishment and maintenance of 
wet-nursing are very frequently encountered in private practice, these 
difficulties almost always result from avoidable errors due to a lack of 

4 This is not true in an ethical sense. The mother who does not nurse her child, but 
leaves its feeding and care to the wet-nurse, has later great difficulty in regaining the 
tender love of her babe which naturally turns from her to its nurse. She risks, further, 
the danger of having the child acquire the personal characteristics and habits of the 
nurse, which are often far from desirable. That individual peculiarities may be trans- 
ferred with the milk is not true, although it was formerly believed. Their acquirement is 
entirely due to the unconscious mimicry of the child. 



CARE AND FEEDING OF THE NORMAL INFANT 53 

knowledge of the basic principles of normal lactation or of the physiology 
and pathology of the breast-fed infant. The conditions for wet-nursing are 
the same as obtain for the feeding of the child at the mother's breast. 
The frequent change of wet-nurses is, therefore, in most cases, a poor 
testimonial to the knowledge of the physician in charge. 

A very common error is made in demanding for a weak infant who can 
take but small quantities of food, a wet-nurse who has a large supply of 
milk, a condition always distinctly specified alike by physicians and parents. 
The natural results, in congestion of the breast and in decrease and final 
disappearance of the secretion, may be avoided, often, only by pumping the 
excess of milk or by permitting the wet-nurse 's own child, 5 which she also 
nurses, to empty the breast completely. It is best, however, when selecting 
a wet-nurse to see that there is a reasonable relation between the quantity 
of milk secreted and the food requirement of the child. 

The provision of wet-nurses was, up to a few years ago, a very serious 
matter and is still difficult from the medical as well as the sociologic and 
ethical viewpoint. 

Wet-nurses recommended and introduced by employment agencies, by 
which they are tempted with promises of well-paid positions, are usually in 
the stage of well-developed congestion of the breasts and are often in danger 
of losing their milk when they accept a position. It is not surprising, under 
this method of hiring a wet-nurse, that her family history and the detail of 
her past life, previous illnesses, etc., most certainly necessary to establish 
her fitness as a wet-nurse, are usually intentionally falsified ; while the child 
which is shown to the physician is often not her own, a fact which develops 
most unexpectedly and unpleasantly later on. 

Her physical examination should, of course, be very complete and should 
be directed especially to the discovery of tuberculosis, syphilis, gonorrhea, 
and parasitic and infectious skin diseases. In view of the frequency with 
which the von Pirquet reaction is positive, indicating latent tuberculous 
foci in the adult, it is not a sufficient reason for rejecting an otherwise 
satisfactory wet-nurse. The Wassermann reaction should be made as a 
matter of routine. The inspection of the wet-nurse 's child, which is not 
always possible, is much less certain than the blood examination in the 
exclusion of syphilis. With practice, it is possible to determine approx- 
imately by palpation of the breast, which is not intentionally congested, 
whether there is a sufficient output. There should be sufficient tense gland- 
ular tissue, which is harder than the surrounding fat. The skin over the 
breast is warmer than over the sternum and has numerous large veins 
passing through it. Exact knowledge of the quantity of milk may be 
obtained only by weighing the child before and after feeding. 

The numerous dangers which arise in hiring a wet-nurse from an 
employment agency, briefly indicated above, may be avoided if the wet- 
nurse is taken from an institution, an infant and lying-in hospital, etc., 

8 This method, which is advisable because it is humane, is practicable in suffi- 
ciently well-to-do families and should be considered whenever possible. 



54 TEXT-BOOK OF PEDIATRICS 

in which she and her child have been observed 6 by unprejudiced attendants, 
for weeks or months, as to their health and general characteristics and the 
adequacy of the breast yield. They have usually learned, in such an insti- 
tution, to handle and to properly care for an infant. 

The old rule that the wet-nurse 's infant should be about the same age as 
the child that she is to nurse is now believed to be without foundation. It 
is rather desirable for the reasons cited to select a nurse for even a new-born 
infant, whose lactation has been established for several months. If we can 
be certain that the lactation is well established, a mother who is nursing for 
the first time will prove entirely satisfactory. 

Even though she takes care of the child and helpswith the housework and 
is not fed with too great luxury, the wet-nurse tends to be a great expense 
because of her high wages and the necessity that a room be provided for her. 

Mixed feeding (allaitement mixte) secured by the employment of a 
wet-nurse who comes to the home to nurse the infant once or twice a day, is 
much cheaper and is in most cases a satisfactory substitute for the exclu- 
sively used wet-nurse. Every healthy woman who has sufficient milk, if 
she wishes to nurse the child several times a day, may accomplish this 
either by going to the child or by having the child brought to her. If the 
child is given the breast three times a day, it will be necessary to give two 
artificial feedings in the intervals. When the nurse comes to the house for 
nursing periods only and keeps her own child, also partially fed at the breast, 
most of the unpleasant features of the situation arising when the wet- 
nurse must be taken into the house and treated as a companion disappear. 
The test weighings of the child, before and after nursing, to ascertain the 
quantity of milk obtained from the nurse, are to be recommended as a 
matter of reassurance to the parents and as a control measure when the 
child does not develop as well as might be expected. In this method of 
mixed milk feeding, a complete knowledge of the physiology and pathology 
of infancy is as necessary as it is in all other forms of feeding. It is especially 
important for the physician to meet the many superstitions of the mother, 
who will see a dietetic error of the nurse in every cry and in every irregu- 
larity of the stools of the infant. 

6. ARTIFICIAL FEEDING 

Artificial feeding, surrounded by a grim troop of dangers, stands in 
distinct contrast to the certainty with which normal growth and develop- 
ment occur at the mother's breast. This is proved most clearly by the 
high mortality rate of the artificially-fed. These dangers depend partly 
upon the decomposition of the component parts of the animal 's milk used 
in making the artificial food, and partly upon chemical differences between 
human and animal milk which cannot be entirely met. These dangers are 
greater the earlier the artificial feeding is begun. 

6 In such institutions the wet-nurse 's child will find a home and be cared for, which, 
in part, reduces the expense. A law regulating wet-nurses, with special regard for the 
wet-nurse 's child, has been rightfully demanded from various sources. 



CARE AND FEEDING OF THE NORMAL INFANT 55 

MILK FOR INFANTS 

The first of these difficulties of artificial feeding may be measurably 
reduced if the most scrupulous care is exercised in the dairying and handling 
of the milk. Milk so secured and treated is usually marketed under some 
distinctive name as "milk for infants," certified, sanitary, or inspected 
milk. Under insufficient legal regulation, no name in itself offers any assur- 
ance of the purity of the milk, unless it stands for actual inspection and 
certification. On the other hand, milk not sold under label, is not necessarily 
contaminated and unfit for infant feeding. 

Aside from intentional contamination, punishable by law, such as 
partial skimming or the addition of water or preservatives, to hide already 
advanced souring, and aside from the accidental admixture of pathogenic 
organisms, the chief source of the impurities of milk lies in the implantation 
of greater or less numbers of saprophytes which, with varying rapidity, 
induce its complete decomposition. 

The larger number of these organisms come from the impurities which 
fall into the milk during the process of milking, and consist of hairs, 
epidermal scales, manure, particles of food and stable dirt. These im- 
purities are carried into the milk by air currents, or from the hands of the 
milker, or from dirty vessels and implements, or by dirty water with which 
the latter are rinsed. 

Therefore, the extreme cleanliness of the cow and especially of the cow's 
udder is important. Care should be taken not to stir up dust in the stable 
from bedding or foddering shortly before milking and the greatest possible 
cleanliness of the entire equipment, not only of the hands and clothes of the 
milkers but also of the vessels used in milking and in gathering and measuring 
the milk, of the straining cloths, etc., should be secured. In other words, 
asepsis, as complete as possible, should be practiced in obtaining the milk to 
be used for infant feeding. Further bacterial contamination occurring in 
the handling and transporting of milk, in pouring it into different containers 
and in measuring it for sale, is relatively small. The primary contamination 
which the milk receives in the dairy increases steadily and extensively, in 
proportion to the degree of its first infection, to the length of time during 
which it is kept at body temperature and to the period of tune consumed in 
carrying it from the dairy to the consumer. 

Thus it will be seen that the proper care of milk demands the greatest 
precautions in milking, in immediate chilling, and in rapid delivery to the 
consumer. After it has reached the home, the responsibility of its keeping 
rests with the housekeeper. 

It is self-evident that the milk of diseased animals should not be used 
for infants. The question whether the milk of cattle which give a positive 
reaction to tuberculin, but present no clinical evidence of tuberculosis and, 
especially, no sign of tuberculosis of the udder, is unsafe and one most diffi- 
cult to decide and is still under discussion. There is no doubt, however, that 
strict adherence to this rule will increase the price of milk very materially. 
In the better dairies, which furnish special milk for infants, it has been found 
sufficient to have the dry udder frequently and carefully examined, say at 



56 TEXT-BOOK OF PEDIATRICS 

least once a month by a veterinarian, thus insuring the timely discovery of 
tubercles, as well as of the streptococcus infection or mastitis. 

Green fodder and silage have to a great extent replaced dry fodder in the 
diets of dairy cattle. Such feedings must be regulated so as not to cause 
diarrhoea which increases the difficulty of obtaining sanitary milk on 
account of the soiling of the udder and the probable introduction of enor- 
mous numbers of acid-forming bacteria into the milk. 

Where there are local dairies or institutions marketing milk for infant 
use which are well equipped and carefully managed, the milk should, of 
course, be procured from them. But the necessity of transporting milk a 
long distance by rail or wagon in the summer, may make the advantages of 
sanitary milking and immediate cooling somewhat illusive; so that it is 
usually better to purchase milk from a near-by source, which may not have 
been obtained under as sanitary circumstances, or even to secure it fresh 
from the cow several times a day and to use it immediately. 

Where neither the one nor the other method of obtaining pure cow's 
milk is practical, all the difficulties may be surmounted by keeping a goat. 
Goat's milk is as satisfactory as cow's milk for infant feeding. Besides, 
tuberculosis is very rare among goats; the animal is more easily kept clean 
and the milk is more readily obtained in a sanitary state. 

A far-reaching control of milk is possible under a system of municipal 
inspection. Such control concerns itself not only with examination of the 
milk as to its dilution, skimming, etc., but it also determines the presence of 
dirt, the number of leucocytes (Trommsdorf test) and of micro-organisms, 
and the degree of acidity, according to the method of Soxhlet-Henkel. 7 
Since the housekeeper has to depend upon the very indefinite tests of 
appearance, taste and smell, or finally, upon an experimental boiling, the 
knowledge of the source and freshness of milk is all the more important 
to her. 

The Pasteurization of milk in bulk, which has been advised so frequently 
and is quite practical, cannot be recommended for milk intended for infant 
feeding. In the ordinary milk purchased in the open market, which is often 
consumed without being boiled, Pasteurization guarantees the destruction 
of pathogenic organisms; but in milk for infant use, which is always boiled 
before being used, it hides the important indications of age and insufficient 
cleanliness by destroying the relatively harmless acid-forming bacteria 
while the much more dangerous spore-forming peptonizing bacteria 
(Fliigge) remain active. Moreover, as the possibility of subsequent con- 
tamination makes the reheating of the milk in the home necessary, it is 
certainly not a particularly advantageous thing. 

7 One degree of acidity is the amount of acidity in 50 c.c. of milk which will be 

N 
neutralized by 1 c.C. -j sodium hydroxide. Phenolphthalein is used as an indicator. 

Fresh milk has 2-4 degrees of acidity and remains at this stage (incubation) for from 
3-8 hours at body temperature; or at 10 C. for 52-72 hours, depending upon the degree 
of cleanliness in milking. Milk curdles upon boiling when it has 5.5-6.5 degrees of 
acidity. Spontaneous curdling occurs in milk of 15-16 degrees of acidity. Thus we are 
able to determine age and composition approximately by titration. (Plaut; quoted from 
Finkelstein's Text-book.) 



CARE AND FEEDING OF THE NORMAL INFANT 57 

The question, actively discussed for years, whether the injuries con- 
nected with artificial feeding may not be more or less avoided by giving raw 
milk, may now be considered answered in so far that no recognizable 
advantage is seen in feeding the healthy infant raw milk rather than 
Pasteurized or sterilized milk. The theory that milk becomes unfit for 
infant feeding by brief boiling, seems most effectually contradicted by the 
observation that human milk, even after boiling ten minutes, is as 
effective in relieving seriously ill infants as is the mother's milk unboiled. 
On the other hand, the view is justified that boiling for a long time (^-1 
hour) or very intense heating for even a short time, causes a definite dena- 
turization. Clinical experience, at least, has shown that the excessively 
sterilized milk of commerce causes anemia and under certain circumstances 
and if used for a long time produces scurvy. 

In the home, only Pasteurization, that is heating to 60 or 65 C, 
(140 -160 F.) for 30 minutes or boiling for a shorter tune, by the method 
to be discribed are to be considered. Pasteurization offers no advantage 
over the boiling of milk for infant feeding and is so awkward in process and 
so uncertain of results, even with the best apparatus, that it has never 
become popular and cannot be recommended. The method of choice, 
therefore, is boiling. It is of no importance whether the whole quantity 
intended for the 24 hours' feeding is boiled at once, in a glazed or enamel 
vessel, or whether the separate feedings are boiled in the bottles. The latter 
method is most readily accomplished by means of the well-known appa- 
ratus of Soxhlet. Instead of the patent rubber cover, which is drawn in by 
the negative pressure as the bottle cools and which seals the bottle hermeti- 
cally, a metal or glass cap may be placed over the mouth. The time for 
boiling may be gauged by allowing ten minutes from the first appearance of 
steam. By sterilizing the separate feedings, every possible contamination 
by later handling is most certainly avoided; but the likelihood of this is 
sufficiently reduced by boiling the entire mixture in a kettle, if everything 
else is cleanly. In this method of minute boiling the milk may be kept from 
running over by using a double boiler or one of the various milk cookers 
with perforated cover. In every case, where this method of sterilization, 
without immediate bottling, is employed, it is essential to cool the food as 
rapidly as possible by placing the container in running water and keeping it 
iced. In order to accomplish this, with the use of small quantities of cold 
water or ice, Fliigge has recommended a cooling-box constructed upon the 
lines of the fireless cooker. 

It is self-evident that the physician must frequently prescribe, and 
often in detail, the methods of maintaining absolute cleanliness of all the 
utensils which come in contact with the infant 's food. Special points should 
be emphasized. All portions of the food which are left in the bottle, after 
the child has finished nursing, must be thrown away and the bottle must 
be washed immediately to prevent the drying of particles which would 
then be difficult of removal. The nursing-bottle and nipple with rubber 
fittings and glass tubing should be absolutely prohibited because it cannot 
be kept clean. The simple rubber cap nipple is best cleaned by washing it 



5$ TEXT-BOOK OF PEDIATRICS 

in running water after each use and boiling it once a day. In the intervals 
the nipple should be kept dry in a clean covered glass or cup, rather than in 
an antiseptic solution. 

THE TECHNIC OF ARTIFICIAL FEEDING 

In the practice of artificial feeding from birth, no food is given during 
the first day of life as with the breast-fed infant. In further imitation of the 
natural conditions, only three or four feedings are given during the second, 
third and fourth days, and five feedings only after the fourth or fifth days. 
Nor should this number of feedings be exceeded later on, the longer time 
required for the digestion of cow 's milk in the stomach making the greater 
intervals (preferably 4 hours) necessary. Artificial food, given in excess 
of the requirements of the new-born, is much more dangerous than is 
human milk. 

Since the caloric values of cow's milk and of human milk are approxi- 
mately equal, it might seem rational to give the infant such quantities of 
undiluted cow's milk as are taken by the child on breast feeding and this is, 
indeed, still recommended by certain authors. The preponderant experience 
of almost all physicians has shown, however that good results may be more 
certainly obtained by the customary use of milk dilutions. 

The researches of the past few years have taught that the advantage of 
such dilution cannot be laid to the indigestibility of the casein of cow's 
milk, for this has not been proved. On the contrary, it is equally question- 
able whether the avoidance of overfeeding with cow's milk of so reduced 
concentration is the only active factor of benefit. Probably other causes, 
which cannot be considered here, play an important role. 

The reduction of the food value which results from dilution may not be 
equalized by an unlimited . increase of quantity, without causing injury 
through the excess of fluid. It is customary, therefore, to select food sub- 
stances which may be added to the diluent to equalize or diminish this 
deficit. Theoretically and empirically, sugar of milk seems to be the most 
acceptable item for this purpose. Cow's milk, diluted with two parts of 
water, to which has been added one level teaspoonful (3-4 grams) of sugar 
of milk for every 100 c.c., (3J/2 ounces) of fluid, is to be recommended for a 
two-day-old infant. Even if, at the end of the first week, the infant is taking 
five feedings of 100 c.c. (3J^ ounces), each, of such a preparation, its actual 
food value is so low that the danger of overfeeding is most certainly avoided. 
Indications for more or less rapid increase of the food, quantitatively or 
qualitatively, are gained by observation of the infant in regard to weight, 
stools and other clinical conditions. 

In increasing the volume of the feeding, 8 to meet the indications of need, 
we have a relatively definite standard in the volume of the daily food taken 
by the healthy breast-fed infant of normal weight and development. 

8 If the amount of each feeding is to be measured by means of marks on the nurs- 
ing-bottle, it is well to be informed as to the accuracy of the markings represented 
by each line. Even with bottles of the same model it is impossible to depend upon 
their accuracy. 



CARE AND FEEDING OF THE NORMAL INFANT 59 

When we remember that the daily quantities of food taken represent 
one-fifth of the body-weight during the first week and that they should 
gradually sink to one-eighth of the body-weight by the end of the first 
half-year and when we see to it that this physiologic volume of the liquid 
food is not exceeded to any appreciable extent in artificial feeding, we 
soon find it necessary to increase the concentration, that is, the food value 
of the dilution, if the requirement of the child is to be met. 

The concentration may be increased either in definite steps by passing 
from the proportion of one-third to one-half and later to two-thirds of 
milk, or it may be gradually secured by adding a few spoonfuls of milk 
without changing the amount of water. The latter method seems to 
resemble more closely the gradually increasing volume of food which the 
breast-fed child receives. 

Since we do not wish to give undiluted cow's milk during the first month 
of life, and it has proved empirically undesirable, it will be necessary to 
increase the food value of the mixture by suitable additions and this is done 
by adding fats or carbohydrates. The latter need is met, in part, by the 
addition of sugar of milk as already suggested. The fat content may 
be increased most readily by the addition of fresh cream, as Biedert 
first proposed. 

Because ordinary centrifuged cream, intended for the use of adults, 
does not fulfill the requirements of milk for infant feeding in the matter of 
freshness, low bacterial count and special selection of the cattle from which 
it is taken, it is better to prepare the cream from well-chosen milk at home. 
For this purpose the milk should be placed on ice in shallow vessels and be 
allowed to stand until the cream has separated. After the milk has stood for 
one or two hours an approximately 10 per cent, cream, or about 100 cc. 
per litre of milk, may be obtained by careful skimming. 

This cream forms the basis for Biedert's "natural cream mixture. " For 
its graduation to the age of the child, he has evolved a scheme which need 
not be given here because it is not commonly used for feeding healthy 
infants. It seems more practical, without reference to any particular 
schedule, to add to the diluted milk and milk-sugar mixture, such quantities 
of fresh cream as are necessary to increase its food value to the desired 
degree, as may be borne by the infant without gastro-intestinal disturbance. 
Additions of cream exceeding a total 3 per cent, of fat in the whole mixture 
are hardly ever beneficial to the infant. 

The ordinary proprietary preparations present absolutely no advantage, 
either theoretically or in their practical results in the feeding of the healthy 
infant, over the milk and milk-sugar dilution mixed with fresh cream. That 
they receive high recommendations and are frequently prescribed by mid- 
wives and physicians is due to the facts that they are sold with directions on 
the container and that no special knowledge of pediatrics is necessary in 
dispensing them. The thoughtful and conscientious physician robs himself 
in their use of the opportunity of changing the value of the food by varying 
its individual components. And this is a necessary opportunity, because 
the mere fact that the coarse chemical composition of such manufactured 



60 TEXT-BOOK OF PEDIATRICS 

food is roughly similar to human milk does not make it at all the equal of 
breast-milk in value. It is useful only with those children who would do 
equally well upon a simple milk dilution sweetened with sugar. In many 
other children, the high fat and sugar content, which is borne without the 
least difficulty in the form of human milk, causes, with these preparations, 
diarrhoea and vomiting and permits only slight increases in weight which 
are not improved by increasing the quantity of the food. 

Recently Czerny and Kleinschmidt have put forth a very valuable 
method of utilizing butter fat in infant feeding by their method of pre- 
paring the "Butter Flour" mixture. By this method it is possible to feed 
large amounts of fat to very young and poorly nourished infants and those 
which are difficult to feed by other methods. It may be continued for long 
periods and the gain of weight and general development is comparable to 
that of the breast-fed infant. 

The food consists of a basic diluent prepared as follows: Seven grams 
butter are melted over a slow fire allowing it to fry until all the volatile oils 
and free fatty acid is evaporated. Then seven grams wheat flour is stirred 
in, allowing the mixture to brown a little. To this mixture is added 100 c.cs. 
boiling water in which five grams granulated sugar has been dissolved. 
This is brought to a boil, strained to remove any lumps and cooled. 

A. Graeme Mitchell recommends the following practical formula: 
Butter 2 level tablespoonfuls, flour 2 l /2 level tablespoonfuls, sugar 1^ 
tablespoonfuls and water 10 ounces. The proportion of this mixture is 
constant and equals 26.6 calories per ounce. 

For children of less than 3000 grams body-weight, one-third milk isadded 
and for larger infants ^5 to }/ milk. The milk should be certified grade or 
Pasteurized. The butter is sterilized by the heating. The authors advised 
200 c.c. per kilo body- weight per day. 

Various sorts of sugar and flour in the form of gruel, may be used to 
increase the food value of diluted cow's milk and, in particular, to enlarge 
its carbohydrate content. Of the former, sugar of milk has been repeatedly 
mentioned. Soxhlet, Heubner and Hofman have recommended its use in 
such quantities that the food value of the milk, lost by dilution will be 
restored. To do this, it is found necessary to use concentrated solutions of 
sugar which decidedly exceed the physiologic sugar content of human 
milk (6-7 per cent.) 9 It is doubtless possible to feed many healthy infants 
successfully with mixtures containing so large percentages of sugar of milk, 
but it must be emphatically said that many infants will not tolerate it and 
that it will not produce satisfactory increase of weight. For this reason, it 
seems advisable to limit its addition so that the entire mixture shall not 
contain more than 6 per cent, inclusive of the 4 per cent, of milk-sugar con- 
tained in the cow 's milk itself and to make up any deficit, if necessary, by 
concentrating the milk or by adding flour. 

Cane-sugar, because of its sweetening power, has played an important 
role in the artificial feeding of infants, even before the science of pediatrics 

9 Milk-sugar is the only sugar that may be used in such quantities without making 
the solution nauseatingly sweet. 



CARE AND FEEDING OF THE NORMAL INFANT 61 

was established upon a scientific basis. In young infants it is better to 
avoid it and to substitute milk-sugar because of the readiness with which 
cane-sugar ferments; but in older children, if it fall short of such concen- 
tration as to make the food sickeningly sweet, it is often well tolerated. 

Malt sugar (maltose) is used in the form of the various malt extracts 
which also contain dextrin, nitrogenous constituents, water, etc., but it is 
not commonly given to the healthy child. In the feeding therapy of sick 
infants, it plays an important part. 

The gruels, representing the insoluble carbohydrates (polysaccharides) 
may be used even for very young infants. These gruels are prepared by long 
continued boiling (3/^-1 hour) of either oatmeal, rolled oats, rice, cracked 
or crushed barley, etc. The quantity of each of these cereals required for 
preparing a suitable gruel cannot be definitely stated because of the vari- 
ability of the manufactured products. A thin gruel should remain liquid 
when cooled, while a thick gruel should gelatinize. The various gruels do 
not in themselves present any essential differences in their use for infant 
feeding. They are distinguished from the flours in that the former do not 
consist so largely of starch, but contain, also, a variable but greater quantity 
of vegetable protein. The amount of solids contained is low, especially in 
thin gruels, and consequently their food value is small. 

Of the flours, we must consider oatmeal, which is distinguished for its 
content of over 5 per cent, of fat, wheat flour and corn flour. Even though a 
large amount of undissolved residue always remains in the preparation of 
gruels, which should be separated by pouring off the supernatant fluid or by 
straining the gruel, the mixture after boiling for 10 to 20 minutes, contains 
exactly the same amount of food material in solution or rather in a col- 
loidal state, as was added in the beginning. The food value of these gruels 
is therefore, high. Corn flour considerably exceeds the other cereals in its 
solubility, so that a 2 per cent, gruel of corn flour equals a 5 per cent, 
gruel of wheat or oat flour in its consistency. 

According to the experimental researches of Klotz, the various flours 
show important differences in their intestinal digestion as well as in their 
intermediate metabolism. It would appear that these differences do not 
permit the several flours to be used interchangeably in artificial feeding; 
but as yet no definite clinical observations are at hand. Nevertheless, a 
change from wheat to oat flour, or vice versa, if the child is not doing well 
may be justified. All flours have an extremely low content of mineral 
matter, so that the addition of a small amount of table salt (.3-. 5 per cent.) 
to all gruels is necessary. 

In the practice of artificial feeding, it is well to avoid the addition of 
flour to the food of the new-born or of infants in the first two or three 
months. I feed cereal waters at the end of the first month and believe they 
are well digested and beneficial. The gruels are used in very thin form at 
first and are gradually thickened, and this only if sugar of milk cannot be 
used successfully which is often possible in healthy children up to the sixth 
or seventh month. 

Certain limitations, which it is dangerous to exceed, are set to the addi- 



62 TEXT-BOOK OF PEDIATRICS 

tion of flour, even after the third or fourth month, because of the limited 
amylolytic function of the infantile digestive tract and the too great 
density of concentrated flour preparations. Further increase of the food 
value may be met by the use of sugar. 

Toasted and baked flours in which the starch is partially dextrinized by 
the heat and is thus changed into a soluble form, stand in close relation to 
the simple flours. According to all observations recorded to the present time 
(Hedenius), they are not digested any better by young infants, but rather 
not so well, as are the pure flours. Some toasts, especially prepared for 
infant feeding, contain added salts, notably calcium phosphates, but no 
advantage attaches to this because they are given only at an age when the 
child receives the required mineral substances in soups, vegetables, or fruit, 
and in much more natural form and concentration. The numerous proprie- 
tary infant foods should be avoided in the feeding of healthy children, as a 
matter of principle, because, on the one hand, they serve no better than 
simple flour or sug^ar and because advertised as the best or the only sub- 
stitute for mother's milk, they are responsible for many dangerous dietetic 
errors and for their invitation to the weaning of many children whose 
mothers are able to nurse them. 

A peculiar position is occupied by condensed milk, which is still in very 
general use. It is whole milk which after the addition of large quantities 
of cane-sugar, is sterilized and condensed to a paste-like consistency. 
Certainly it is no better for feeding healthy infants than fresh sweetened 
milk dilutions. It should be given only temporarily when other milk 
cannot be obtained and even then it is a fair question whether the ex- 
cessive amount of sugar present may not be harmful to the child. 

The food requirement of artificially-fed children maybe taken as approxi- 
mately the same as that of breast-fed infants of the same age and weight. 
Even though the metabolism of the breast-fed infant is probably maintained 
more economically as we have shown in the first chapter, it must still be 
remembered that the breast-fed infant is able to stand a considerable 
amount of overfeeding which, in the artificially-fed would result in injury. 
We may, therefore, transfer the caloric requirements, cited for breast-fed 
infants on page 22, directly to the artificially-fed child and may safely go 
even below them. 

The following caloric values of the foods, commonly used, may serve 
for comparison: 

Calories 

Whole milk per litre 700 

Cream 10 per cent, per litre 1300 

Flour (100 gms.) 400 

Sugar (100 gms.) 400 

From these few equivalents, the caloric value of a food mixture may be 
approximately calculated and from these calculations we may draw con- 
clusions as to whether the daily supply of food con-tains the required 
number of calories. By way of example: An eight weeks' old infant 
weighing 4500 gms., may receive five feedings of 280 c.c., or a daily total 
of 900 c.c., of a mixture consisting of one-half milk, one-half water and 20 



CARE AND FEEDING OF THE NORMAL INFANT 63 

grams of sugar of milk. The food value of this mixture is 315+80 = 395 
calories. In this mixture, there would be 55 calories less than the required 
450, a deficit which could be made up by six grams of fat contained in 60 cc. 
of 10 per cent, cream, or by 14 grams of sugar. Since the total sugar content 
would be 18 grams contained in the milk, +34 grams added, =52 grams or 
5.8 per cent., which still lies within permissible limits, the latter would be the 
easiest way of adding the required calories. 

While, on the one hand, this mathematical method aids in the avoidance 
of definite errors, 10 which are not uncommon in the choice and dosage of 
artificial food mixtures, yet, on the other hand it does not follow that food 
known to contain sufficient calories will necessarily produce the proper 
development of the child. The limitations of the usefulness of the caloric 
method of infant feeding have been already discussed in Section I. 

It is impossible, therefore, to formulate a schematic table for the feeding 
of the healthy infant, much as this trouble and thought-saving device 
might serve for the busy physician. In the difficult field of artificial infant 
feeding, which requires both a knowledge of theory and the practice of 
clinical experience, no goal can be successfully reached without scientific 
observation and careful consideration of each individual case. 

The French obstetrician, Budin, has achieved great renown by his 
researches in the physiology of infant feeding. He has instituted the 
so-called " Budin 's factor," which gives a reasonably safe standard for the 
quantity of milk to be allowed. He proposes that the artificially-fed infant 
receives about 10 per cent, of his body-weight in cow's milk daily. To this 
quantity of milk, which does not fully meet the caloric need, may be added 
cream or sugar, or sugar and flour to balance the requirement. 

Pfaundler has devised a similar schematic formula; as follows: "Take 
the tenth part of the infant 's body-weight in cow 's milk and add to it one- 
hundredth part of its body-weight in carbohydrate, not exceeding, however, 
50 grams a day; add water to make 1 litre. Divide into five feedings and let 
the child take as much at each feeding as it will. In young infants the 
carbohydrate may be given in the form of milk-sugar or dextri-maltose ; 
in older children, in the form of a 2 to 3 per cent, oatmeal gruel or 
a 3 to 4 per cent, flour paste. " This formula will not apply in all cases. 
The caloric requirement of a child fed with food prepared according to this 
prescription is met only when the child takes relatively larger quantities 
than a breast-fed child of the same weight will do. This is usually true if 
the feeding intervals are not intentionally shortened. 

In the application of the rules for the feeding of normal healthy infants 
it must be remembered that each infant must be fed to meet its individual 
requirements. If milk dilutions with the addition of carbohydrates are 
used, the simplest and most natural standard would be one that would tell 
us how much milk and carbohydrates per pound or per kilogram body- 
weight the baby should get. To be exact we should express, or at least be 
aware of the number of grams of protein, fats, carbohydrates and salts that 
the infant is receiving for each pound of its body- weight. We believe that 

10 Especially the errors of underfeeding. 



64 TEXT-BOOK OF PEDIATRICS 

if statistics on infant feeding were collected on this basis rather than in per- 
centages of the ingredients in the milk mixtures (the total mixture being of 
such variable quantity) the collected data would be far more valuable as a 
basis for future work in infant feeding. 

The average infant fed on cow's milk will metabolize advantageously 
1.5 grams of protein, 1.5 to 2.0 grams of fat, 4.0 to 6.0 grams of carbohy- 
drates, including that contained in the milk and cereal for each pound of 
body-weight. 

Feeding the following amounts of the milk and carbohydrates will 
approximate these requirements and furnish between 43 and 55 calories per 
pound body- weight: 

To meet these protein and fat requirements, the average normal infant 
will require each day a minimum of 1^ ounces (45 milligrams) of cow 's milk 
per pound of body-weight. 

Infants under five months of age will frequently require amounts ap- 
proximating 2 ounces (60 milligrams) of cow's milk per pound body- weight, 
except during the first few weeks of life when smaller quantities of whole or 
skim milk are indicated. 

In beginning feeding with cow 's milk, mixtures must always be started 
as weak formulae, more often using only 1 ounce (30 milligrams) of cow's 
milk to a pound body-weight, gradually increasing the strength to meet the 
infant's needs. 

Underweight infants should at first be fed according to their present 
weight, gradually increasing the strength of the mixture as rapidly as con- 
sistent with the baby's ability to handle the diet, and thus approximating 
the needs of a full weight baby of the same age. These babies will fre- 
quently take over 2 ounces (60 milligrams) of milk per pound body- weight. 

With the institution of a mixed diet, the infant thrives with less milk 
per pound body-weight. 

From birth to the fifth month the average healthy infant may be satis- 
fied with an amount of food approximating 2 ounces more per feeding, than 
the infant is months old. 

In our own experience we have found that a concentrated milk mixture 
does not disturb the infant 's digestion when the milk is boiled or alkalinized. 

The amount of water is calculated by multiplying the number of feedings 
by the amount of each feeding, and subtracting the milk to be given. 

Having the necessary amount of milk and water, we ascertain the carbo- 
hydrate to be added. 

Cane and milk-sugar are added in such quantities that the normal 
infant in its food mixture receives a total of from 4 to 6 grams of carbo- 
hydrates per pound of body-weight per day, including that contained in the 
milk in the mixture. As \ 1 A ounces of milk contains approximately 2 
grams of lactose it will be necessary to add from 2 to 4 grams of car- 
bohydrates for each pound of body-weight to the diet besides that con- 
tained in the milk. One-tenth of an ounce (3 grams) of cane or milk-sugar 
per pound body-weight answers the needs of the average normal infant in 
its first months. 



CARE AND FEEDING OF THE NORMAL INFANT 65 

Cereal water may be added to the diet after the infant is one month old. 
One-sixtieth to one-thirtieth of an ounce (0.5 to 1.0 gram) of starch for 
each pound of body- weight may be added to the mixture. This is best 
given in the form of cereal waters or well-cooked cereals. 

We find it especially valuable in those cases in which we are feeding cane- 
sugar, and in which the infant takes a dislike to its food because of the 
intense sweetness of the mixture. 

In underweight infants the amount of sugar and cereal to start with 
should be calculated on the basis of the present weight, approximating 
the quantity needed for a full weight infant as rapidly as the sugar 
tolerance permits. 

When more than one quart of milk mixture is needed to properly 
nourish the infant, the age has been reached when a mixed diet should be 
instituted. No infant should be fed more than one quart of cow 's milk in 
24 hours. 

It is to be remembered that the amounts of food recommended are 
relative and must be increased or decreased according to the infant 's prog- 
ress and individual needs. 

The transition to mixed feeding is conducted similarly in method with 
that employed in breast-fed infants, in that the child is given cereal soup 
prepared with broth at the end of the sixth or seventh month, this food 
being soon followed by the use of vegetables. 

In estimating the result of the feeding, increase in weight remains the 
most important index only during the first few weeks or months. The older 
the child, the more particular stress is to be laid upon other factors. This is 
to be especially emphasized because of the many errors that are made in this 
respect in the nursery since the practice of daily weighing has become 
popular. Of more consequence than the absolute gain in weight, which 
usually depends upon the size of the child and the rapidity of its growth, are 
the steadiness of this gain, the muscular tone, the turgor, color, bone devel- 
opment, the adequate sleep, the good disposition, the regularity of the 
bowels and bladder, etc. Excessive fattening should be especially avoided 
in artificially-fed children, because such constitutional diseases as rickets, 
spasmophilia and the exudative diathesis, take a more severe course in fat 
children than in moderately nourished infants. 

During the second year, the child's protein requirement should still be 
largely met by the feeding of milk, of which Y to 1 litre (a pint 
and a half to one quart) a day is quite enough. During this period, indeed, 
even such quantity may be gradually reduced to half a litre (1 pint) and 
replaced by other foods. As in the first year, no milk should be given at 
noon either with the meal or after it. The menu should be selected accord- 
ing to the recommendations on page 51 ; but with greater latitude in the use 
of vegetables. For breakfast and in the afternoon, the child should receive 
200 c c., or at most 250 c.c. (7 or 8 ounces) of milk, with as much bread as it 
likes, but without butter. In the evening, a similar quantity of milk may 
be given with a cereal (rice, cornmeal, etc.). During the morning, a light 
lunch, consisting of 100 to 150 c.c. (3-5 ounces) of milk, may be served; to 
5 



66 TEXT-BOOK OF PEDIATRICS 

which, after the middle of the second year, a thin slice of bread or a roll r 
with a little butter and fresh or stewed fruits, may be added. 

At about the end of the second year, the quantity of milk should be 
gradually reduced further, until the child receives only a small supply with 
its breakfast, when the protein requirement may be met by giving a little 
meat and egg. In view of the much greater concentration of the protein in 
these foods, only small rations of them are required in addition to the 
vegetables, legumens and fruits necessary, not only to satisfy the appetite 
but for the normal mass formation of the feces and for the maintenance of a 
positive alkali balance. Thus the diet of a 3-year-old child gradually 
approaches that of the adult so closely that particular directions no longer 
seem necessary. Strong spices (mustard, pepper, etc.), do not appeal to the 
taste even of older children and naturally no one should attempt to accus- 
tom the child to them. 

THE CARE OF THE CHILD 

The care of the child during the first months of life and even throughout 
the entire first year, provided it be healthy and free from constitutional 
anomalies, is so far secondary to the problem of feeding that breast-fed 
infants, in poor and unhygienic surroundings, often thrive and develop 
better than do the artificially-fed who are cared for, according to all the 
rules of hygiene, in the homes of the wealthy. That despite of this 
warranted assertion, the value of proper hygienic care is not be under-esti- 
mated, is shown by the greater morbidity and mortality among artificially- 
fed infants of the poorer classes of society, as compared with the children of 
the educated and well-to-do. After the completion of the first year, when 
the feeding is no longer of preponderant importance, the general care in its 
broad applications is of larger influence upon the health of the child. 

One of the first rules in the care of infancy and childhood is cleanliness. 
At the outset, it involves the asepsis and uneventful healing of the umbilical 
wound. The mummification of the umbilical stump is best accomplished by 
the use of such drying powders as bismuth subgallate, talcum with sodium 
salicylate, sterilized bolus alba and the like,' and by wrapping the stump in 
sterile gauze or absorbent cotton. Ointments and moist dressings are 
undesirable. Certain authors advise that the daily bath be omitted after 
the first cleansing until the umbilical wound has healed. 

Until the end of the first year, or until the child has acquired habits of 
cleanliness, it should be bathed daily. The temperature of the bath should 
be about 35 C. (95 F.), at first and may be decreased by 2 -3 C. 
(3-5 F.), as the child grows older. The bath should not be continued 
longer than is required for the careful cleansing with soap and water of the 
entire body and especially of the skin folds and the anal region. After the 
bath, the parts mentioned should be scrupulously dried and dusted with an 
inert powder (salicylic or zinc-oxide powder, or even rice powder or 
starchX The face and especially the eyes, should be washed with fresh 
luke-warm water either before or after the bath. All attempts at mouth 
cleansing should be forbidden. They are not only unnecessary but harmful 



CARE AND FEEDING OF THE NORMAL INFANT 67 

on account of the injury to the mucous membrane which may result 
(Bednar's aphthae). After all the incisors have appeared, we may recom- 
mend that the teeth be cleansed, at first with a soft linen cloth and later 
with a soft brush. Early defects should be looked for, because the timely 
treatment of the milk teeth preserves them longer and gives better oppor- 
tunity for the development of the permanent set. 

The deplorable custom, so widespread, of permitting the child to form 
the habit of sucking a pacifier must be forcefully combated. The pacifier 
is not only unesthetic but dangerous, on account of the frequency with 
which it serves as the carrier of dirt and disease germs from the pockets of 
the clothing, from the mouth of the mother, who at times moistens it with 
saliva, and from the floor upon which it may fall, etc. Czerny's statement 
that there are constitutionally restless, neuropathic infants who are soothed 
most readily by the pacifier and harmlessly, provided it be kept clean 
and does not contain sugar, is true; but the number of such children is 
small and does not justify the widespread abuse of an undesirable method 
of quieting a child. 

The infant should be changed before each feeding and should be washed, 
dried and powdered carefully every time it is soiled by a fecal discharge. 
In cleansing the anal region in girls, the parts should always be cleaned 
from before backward, since particles of fecal matter may easily be carried 
into the gaping vulva and especially into the urinary meatus, eventually 
causing infection. At the slightest indication of chafing it is well to cover 
the parts with oil or petrolatum, or better with a thin layer of zinc oxide 
ointment, to protect them from the irritation of repeated wetting. 

The healthy infant maintains his normal temperature when he is 
dressed in a shirt, gown and diaper and is covered with a light down quilt 
or with a linen-covered wool blanket. Applications of artificial heat, in the 
form of water bottles and the like are not necessary. The room temperature 
should be 19 to 20 C., (66 to 68 F.) as nearly as possible, and may be 
even a little less for older children. The child should, under all circum- 
stances have its own bed. 

The use of the cradle has rightfully gone out of fashion, for children are 
easily spoiled by becoming accustomed to the quieting rocking movement 
and are broken of the habit with difficulty. The unquestionably injurious 
effect of rocking, belief in which rests upon purely theoretic considerations, 
has yet never been demonstrated. 

If care is taken to provide for the plentiful supply of fresh cool air 
to the nursery by the necessary oft-repeated and complete airing of the 
room, the initial attempt to take the infant out of the house in winter 
may be delayed without harm to the child. Older infants may be warmly 
dressed and taken into the open daily, eve in winter when the temper- 
ature is mild. Later, when the child can go about, it is better to let it walk 
and run than to take it out in the go-cart. Even wet feet are not injurious 
so long as the child is in motion. Dry shoes and stockings should be put 
on, however, so soon as the child gets home. 



68 TEXT-BOOK OF PEDIATRICS 

Through the first half-year, the child should be taken up only for some 
such definite purpose as bathing or feeding; and otherwise should be left 
to itself even when it is awake. During the second half-year it may be held 
and allowed to sit up on the arm or in the lap. This gives it a free survey 
of its surroundings and exercise for its muscles while the natural tiring 
which results, produces sound sleep. The first attempts at standing and 
walking should not be hastened, nor should attempts be made to retard 
them, since no dangerous effect upon the back or legs is to be feared. The 
strengthening of the musculature, indeed, rather counteracts the tendency 
to deformities. In carrying an infant, care should be taken to hold the child 
first on the right arm and then on the left in order to prevent the develop- 
ment of scoliosis. If the child is permitted to sit up in bed, he should be 
laid down again as soon as he betrays by any abnormal posture the first 
sign of tiring. When the child is learning to walk, a pen gives him the best 




FIG. 10. Nursery pen (Feer). 

outlet for his activities. The floor of the inclosure may be formed of a soft 
smooth cover, which should be kept scrupulously clean. The walls should 
permit the child to look freely out as in the nursery pen of Feer, shown in 
Fig. 10. 

The habit of cleanliness is dependent upon the attention and care 
devoted to accustoming the child to the control of bowels and bladder. 
It may be earlier developed, therefore when an efficient nurse has the 
entire care of the infant and is relieved of other duties. At about the sixth 
month, at latest, the child should be taken to the toilet or placed upon a 
wide-rimmed vessel for the purpose of moving the bowels and emptying 
the bladder. Further, the child should be watched and waited upon when it 
expresses a desire. The rapidity with which results are obtained depends, 
in part, upon the skill of the nurse and in part upon the individuality of the 
child and it therefore varies greatly. In general it may be expected that 
with ordinary care the child of normal development will give evidence of its 
bodily needs by the end of the first year, and that within a short time later 



69 

it will learn to make known its desire. Even then, it may take several 
months before full control of its habits is established. If proper care is 
given to the child and success is not attained by the third or fourth year 
pathologic conditions must be suspected. 

The habit of obedience in the child and of subordinating its wishes, 
tendencies and desires to the direction of its elders is of frequently under- 
estimated importance in the entire future training of the child. This is 
secured the more readily by a quiet and purposeful demeanor upon 
the part of its instructors, whereas the child is confused and injured by 
moody treatment and may easily acquire an unpleasant and unreason- 
able disposition. 

The training of the child should begin with the day of its birth, and the 
method by which this is best accomplished is classically described by Czerny 
in his lecture "The Role of the Physician in the Training of the Child." 
(Deuticke, Leipzic and Vienna; 1911, 3rd edition.) 



III. GENERAL SYMPTOMATOLOGY AND TECHNIC 
OF EXAMINATION 

REVISED BY 

L. R. LeBUYS, B. S., M. D., F. A. C. P., 

Professor of Diseases of Children, School of Medicine, Tulane University of Louisi- 
ana, New Orleans. 

THE technic of the examination of children can be acquired and the 
valuation of its findings appreciated only by practical demonstration in the 
clinics. The instructions in the following chapter presuppose that the stu- 
dent has mastered the methods of internal medicine. Only such methods 
of examination are described as are specific to the child and especially to the 
infant. A few suggestions as to variations in the interpretation of certain 
findings are offered. 

The history of the case should be taken before the examination is made. 
In estimating the value of such history, careful distinction must be drawn 
between the parents ' actual observations and their attempted explanations 
of events which often lead to misinterpretation, since they are based upon 
preformed ideas. Indefinite statements as to symptoms as for instance in 
the matter of convulsions, the indefinite term applied to varying and hetero- 
geneous symptom-complexes should be cleared up or elaborated by 
precise questioning. If possible, the question should be asked so that the 
mother does not have to answer by a statement of opinion or by a descrip- 
tion of events, but rather numerically or by yes or no. I have to thank my 
teacher, the late Richard Forster, the ophthalmologist, for the suggestion of 
this method. It was the result of his long medical experience. By this 
means a probable diagnosis will soon be foreseen, which later may be con- 
firmed or modified by the complete history or by the examination findings. 
As compared with the experience of the adult, there is a monotony in the 
disease-picture in the infant which makes this method of diagnosis easier. 
This fact depends upon the comparative rarity of many disease conditions 
in infancy which many be excluded from the first. 

The family history with its hereditary tendencies and contributing 
factors, as also the history of the previous illnesses, particularly those which 
may predispose to subsequent ailments, are frequently of considerable 
value. The history of the present illness with its mode of onset and the 
appearance of its symptoms is essential to a proper conclusion. 

Even in taking the history, the physician is often able to form a certain 
impression of the child by casual observation, which is all the more valuable 
because in the young child self-consciousness and intentional deception do 
not play any confusing part. The posture and behavior of the child, the 
expression of his face, etc., may give valuable diagnostic hints. Soltmann, 
in a brilliant study of the facies and facial expression of the sick child has 
indicated many peculiarities which cannot, however, be discussed here. 
70 



SYMPTOMATOLOGY AND TECHNIC OF EXAMINATION 71 

The actual examination should be thorough and the beginner should 
proceed according to a definite plan. It is advisable to examine first that 
part of the body or that organ to which the history points. The parts of 
the examination which tend to excite the child, to cause it to cry or to 
resist the examiner, as for instance, the examination of the throat should be 
left to the last. 

The color, respiration and pulse may be studied and an estimation of 
the temperature may be made by the hand before the child is undressed, an 
event which may, in a measure, disturb him. For complete examination the 
child should always be stripped; infants completely and at once, so that the 
entire body may be surveyed. 

At this time observation should be made upon the skin, state of nutri- 
tion and development of the patient, condition of the muscular and gland- 
ular and bony systems. The existence of abnormalities should be looked 
for and a thorough inspection of the external genitalia and anus should be 
made. The motility of the neck and spine should not be overlooked. 

After this he may be again covered as examination, part by part, permits. 

In older children, the consideration of modesty may make it necessary 
to undress them little by little as the examination proceeds. 

The examination should begin with the determination of the temper- 
ature which for accuracy in the infant should be taken by rectum. The 
child is laid upon his side and his flexed thighs are held with the left hand 
while with the right the thermometer is inserted into the rectum as far as 
the lower edge of the scale. Another position is one in which the patient 
is placed prone upon the lap of the nurse with his feet hanging over. The 
thermometer is -inserted into the rectum as usual. This position is espe- 
cially adapted to the resisting child. It should be held in place several 
minutes, the so-called "minute" thermometer requiring 2 or 3 minutes and 
others 5 minutes or longer until the column of mercury remains stationary 
for 1 minute. With an accurate minute thermometer the allowance of an 
extra half minute should be all that is required. It is unnecessary to lubricate 
the bulb of the thermometer. Even though the child lies perfectly still, the 
nurse should be warned against fastening the thermometer in place with a 
diaper or in any other fashion, and leaving it there, since an unexpected 
movement on the part of the child may break the thermometer and cause 
injury to the rectum. 

During succeeding years the rectal temperature remains the most exact, 
although after infancy in very unruly children it may be taken in the 
inguinal fold, where the thermometer is placed between the strongly flexed 
thigh and the abdomen. After the eighth or tenth year, in children who are 
extremely emaciated, the axillary temperature may be accepted as fairly 
accurate. It should be remembered that in infants the cooling effect of a 
long journey, as for example to the physician's office, is often sufficient to 
conceal, for the time being, a high temperature. 

The number of times the temperature should be taken and the hour of 
taking it should be prescribed by the physician. Usually it is taken in the 



72 TEXT-BOOK OF PEDIATRICS 

morning and in the afternoon. The normal range of temperature has been 
discussed on page 14. 

In counting the respiration and the pulse, as in the adult, the attention 
of the child should be averted, if possible, so that satisfactory results may 
be obtained while he is quiet. The most accurate information is obtained 
while the patient is aslf ep. The only quality that can be definitely deter- 
mined in the peripheral arterial pulse is the frequency. When awake the 
pulse may be considerably accelerated by excitement or upon the approach 
of the physician or a stranger. 

Conclusions as to the force of the heart-beat must be determined by 
direct auscultation of the heart sounds. 

The size, weight, growth and development should be carefully observed 
and compared with the normal average, inasmuch as nutritional disturb- 
ances may influence these factors considerably. These disturbances with 
their far-reaching effects should be constantly kept in mind for their influ- 
ence upon the future of the individual. 

Head and Neck. In palpating the back of the cranium for craniotabes, 
the head is taken firmly between the palms of the hands which are applied 
flat to either side of it leaving the fingers free,- for palpating movements to 
discover soft spots. The same method is employed in palpating all other 
parts of the head and especially the great fontanelle. In estimating the 
tension of the latter, it must be remembered that crying and straining of the 
child may increase the pressure even under normal conditions. The size 
of the fontanelle should be measured diagonally, the results being stated 
either in centimeters, inches, or finger-breadths which latter usually is 
sufficiently accurate. The size of the cranium is commonly measured only 
in the greatest horizontal circumference and is considered in comparison 
with the circumference of the chest, measured with the arms extended, 
immediately below the scapular angles and over the nipples. In the new- 
born the circumference of the head is the greater, but at one and a half 
years the circumference of the chest becomes equal and never again falls 
below it. 

The following table gives several average measurements: 

Circumference of head. Circumference of chest, 

Centimeters Inches Centimeters Inches 

End of the 1st month 35.4 13.95 34.2 13.46 

End of the 6th month 42.7 16.8 41.0 16.1 

End of the 12th month 45.6 18.0 46.0 18.1 

End of the 2nd year 48.0 18.9 47.3 18.6 

End of the 3rd year 48.5 19.0 48.0 18.9 

End of the 4th year 50.0 19.68 49.0 19.2 

End of the 6th year 50.9 20.0 54.8 21.5 

End of the 9th year 51.7 20.35 00.2 23.7 

End of the 12th year 52.3 20.58 65.0 25.6 

For the inspection of the throat the child is laid upon the bed or upon the 
nurse's lap, his hands being held firmly; the physician grasps the head from 
behind with his left hand and introduces the tongue-blade or spoon-handle 
with his right. This gives him full power to turn the head of the child so 
that the light will fall into the mouth. If the child bites the tongue-blade 
the physician waits patiently, pressing gently upon the blade until the 



SYMPTOMATOLOGY AND TECHNIC OF EXAMINATION 73 

child lets go, and then pushes the instrument rapidly toward the posterior 
pharyngeal wall keeping the tongue well down. The touch of the instru- 
ment on the walls of the pharynx will stimulate the gagging reflex and 
force the child to open the mouth wide. 

Probably the most satisfactory ways in which to hold the patient for the 
examination of the throat are as follows : 

(1) Hold the patient with his back against the chest of the nurse with 
the back of his head against her right shoulder. Her left arm is held firmly 
about the patient against her over the patient's lower abdomen. Her right 
arm held firmly also, is placed around the patient's arms at about the level 




FIG. 11. The depressor is introduced just far enough to hold the tongue down. 

of his elbows, pinioning his arms tightly against his sides. The head is then 
grasped by the examiner's left hand and may be moved in any direction 
desired, when the tongue depressor is introduced into the mouth (Fig. 12). 
The depressor is introduced just far enough to hold the tongue down out 
of the way so the examination may be clearly made; in this way a definite 
idea is had of the conditions existing. If it is desired to cause gagging the 
tongue depressor may be passed further back so as to produce the desired 
effect. This method of holding the patient may be employed either with 
the nurse sitting or standing. The other method (2) is employed when the 
patient is too ill to be raised out of bed or if the examiner, for any reason, 
wishes to make the examination with the patient in the recumbent position. 
The patient is placed flat on his back, his arms are extended horizontally 



74 



TEXT-BOOK OF PEDIATRICS 



above his head on a line with the bed. The nurse holds the arms tightly so 
that the head is secure between the arms (Fig. 11). The examiner pro- 
ceeds as above. In both methods the feet may be readily controlled. 
Direct lighting or reflected light may be employed. 

Holding the nose, or any other attempt at force is unnecessary and has a 
very bad effect on the parents. The tongue-blade to be used, in preference 
to the common thick glass form, is the smooth metal spatula best made of 

nickel which does not rust, or of nickeled 
wire according to the description of von 
Pirquet. Wooden blades, which may be 
thrown away after a single use, are very 
clean, but if not carefully prepared and 
the edges left rough may injure the mouth 
of the child who resists examination. 
When it is necessary for further inspection 
or digital examination a mouth gag may 
be used. The Dwyer, or the self -retaining 
Whitehead model will serve. 

In making a digital examination for the 
determination of the existence of adenoids, 
the patient is held with his head pressed 
firmly against the left side of the examiner 
by the examiner's left hand; the forefinger 
of the left hand of the examiner presses 
the left cheek of the patient in between the 
teeth when the mouth is open. The right 
forefinger is then passed into the mouth 
and behind the soft palate making a 
thorough examination of the pharynx. 
The tendency of the patient is to close the 
mouth. In doing so, however, the teeth 
come in contact with the inner wall of the 
cheek and this affords protection to the 
examiner's right forefinger (Fig. 13.) 

Laryngoscopic examination is difficult 
in young children. According to Roth, 
the mirror must be set at a more acute angle (100 instead of 135) than 
in the adult. Many, however, prefer the latter. Anaesthesia of the throat 
with cocaine, novocaine or the like can hardly ever be avoided. Broncho- 
scopy according to Kirstein's method is possible only with extra small in- 
struments and after much practice; even then it fails with some infants. In 
case of necessity, the examination must be done under complete ansesthesia. 
According to Lynch, ansesthesia of the throat for laryngoscopic exam- 
ination is never necessary, on the other hand, bronchoscopic examination 
should always be done under general ansesthesia and the latter examination 
should never fail, instruments smaller than those ordinarily employed in the 
adult, being used, but not extra small ones. 





FIG. 12. 



SYMPTOMATOLOGY AND TECHNIC OF EXAMINATION 75 



Anterior rhinoscopy and otoscopy is performed as in the adult, but of 
course with relatively small specula. It is usually necessary to remove all 
particles of cerumen from the infant's small auditory canal. The sharp 
angle of the tympanic membrane to the direction of the canal makes the 
picture less definite. However, by 
pulling the lobe of the ear down- 
ward, thereby straightening the 
external auditory canal, the exam- 
ination of the tympanic membrane 
is considerably facilitated. 

Pressure upon the tragus is usu- 
ally sufficient to give indication of 
the presence of an acute painful 
inflammation of the external audi- 
tory canal, but at this point, as in 
all examinations to determine the 
presence of pain, one must be cer- 
tain that the pain is local and is 
not stimulated by fear or excited 
by the condition of the child. 

The examination of the eye 
does not offer any technical differ- 
ences from that employed in the 
adult. The ophthalmoscopic ex- 
amination is best made With the 

/>Viilrl Iviner iinnn Vii 
1 1 y m ^ U P 




rm 



FIG. 13. In making a digital examination for de- 
termination of adenoids hold the patient with head 
pressed firmly against left side of examiner. 



bed or upon the nurse's lap. If 

necessary it should be done after dilatation of the pupil with homatropin. 

The lids may be separated by the retractor. 

CHEST 

The Examination of the Heart. The apex, beat in the infant is ' 
not normally visible and can be felt but slightly in the fourth intercostal 
space, half a centimeter outside of the nipple line. With increasing age, it 
gradually becomes visible and changes its position so that after the second 
or third year it is found in the fifth intercostal space, continually moving 
medially until puberty, when it has taken the position, normal to the adult, 
inside of the mammillary line. 

Bulging of the precardia should require the exclusion of cardiac disease, 
as it is a frequent finding in such conditions in early life. 

Percussion of the cardiac area of the infant gives but indifferent infor- 
mation as to the size of the heart and permits of definite conclusions only in 
the event of great enlargement. Mediate percussion with the fingers should 
always be employed and should be very light. It is best done with the child 
in a sitting posture, since when the child lies on his back the heart sinks away 
from the thoracic walls. In the infant, the relative dulness extends one- 
half centimeter to the left of the mammillary line to the second rib above, 



76 TEXT-BOOK OF PEDIATRICS 

slightly beyond the right sternal margin on the right and to the fourth 
intercostal space below. The absolute dulness covers only a small area to the 
left of the sternal margin. The relative dulness diminishes with increasing 
age, becoming narrower to the right and extending by one intercos- 
tal space in the downward direction, corresponding with the gradual sinking 
of the diaphragm after the second to the third year. The absolute dulness 
enlarges, especially to the left, and correspondingly downward. 

Exploratory puncture of the pericardial cavity is seldom employed for 
diagnostic purposes, but may be done as a therapeutic measure. 

A slight sternal dulness over the manubrium may be frequently 
demonstrated and is termed the thymus dulness. It is separated from the 
upper border of the heart dulness by a zone of clear lung resonance. In my 
experience the dulness of the thymus merges into the cardiac dulness. 
More intense sternal dulness is undoubtedly always pathologic and may be 
accompanied by a bulging of the upper segments of the sternum. 

Auscultation gives more definite results. In order to localize the indi- 
vidual tones and sounds accurately, it is well to use an instrument rather 
than the naked ear. In applying a solid stethoscope to the soft thoracic 
wall any pressure should be avoided that may tend to make the child rest- 
less. In the use of a tube stethoscope the sounds are subdued and less 
distinct. With the phonendoscope, or any similar binauricular the sounds 
may be heard very distinctly, but the user must grow accustomed to the 
instrument in order to be able to exclude extrinsic sounds. The heart 
sounds of young children are as a rule relatively louder than in the adult 
and more sharply defined and sudden. At the apex the first sound is dis- 
tinctly the more prominent while the predominance of the second sound at 
the base, physiologic in the adult, is scarcely or not at all demonstrable. 
On account of their volume, the heart-sounds may often be heard distinctly 
outside of the heart areas, and at times, even over the back. If the respi- 
rations are especially rapid, while auscultation of the heart is being at- 
tempted, and this can hardly be avoided in nervous children, the so-called 
heart-lung sounds may be mistaken for actual heart sounds. These 
complicating sounds are hardly ever present in infants. In children, 
who breathe during the auscultation of the heart a slight imperfection or 
splitting of the sounds, and especially of the first sound at the apex, is 
common, but is of no diagnostic significance. As a rule, endocarditic 
disease and resulting organic lesions are rare in infants. This is true, also, of 
accidental sounds. Every loud heart murmur should, therefore, arouse 
suspicion of a congenital lesion. This infantile peculiarity disappears 
progressively between the fourth and the sixth year. 

Direct auscultation is most simply done with the naked ear and serves 
well in infants, during the first month, in determining the force of the 
heart. The examination with the stethoscope is much to be preferred. If 
the force is lowered, the sounds become duller and more subdued until 
finally only a dull tone, synchronous with the first or muscle sound, is 
heard at the apex. In the young infant, this method of examination takes 
the place of the examination of the radial pulse which, on account of its 



SYMPTOMATOLOGY AND TECHNIC OF EXAMINATION 77 

smallness, does not permit definite determination of arterial tension 
volume, etc. 

Blood-pressure, measured with the usual instruments, gives good results 
only with older children and should be interpreted with great caution. Its 
practical diagnostic value is slight. 

During the examination of the lungs, as in the examination of the 
heart, the child should be as quiet as possible. This is usually best 
assured when the child remains in the arms or upon the lap of the mother; 
but this, again, makes it difficult to secure the complete symmetry of 
posture which is absolutely necessary to accurate comparisons. It is 
better, therefore, to have the child lying on his back upon the bed when 
percussing the anterior thoracic wall and to percuss the back with the 
child in a sitting position or while lying on his abdomen. If the child is 




14. Percussion of chest in sitting position. 



sitting it will be necessary to straighten the spine by gently pulling upward 
on the head, as is shown in Fig. 14, because the liver and diaphragm are 
pressed upward and to the right by the kyphotic posture resulting from 
the sinking down of the weak spine, and may thus cause dulness. In the 
examination with the child prone (Fig. 15) which is especially applicable 
to young infants, the breast of the child with adducted and flexed arms, 
rests on the hands of the nurse; then the back is stretched out and the 
examination may be made very comfortably. The percussion of the infan- 
tile thorax must be done very gently, finger to finger, on account of the 
great flexibility of the thoracic walls. When dulness or increased sense of 
resistance is encountered by this gentle percussion, the force of the stroke 
may be increased in order to arrive at a conclusion as to the intensity of 
the dulness. In the infant, small pneumonic foci either do not change the 
percussion sounds at all or may even impart a tympanic quality to it on 
account of the surrounding lung tissue. For this reason, any marked dul- 
ness which remains with even deeper percussion should arouse a suspicion, 



78 



TEXT-BOOK OF PEDIATRICS 



at least, of exudate. In percussing children who are screaming, two things 
are to be noted; first, a loud "cracked pot" resonance, which often sounds 
like the clink of coins is frequently heard over areas of normal lung tissue 
and especially over the anterior of the thorax. Secondly, the increased 
tension of the intercostal muscles during crying causes a reduction of the 
sounds and increases the sense of resistance, both of which disappear in the 
phase of inspiration. This fact makes it possible to distinguish between the 
dulness due to the increased tension and the dulness due to actual diseased 
conditions of the lung. In thoracic exudation the percussion sounds of the 
normal side also frequently show changes. 

In the auscultation of the lungs in the young infant the stethoscope has 
always given the most reliable information. In direct auscultation the 




FIG. "15. 



child may very properly be held in the position shown in Fig. 16, which 
gives the physician great freedom of motion. 

In auscultation the crying of the child does not usually disturb the ex- 
aminer as it does in percussion. In fact the cries rather give enlarged oppor- 
tunity by bringing out indistinct sounds which can be heard clearly only at 
the height of the inspiration. It may be necessary, therefore, to excite crying 
at times. The breath sounds of the young child are much louder and more 
distinct than in older children or in adults, the so-called "puerile" breath- 
ing; even normal expiration is distinctly audible. The auscultation phenom- 
ena in the infant are not essentially different from those of the adult, 
aside from the fact that a certain amount of practice is necessary in order 
to distinguish the normal breath sounds from the transmitted sounds of 
the upper respiratory passages by which they are accompanied and 
sometimes concealed. 

D'Espine's sign should be looked for while examining the thorax. 
When present it is indicative of enlarged bronchial lymph glands. Finally, 
it is necessary only to mention that at this age bronchophony is often 
clearer, and appears earlier than bronchial breathing in pneumonia. 



SYMPTOMATOLOGY AND TECHNIC OF EXAMINATION 79 

Exploratory thoracentesis should be performed wherever flatness exists. 
The point of selection when the flatness is general should be in the posterior 
axillary line at the fifth interspace on the right and at the sixth interspace 
on the left. If, however, the flatness is more localized, the point of intro- 
duction of the needle should be at that of greatest flatness. 

A needle sufficiently large so as not to become blocked by particles of 
pus should be used, preferably one of about one millimeter in diameter and 
it should be introduced from one to two centimeters. The procedure 
should be performed under aseptic conditions. In order that the pus should 
not be missed in the path of the puncture, the piston of the syringe should 
be slightly withdrawn, thereby creating a little suction immediately after 
the needle is introduced beyond the skin layer. The needle should pass 
between the ribs nearer to the upper than 
the lower border, so as to avoid the inter- 
costal artery. The child should be in a 
sitting position and held firmly; the hand 
on the affected side should be brought 
over the opposite shoulder. 

The Abdomen. In the infant the 
condition of the abdominal wall offers 
important points in diagnosis. Abnormal 
laxity of the walls always indicates that 
the diseased condition has gone on for a 
considerable length of time or that the 
attack is serious. If, at the same time, 
there be extreme emaciation, it is possible 
to see the peristaltic movements of the 
intestine through the abdominal wall. FlG 16 ._ Direct auscultation. 

The peristaltic waves of the stomach 

in the instance of pyloric obstruction are readily seen and are more pro- 
nounced if much loss of weight has occurred. 

The size of the liver and spleen can be determined definitely only by 
palpation, while percussion gives uncertain results. In the infant the 
liver is relatively larger than in the adult. Its anterior border extends 
further downward and under normal conditions may even be felt distinctly 
below the costal margin. 

It is not true that every spleen that is easily palpated is enlarged, 
since it may have a normally greater mobility. 

The kidneys are palpable from above only when the abdominal wall is 
very thin and lax. More often it is possible to locate and feel the lower pole 
from the rectum, as they are extremely movable. This condition can hardly 
be said to have any pathological significance. 

It is often quite difficult to demonstrate any localized tenderness to 
pressure in the abdomen of the child during the first year. The close 
observation of the facial expression during palpation, and of other reactions, 
as for instance, the position of the legs, the gait, the maintenance of a 
certain posture upon one side or upon the abdomen, are more important 




80 



TEXT-BOOK OF PEDIATRICS 



than the indefinite and unreliable subjective symptoms of these small 
patients. Otherwise the topographical conclusions which may be drawn from 
the determination of a circumscribed area of pain are the same as in later 
life. The same methods are used as in adults for determining the position 
and size of the stomach or of a certain portion of the intestines. The technic 
of the use of the stomach tube is much easier. The method is described 
under lavage of the stomach on page 113. 

The methods of examination of the gastric contents and gastric motility 
are the same as in the adult. The size of the catheter should be 14 to 18 
French scale. 

Abdominal paracenteses is done, diagnostically only to secure the 
fluid for bacteriologic or cytodiagnostic examination. The point of selection 
for the introduction of the needle is midway between the pubes and the 
umbilicus. The procedure is done under aseptic precautions. The needle 




FIG. 17. Method of collecting urine from a male infant. Test-tube 
fastened over penis by means of adhesive plaster. 

should be about one millimeter in diameter. The syringe should be tested 
before using. 

Catheterization of the urinary bladder is possible in the infant, but 
requires some practice. In boys it is done with a metal or elastic catheter, 
the caliber of which should correspond with that of the urinary meatus, and 
in girls it is more easily done with a metal catheter of about the thickness of 
knitting-needle. When necessary, a cystoscope of the smallest calibre 
may be introduced under anaesthesia in girls at the end of the first year. 
A paralysis of the sphincter, however, will remain for several days, so that 
this method of examination should be used in cases of extremity alone. 
Catheterization of the ureters is technically impossible during the 
first year. 

When urine is to be collected for examination, the danger of bladder 
infection by the use of the instrument, even under proper precautions may 
be easily avoided by employing instead a strong test-tube fastened over 
the penis with adhesive plaster, as is shown in Fig. 17. In girls, a small 
Erlenmeyer flask (Fig. 18) may be placed over the labia which have been 
separated and carefully cleansed. 

These methods of collecting urine suffice for the ordinary routine exam- 



SYMPTOMATOLOGY AND TECHNIC OF EXAMINATION 81 

ination, but where it becomes necessary to determine the existence of a 
pyelitis or for the culturing and examination of the urine for bacteria, 
catheterized specimens are essential except possibly in the male patient, 
with no phimosis and an easily cleansed glans and the urine voided under 
direction. The first several streams of urine should not be collected, as they 
may be contaminated with washings from the urethra. When properly done 
the possibility of infection from catheterization is practically nil. 

Because of the relatively high position of the bladder in the infant cath- 
eterization may become necessary at times to differentiate between a dis- 
tended bladder and ascites or a new growth. 

Rectal examination should be made whenever an intestinal obstruction, 
intussusception or an obscure abdominal condition may exist. The exam- 
ination is best made with the patient lying on his back, the oiled finger 
being inserted into the rectum. 

The Nervous System. In order to test the passive motion and the 
tendon reflexes, it may be necessary to distract the attention of the child 




FIG. 18. Method of collecting urine from female infant. Small Erlenmeyer flask 
or large test-tube fastened over vulva. 

and thus diminish the increased muscle tone, since voluntary tension of the 
musculature in nervous children often makes it impossible to bring out 
these reflexes. In the infant this is most easily done if the child is examined 
while taking his food. The absence of the patellar reflex when these pre- 
cautions are taken, is always pathologic. Ankle clonus is common during 
the first year, especially in feverish or excited children, without having any 
diagnostic significance. 

Because of the frequency and the clinical importance of spasmophilia 
in infancy, attention must be called to its symptoms and especially to the 
facial and peroneal phenomena. Special discussion of these is to be found 
in the section on nervous diseases. 

Of the various tests for the quality of sensation, only that for the pain 
sense can be applied in children who have not learned to talk, and even this 
test must be done very carefully because the infant is often so alarmed by his 
first experience that he will cry out to non-painful stimulation, and often 
at the mere approach of the examining hand or when he is but gently 
touched. The final findings must always be controlled by comparison with 
normal parts. 
6 



82 TEXT-BOOK OF PEDIATRICS 

Electrical tests are applied as in the older person. Despite the smallness 
of the child the stimulating electrode should be of the same size as that used 
in the adult (a Stintzing normal electrode one cm. square, see Diseases of 
the Nervous System) so that the results of the reactions at all ages may be 
directly compared. A plate, fifty centimeters square, may be used for the 
indifferent electrode which should be placed over the breast or abdomen. 
The technic of the examination requires not only a certain amount of 
practice but also close attention, if voluntary muscular contractions, inde- 
pendent of the electric stimulus, are not to lead the observer into error. 

Lumbar puncture is of extraordinary diagnostic value in children as it 
is in later life, but it is done much more frequently on the infant because, 
on the one hand, of its simplicity of technic, and on the other hand, 
because the greater elasticity of the cranial wall entirely relieves it of 
danger. The most satisfactory instrument is a trocar of about the size of a 
knitting-needle. Only in case of necessity should a heavy hypodermic 
needle be used, because in the use of the trocar all danger of injury is 
avoided after the stylette has been withdrawn. Many prefer needles to 
trocars. The size of the needle depends upon the size of the patient. 

Aspiration of the fluid by means of a syringe is frequently not only 
useless but dangerous and, therefore, should never be attempted. 

The pressure is measured either by means of a long tube of small 
calibre, according to Quincke, which is attached to the trocar by means of 
rubber tubing; or by the method of Pfaundler, with a manometer filled with 
mercury or salt solution. By the first method we actually measure the 
pressure after a certain amount of the fluid has been withdrawn; and, as a 
result, lower figures are obtained than by the second means the result of 
which can be calibrated only by comparison with those obtained with 
similar apparatus. It is to be further noted that the pressure is naturally 
lower when the patient is lying down than when he is sitting up. Sahli 
gives from 69 to 100 or 150 mm. water pressure ( =5 to 7 or 11 mm. mer- 
cury), measured, according to Quincke 's method, with the patient lying 
down; while Pfaundler, with the iris mercury manometer, has found 20 
mm. in the infant and 25 mm. in children of from two to twelve years, in 
an upright position. In comparing Pfaundler 's figures with those taken 
by the hydrostatic method, values of from 12 to 19 mm. mercury are ob- 
tained in children lying down. It is superfluous to say that the mensura- 
tion, as well as the puncture itself, should be done under absolute asepsis. 

Whenever tumors of the brain are suspected the lumbar puncture should 
be carefully performed, with the patient in the prone position, and pref- 
erably with the head lower than the feet, so as to avoid the danger of a 
possible damage to the vital centres of the medulla from pressure from 
above. If after the spinal canal has been reached the fluid does not flow 
through the aspirating needle the position of the patient should be gradu- 
ally changed to approach the sitting posture or to such an angle that will 
allow the fluid to flow through the needle. 

In making the puncture with the child lying on his side, which position 
is to be greatly preferred because the child may be held more firmly, 



SYMPTOMATOLOGY AND TECHNIC OF EXAMINATION 83 

the back is arched as much as possible by bending the head forward on to the 
breast and flexing the thighs upon the abdomen, as is shown in Fig. 19. 
The point of entry is then marked by connecting the iliac crests by a line 
and by locating with the under finger of the left hand, the inner-vertebral 
space lying nearest this line. The level so located will usually be the fourth 
or more surely the third lumbar space. In young children it is not well to go 
above this point, on account of the fact that the spinal cord extends lower 
than in adults and may therefore be injured by higher puncture. The 
entry is best made in the median line and the needle should not deviate 




FIG. 19. Position for lumbar puncture. 

from the middle plane, but should follow the direction of the spinous 
process inclined slightly upward. A slight decrease of resistance may be 
felt the moment the needle enters the canal, 2-4 cm. (^i-l/'i inches) beneath 
the skin. At this point the trocar should not be pushed any further on 
account of injuring the large venous plexes on the anterior wall of the canal. 
Even though the hemorrhage caused by such an injury is not at all danger- 
ous, the admixture of blood with the spinal fluid is very disturbing and may 
even make the specimen entirely useless for examination. The cerebro- 
spinal fluid begins to drop from the trocar immediately after the stylette 
is withdrawn, if the puncture has been properly performed. If the pressure 
is increased it may flow out in a steady stream. If the opening of the trocar 



84 TEXT-BOOK OF PEDIATRICS 

is blocked by a root of the cauda equina a slight movement of the needle 
will often cause the flow to begin. If no outflow appears, in spite of the fact 
that the needle has been properly introduced (a dry puncture) it may be due to 
the abnormal viscosity of the highly fibrinous cerebrospinal fluid, which 
cannot pass the fine calibre of the needle. In such an event the injection 
of a few cubic centimeters of sterilized physiologic salt solution will often 
dilute the fluid sufficiently to permit enough to flow off for purposes 
of examination. Great caution should be exercised so as not to produce 
additional pressure when there is already an increased intercranial pressure. 

A few cubic centimeters (5-10) of the fluid will suffice for examination. 
In cases where the pressure is increased larger quantities may, of course, be 
removed, continuing so long as there is a free flow. After the needle has been 
withdrawn, the puncture wound is covered with sterilized gauze fastened 
with adhesive. The method of examination of the fluid and the conclusions 
to be drawn from the results of examination are given in a special chapter. 

Cranial puncture, a diagnostic measure which in the adult is rapidly 
gaining importance, may be done all the more easily in the infant because it 
is unnecessary to trephine. It is usually possible to puncture the thin 
cranial wall, or rather the membranous fontanelle, very readily with 
the trocar. The puncture is made 1-2 cm. (0.4-0.8 inch) to one side of the 
sagittal suture at the top of the head or slightly anterior to it and preferably 
in the area of the fontanelle. The trocar is inserted perpendicularly to the 
tangential planes for a short distance only and the stylette is withdrawn to 
note whether fluid is present at this level. Many prefer the use of a needle 
to that of a trocar. 

Fluid at this point indicates an external hydrocephalus. If there is no 
fluid the needle is pushed in a few centimeters further in the direction of 
the lateral ventricles. In older children with a completely ossified cranium, 
it is necessary to trephine. The removal of the hair, which is necessary 
before preparing the field of operation, may be done much more easily in 
young children by using a depilatory, applied to the skin for a few minutes 
in the form of a freshly prepared paste, than by shaving the scalp. 

Stools. The physician usually sees the bowel movements of infants 
upon the diaper and often they are not very fresh. It is necessary to 
remember that, on account of the drying, thin stools may appear more solid 
than they were when fresh and that the green color so frequently seen may 
be reasonably due to the oxidizing influence of the air, and, therefore, is of 
no clinical significance. 

Sputum. On occasion, and especially where there is an open tubercu- 
lous lesion, the examination of the sputum may be of great clinical interest 
even in children of early years who always swallow their sputum. In these 
cases it may be secured for examination or for culture, by passing a tongue- 
blade far back in the throat and catching the sputum thrown up by the 
coughing on the blade or on an applicator covered with cotton. This 
method is much more simple and more successful than the difficult search 
in the feces for tubercle bacilli swallowed with the sputum. 



SYMPTOMATOLOGY AND TECHNIC OF EXAMINATION 85 

Blood. The blood of young children, to be used for microscopic exami- 
nation is preferably taken from a toe, usually the great toe, or from the ear 
rather than the finger-tip. When larger quantities are required (2-5 cc.) 
for serum diagnosis, as for instance in the Wassermann reaction, a super- 
ficial vein may be punctured. For this purpose one of the superficial veins 
of the head is better than the veins of the arm. A cupping glass may be 
used. For this purpose, one or two long incisions (!-!}/ cm.) are made over 
the back and a cupping glass placed over them is permitted to draw out the 
required amount of blood. 

Sinus Puncture. The puncture of the longitudinal sinus for the pur- 
pose of obtaining blood and for the injection of therapeutic fluids has proved 
very useful. The technic is quite simple and free from danger. A Luer 
syringe with an 18 or 20 gauge needle, about 1^ inches in length is used. 
By a series of measurements it has been determined that the sinus lies 
He to ;h$ inch beneath the surface of the scalp and is about %2 of an inch in 
calibre at the posterior angle of the fontanelle. For this reason it is con- 
venient to have a guard firmly fixed about % inch above the point of the 
needle to prevent deeper penetration. Reports tend to show that even 
though the sinus be transfixed no special injury results. 

Roentgen Rays. The diagnostic use of the Roentgen rays is hampered 
by the fact that many parts of the skeleton which are not completely ossi- 
fied permit the passage of the rays fully as well as the surrounding soft 
parts. The comparison, therefore, with radiograms of skeletons of normal 
infants in the same stage of ossification is always unreliable in the matter of 
pathologic findings. In the recognition of alterations in the internal organs, 
for" instance of enlarged bronchial lymph nodes, pneumonia areas, pleuritic 
exudates, enlargement of the heart, etc., examination with the Roentgen 
rays has gained in importance in pediatrics as well as in internal medicine. 
The Roentgen rays are of great value in the determination of stenoses and 
atresia, as for example, those of the oesophagus, stomach and intestines, 
also for obstructions due to intussusception, etc. With good apparatus and 
careful technic, changes which cannot be determined by other means may 
be demonstrated in the same degree as in the adult. 



IV. GENERAL PATHOGENESIS 



MORTALITY AND MORBIDITY 

REVISED BY 
B.RAYMOND HOOBLER, M.D., 

Professor of Pediatrics, Detroit College of Medicine and Surgery, Detroit. 

THE mortality of infants and children is of great significance because it 
exerts a pronounced influence upon the growth and quality of the popula- 
tion upon which depends the expansion of a Nation. In fact the infant 
mortality rates should be a matter of national concern. 

Table I. shows in outline form the relation between the birth and death- 
rate, also the relative high mortality of the first year. 

TABLE I. 





"Co. of Children 
Born Alive Per 
1000 inhab- 
itants 


No. of Deaths 
Per 1000 Inhab- 
itants 


Deaths in First 
Year Per 1000 
Children Born 
Alive 


No. of Children 
Born Alive Ex- 
ceeds No. of 
Deaths Per 1000 
Inhabitants 


France 


.1906 


19.6 
24.9 
25.6 
25.6 
26.2 
26.3 
28.3 
29.1 
31.0 
32.3 
32.4 
33.6 
37.0 
48.0 


19.3 
16.5 

13.7 
14.5 
13.5 
16.6 
13.3 
13.7 
17.1 
20.0 
21.4 
22.4 
25.1 
29.5 


143 

147 
85 
109 
76 
108 
123 
99 
170 
158 
148 
209 
212 
272 


0.3 
8.4 
11.9 
11.1 
12.6 
9.7 
15.0 
15.5 
13.8 
12.3 
11.0 
11.2 
11.9 
18.5 


Belgium 


.1908 


Sweden 


.1908 


England (Wales) . 
Norway 


.1909 
.1908 


Switzerland 


.1908 


Denmark 


.1908 


Holland 


.1908 


German Empire. . 
Japan 


.1909 
.1908 


Italy 


.1908 


Austria 


.1907 


Hungaria 


.1909 


Russia .... 


.1901 







The comparison of the four columns shows that the number by which 
the birth-rate exceeds the death-rate per thousand inhabitants is quite 
variable ranging between 0.3 in France to 18.5 in Russia. Germany has an 
excess birth-rate of 13.8 which is exceeded not only by Russia, but also by 
Holland and Denmark. Most of the other civilized countries have the 
same number of excess births as Germany. 

In Table I. it can readily be seen that a growth in population can take 
place in two ways. First, by a birth-rate so large that even after deducting 
a large death-rate we have an excess; second, by a lowered mortality rate 
such that even a small birth-rate would give an increase in the population. 
Russia is an example of the first instance; the Northern European countries 
of the second. 
86 



MORTALITY AND MORBIDITY 



87 



Each people pursue their own course in this matter depending upon 
their many circumstances. The second way seems at first glance to be the 
most rational, but the experience of the civilized people seems to show that 
not only is it very difficult to reduce the death-rate, but that a decrease in 
the number of births due to prevention of conception is, in itself, a sign 



TABLE II. (GERMAN EMPIRE.) 
To Each 1000 Inhabitants. 



Year 


Were Born Alive 


Deaths Including 
Still-Births 


Excess No. of 
Births Over 
Deaths 


1901 


35.7 


21.8 


15.1 


1902 


35.1 


20.6 


15.6 


1903 


33.8 


21.1 


13.9 


1904 


34.0 


20.7 


14.5 


1905 


33.0 


208 


13.2 


1906 


33.1 


19.2 


14.9 


1907 


32.3 


19.9 


14.2 


1908 


32.1 


19.0 


14.0 


1909 


31.0 


18.1 


13.9 


1910 


29.8 


17 1 


136 


1911. 


28.6 


182 


11 3 


1912 


28.3 


16.4 


12.7 


1913 


27.5 


15.8 


12.4 











of degeneration. It seems, therefore, that when we try to understand what 
would be rational sex life in the peoples of all classes in the various nations, 
there is no safe means by which to stop the growth of a people. Unfortu- 
nately even in Germany, which up to the beginning of the World War had 
a greater birth excess than most civilized countries, there has been a defi- 
nite tendency to a decrease in the birth excess. 

Table II. shows not only what was pointed out in Table I., namely the 

TABLE III. 









Deaths in 1st Year Not 


Deaths Per 100 Born 




Births Not 


Deaths Not 


Illegitimate 
Births In- 


Including Still-Births 


Alive 


Yrs. 


Still-Births 


Still-Births 


cluding 
Still-Births 


Legitimate 


Illegit. 


Totals 


Aver- 
age 


Legit- 
imate 


Illegit. 




2,032,313 


1,174,489 


179,683 


361,745 


58,478 


420,223 


20.7 


19.4 


33.9 


1901 


2,022,477 


1,112,202 


177,060 


324,592 


50,044 


374,636 


18.5 


17.5 


29.4 


1906 


1,924,778 


1,045,665 


179,584 


267,171 


44,291 


311,462 


16.2 


15.2 


25.7 


1910 


1,838,750 


1,004,950 


183,977 


235,272 


41,924 


277,196 


15.1 


13.5 


21.8 


1913 



great influence of infant mortality on the general mortality rates, but 
teaches us above all. the fact that since about the year 1900, the number of 
births have decreased more rapidly than the number of deaths; also, that if 
there is further decrease in frequency of births, Germany will soon present 
a condition like that of France. 

Table III. shows for the German Empire the exact number of those 
living, those born and those that die in a population of over sixty million. 



88 



TEXT-BOOK OF PEDIATRICS 



Also, the unfavorable position of the illegitimate child, the cause of which 
will be elucidated further on. 

As has already been mentioned, the danger to life is not the same at all 
times during childhood but by far the greatest in the first year and propor- 

TABLE IV. 
Deaths according to age per 1000 deaths (in German Empire). 



Between 
ages of 

0-1 yr 


In the Year 
1911 

. .. 317.1 


In the Year 
1913 

275.1 


1-2 vr. . . 


. . . 48.81 


45.1] 


2-3 yr. . . 


17.0L, K 


16.0Un o 


3-4 yr 


10? 84.5 


10.4 79 ' 3 


45 yr. 


7.9 


7.8J 


5-6 yr 


. . . 6.0) 


6.1 


6-7 yr. ... 


4.9 


5.1 


7-8 yr. . 


4.0[21.6 


4.2 22.1 


8-9 yr 


... 3.4 


3.5 


9-10 vr. . . 


3.2 


3.0 



Between 



In the Year In the Year 



ages of 1911 1913 

10-1 lyrs 2.8 2.9) 

11-12 yrs 2.8 2.7 



12-13 yrs 2.4 

13-14 yrs 2.7 

14-15 yrs 3.0 



13.9 2.7 
2.7 
2.9 



14.0 



tionately great, during the second year. From then on the mortality curve 
sinks rapidly. 

In Table IV. the author has purposely contrasted the years 1911 and 
1913, one a very warm, the other a very cool year. It can be seen by noticing 

TABLE V. 

Number of deaths per 1000 at various times according to mortality tables for years 1901 to 1908. 

Still births 33.47 Previous mo. 165.53 Previous mo. 219.39 

1st. mo. 59.07 5th. mo. 18.39 9th. mo. 8.53 

2nd. mo. 26.77 6th. mo. 13.73 10th. mo. 7.41 

3rd. mo. 25.55 7th. mo. 12.31 llth. mo. 5.79 

4th. mo. 20.67 8th. mo. 9.43 12th. mo. 5.45 



Total 



165.53 



Total 



219.39 



Total 



246.57 



the five year periods as well as the single years, that a difference exists 
mainly in the first and to a lesser extent in the second year. 

The infant mortality is not uniform during the first year but is the 
greatest during the first part of infancy. This fact is shown by a large 
number of statistics, and in Table V. by the Magdeburg Statistics. 

During 1918 there were 193,855 deaths of infants under one year of age 
in the registration area of the United States. They were distributed 
through the year as follows : Number Percentage 

Death occurring at of Deaths. of deaths. 

Less than 1 day 29,106 15 

1st day 9,554 4.9 

2nd day 6,829 3.6 

3rd to 6th day 12,645 6.5 

Less than 1 week 58,134 30 

1st week 11,750 6 

2nd week 8,292 4.25 

3 weeks but less than 1 month 6,572 3.39 

Less than one month 84,748 43.64 

1st month 16,278 8.39 

2nd month 13,238 6.8 

3rd to 5th month 31,503 16.25 

6th to 8th month 26,111 13.66 

9th to llth month 21,977 11.26 



MORTALITY AND MORBIDITY 



89 



Within the first month, 
which is the most critical 
one as far as the life of 
an infant is concerned, we 
note that the first day and 
week are of greatest im- 
portance. For example, 
according to carefully col- 
lected statistics in Berlin, 
there are two and one-half 
times as many deaths in 
the first week, as in the 
second week of life and 
one-half as many deaths 
during the last half of the 
first month, as during the 
first two weeks. 

Two other definite fac- 
tors are to be noted in the 
statistics given thus far, 
namely the very much 
higher mortality of the 
illegitimate as compared 
to the legitimate child in 
the first year (Tables III 
and IV) and secondly, the 
rise in infant mortality 
in the summer months 
(Table VIII). 

Many of the diverse 
factors influencing the ex- 
pectation of life in infants, 
which a physician meets 
in daily routine but has 
not learned how to eval- 
uate, can only be expressed 
truthfully if the statisti- 
cian is allowed absolute 
liberty in choice of mate- 
rial. This is possible, how- 
ever, in only more or less 
limited way and for only a 
short space of time. 

The high mortality of 
infants is, according to Malthus, a natural protection against an excessive 
increase in population so that individuals may be enabled to obtain the 
necessities for life. Later under the influence of the Darwinian theories 



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Fia. 20. Deaths under 1 year of age per 1000 births. Rates 
are for latest available years up to 1918 as compiled by the Chil- 
dren's Bureau, U. S. Dept. of Labor. Within the first year after 
birth the U. S. loses 1 in 10 of all babies born. It rauks 1 1th 
among the principal countries of the world. New Zealand loses 
fewer babies than any other country. 



90 



TEXT-BOOK OF PEDIATRICS 



this was explained on the basis of natural selection. Thus only the strong 
survive, the weaker, being worthless to the race, are cast out. Many 
statistically established facts, as for example, the infant mortality among 
the different classes of people (which is firmly established and noticeable 
in the German Empire) have been quoted as proof of the Darwinian Theory 
by its supporters. As also, the higher mortality of the illegitimates. HOW- 
TABLE VI. 

Infant Mortality in Berlin 1900 to 1902. 
IN FAMILIES OF Per cent. 

1. Officers, officials and professional men 11 

2. Business men 15 

3. Skilled artisans 16 

4. Unskilled laborers 18 

ever, any one who will look at the facts as a true physician and scientist, 
will soon see that the explanation is not to be made on biological grounds 
but on the basis of social status. Much more important is the effect of 
the social conditions under which the child is born and those under which 
he develops, as for example, the financial condition of the parents. Accord- 
ing to statistics, if we choose the calling of the parents or the size of dwelling 

TAELE VII. 
Nutrition and Infant Mortality in Berlin. Deaths, per 1000 infants. 







Breast-ted 




, 


\rtificially-fec 






1885-86 


1895-90 


190C 


1885-86 


1895-96 


1906 


1 


22.4 


19.6 


22.4 


142.0 


111.9 


58.1 


2 


9. 


7.3 


7.9 


82.7 


58.7 


31.3 


3 


6.8 


4.3 


4.3 


72.2 


49.7 


27.3 


4 


6.4 


3.6 


2.4 


61.8 


46.6 


22.1 


5 


5.3 


2.6 


1.7 


57.1 


37.0 


18.5 


6 


4.9 


2.5 


2.2 


50.7 


31.0 


16.1 


7 


4.7 


2.5 


1.4 


46.5 


27.7 


14.1 


8 


4.5 


2.3 


1.8 


40.8 


24.1 


12.2 


9 


5.3 


2.0 


2.1 


33.3 


21.3 


10.2 


10 


5.4 


3.8 


1.5 


29.5 


19.1 


9.2 


11 


6.3 


3.1 


1.3 


24.9 


16.7 


8.0 


12 




3 6 


1 5 




14 6 


8 
















Average per rr.o. 


8.4 


6.0 


6.3 


54.1 


35.8 


23.6 



as an indication of social status, \ve can see the increased danger of life to 
infants born in unfavorable surroundings. 

A fundamental law, substantiated not only in every day medical prac- 
tice but also by a large number of statistics, is the high mortality of the arti- 
ficially-fed as compared to the low mortality of the breast-fed infant. This 
fact does not coincide with the idea of natural selection. If it were true 
that children do w r ell only when nursed by their own mothers we could say 
that the nursing ability of the mother would give us prognostic knowledge 
as to health of the child. But we know that children do well on breast-milk 



MORTALITY AND MORBIDITY 



91 



of other women beside their mother, and also that observation has firmly 
established the fact that children that are ill and on artificial food recover 
most rapidly on breast-milk. Thus even though a very small per cent, 
of breast-fed children may not do well on the breast, we should notice 
more particularly the problem of nutrition rather than that of hereditary 
defects, thus keeping down the infant mortality and assuring good health 
to most infants. 

The infant mortality rate in many of the cities of the United States has 
been reduced much below the average, due to the intensive Infant Welfare 
work done through many agencies and especially through breast feeding 
propaganda. The American Child Hygiene Association is the leading 
National agency working for the reduction of Infant Mortality. 

The figures for the ten largest American cities taken from publication of 
American Child Hygiene Association is given below. 





1916 


1917 


1918 


1919 


New York 


93 


89 


92 


82 


Philadelphia 


105 


108 


124 


90 


Detroit . 


112 


103 


101 ' 


97 


Cleveland 


109 


109 


98 


91 


St. Louis . 


89 


85 


93 


75 


Boston 


105 


99 


115 


97 


Baltimore . 


122 


118 


149 


97 


Pittsburgh . 


115 


120 


139 


115 


Los Angeles 


69 


71 


77 


67 


San Francisco 


67 


63 


67 


65 













The following table shows the lowest and highest infant mortality 
rates in cities of various sizes in the United States as published by the 
American Child Hygiene Association, 1920. 

CITIES WITH HIGHEST AND LOWEST RATES 

Population over 250,000 
Lowest Highest 

Seattle, Wash 54 Pittsburgh, Pa 115 

Minneapolis, Minn 61 Buffalo, N. Y 107 

San Francisco 65 Kansas City, Mo 103 

Population 100,000-250,000 

Lowest Highest 

Houston, Tex 61 New Bedford 124 

Oakland, Calif 62 Camden, N. J 121 

Cambridge, Mass 64 Nashville 116 

Population 50,000-100,000 

Lowest Highest 

Berkeley, Calif 44 El Paso, Tex 245 

Fort Wayne, Ind 51 Knoxville, Tenn 135 

Topeka, Kan 59 Racine, Wis 123 

Population under 50,000 
Lowept Highest 

Brookline, Mass 40 Burlington, Vt 150 

Marinette, Wis 45 Paducah, Ky 146 

Aberdeen, Wash 45 Hannibal, Mo 145 



92 



TEXT-BOOK OF PEDIATRICS 



Aside from the evidence given by statistics that the breast-fed infant 
has a lower mortality and morbidity rate, statistics can be adduced to show 
the increased mortality as resulting from variations of temperature. In 
Table VIII. , the years 1911 and 1913 were chosen because the summer 
months in the latter were not excessively hot while in the former there 
was persistent high temperatures during the months of July, August 
and September. 

TABLE VIII. 
Deaths in infants during first year of life. 



1911 1913 

January 20.99 21.50 

February 22.60 22.83 

March 21.04 24.84 

April 25.04 20.99 

May 25.37 23.33 

June.. ..27.08 24.52 



1911 1913 

July 49.38 27.41 

August 62.11 27.36 

September 45.04 29.15 

October 23.36 26.01 

November 18.28 25.08 

December 21.71 17.60 



The editors add here a table by Graham consisting of statistics from 
the city of Philadelphia showing again the increased mortality in infants 
on artificial foods. This table further brings out the increased mortality 
coincident with the summer heat. 





Breast-fed 


Artificially-fed 


Feeding not known 


January 


8 


21 


9 


February 


9 


14 


18 


March ... 


13 


15 


21 


April 


9 


13 


17 


May 


10 


16 


27 


June 


7 


4 


50 


July 


8 


155 


138 


August 


28 


148 


161 


September 


22 


104 


71 


October 


18 


56 


73 


November 


11 


36 


36 


December 


10 


24 


34 




153 


606 


655 



Of the 759 deaths with known type of feeding, 20 per cent, were breast-fed 
and 80 per cent, were artificially-fed. This is a strong appeal for maternal 
nursing. Maternal nursing is considerably reduced because of the very 
high maternal mortality rate prevailing in the United States. According 
to the Children's Bureau the United States lost over 23,000 women in 
1918 from Childbirth. We have a higher maternal mortality rate than any 
other of the principal countries. 

In the United States the deaths from diarrhoea and enteritis under 2 years 
of age increase greatly during the summer months. The total deaths (47,- 
753) from these causes in 1918 is divided among the months as follows: 



January 1775 

February 1712 

March 2040 

April 2192 



May 2712 

June 4027 

July 6811 

August 9822 



September 8128 

October 4458 

November 2394 

December . . . 1682 



MORTALITY AND MORBIDITY 



93 



Broncho-pneumonia which occurs more often in children has a much 
higher death-rate in the colder months. The 54,697 deaths from broncho- 
pneumonia in 1918 were divided among the various months as follows: 



September 1853 

October 13078* 

November 6208 

December 5883 



January 5256 May 3005 

February 4901 June 1507 

March 5515 July 1309 

April 5194 August 988 

* During influenza epidemic. 

The following circumstances acting together influence the mortality 
rate of infants namely, financial and social status of the parents, the 
character of their dwelling place, the kind of nourishment, and also the 
tune of the year, but, the most striking factor is the kind of nourishment. 
H. Neuman 's statistics of Berlin are of interest. 

TABLE IX. 
Deaths per 100 children according to housing conditions. 





1-2 rooms and 
kitchen 
Percentage 


3 rooms and 
kitchen 
Percentage 


4 rooms and 
kitchen 
Percentage 


Total 


17.7 


12.8 


7.3 


Bottle-fed ' 


12.8 


10.9 


4.7 


Breast-fed 


4.9 


2.6 


2.6 











Besides the factors mentioned above, others worthy of mention but 
closely related are, the unfavorable prognosis for the illegitimate child 
because of the lack of breast-milk and a mother's care and the influence of a 
large or small number of children in individual families. 

Statistics covering illegitimacy in the United States are meagre. The 
latest authoritative statement is from the Eighth Annual Report of the 
Children's Bureau 1920. Miss Lothrop states that, "Each year in the 
United States at least 32,000 white children are born out of wedlock." 
This is proportionately fewer than in most foreign countries. The death- 
rate of illegitimate birth, according to the studies made by the bureau, is 
three times as high as that of other children. 

The above statistics cannot be discussed fully, except that a lesson is 
given in the realm of Pediatrics which is familiar to all physicians who 
understand social conditions, namely, that families in which the children 
are breast-fed and in which there is a pause of one and one-half to two years 
between children have a minimum infant mortality and that the later 
children do not labor under any disadvantage (especially when we have 
large families of eight, ten or more). 

In order to understand the above mentioned facts a knowledge of the 
causes of death and the proportion of each is necessary. However, it is 
with reluctance that one presents statistics of the causes of death, even 
though there are a great number available, both of the civilized countries 
and great urban communities The value of statistics is depreciated be- 
cause of poor raw material on which they are based, giving conclusions at 
variance with the facts noticed by the physician in every day medical 



94 TEXT-BOOK OF PEDIATRICS 

practice. All these statistics agree, however, that gastrointestinal disease 
causes one-third or more of the deaths in the first year and that during this 
same time the acute infections and inflammation of the respiratory tract 
cause but a small part of the total number of deaths. This great number of 
gastro-intestinal infections tells only half the truth, because there are many 
indefinite diagnoses made, in which the artificial feeding was the principal 
fault. Thus the diagnosis of congenital weakness, debility, etc., have 
been shown many times to be clinically only the manifestation of artificial 
feeding. Even congenital lues which is given as a cause of death, very 
often means that death was due to artificial feeding because many luetic 
infants gain well on the breast. Again the cause of death may be ascribed 
to pneumonia, furunculosis or heart lesions, all of .which are but terminal 
affairs following severe nutritional disturbances. 

Close examination of the high death-rate in summer, with due consid- 
eration of the mode of feeding, reveals the fact that only the partially or 
entirely artificially-fed infants contribute to the increased death-rate. 

The possible explanations of this fact are given in detail in the Chapter 
on The Disturbances of Nutrition in Infants. 

All the injuries of artificial feeding react most severely upon the children 
of the poorer classes. H. Neumann says, as a result of his experiences in 
Berlin, "The results of natural feeding are very good in the various strata 
of society. In artificial feeding the expectation of life is reduced in pro- 
portion to the level of the social stratum." Special proof of this general 
rule is seen in the high mortality of illegitimate infants. 

The death-rate decreases markedly from the second year and this is 
probably due to the fact that after the second year disturbances of nutri- 
tion, as a cause of death, become more and more uncommon. In their 
place, however, the acute exanthemata, diphtheria and tuberculosis appear 
more frequently. 

Even though vital statistics give us exact information as to mortality 
in its many sided relationship to age, season, social welfare, methods of 
feeding, etc., it is impossible for obvious reasons to draw from them even an 
approximate picture of the morbidity. 

The statistician obtains reliable figures for only one group of diseases 
the acute infections of childhood which must be reported to the health 
authorities, and then, of course, only of those cases which are seen by a 
physician. In some classes of society and in some parts of the country, 
this is only a negligible number. All the statistics based upon the material 
of various dispensaries and clinics suffer from similar errors and, therefore, 
we forego citing any of them. 

All these arduous compilations, among which the work of Escherich 
must, at least, be mentioned, have so far succeeded only in proving -to 
every observing physician the fact that every period of childhood has its 
peculiar disease groups, which are notable for their frequency, rarity, or 
complete absence ; or for the definite combinations they present of seemingly 
unconnected disorders and anomalies which indicate close pathogenetic 
relationships between them. It would not seem that the time has arrived 



MORTALITY AND MORBIDITY 95 

when a general pathology of the diseases of childhood may be written, since 
pediatrics is still a young science and must concern itself for a long time 
with the collection of data. But the attempt to examine the disease groups 
of the various stages of development more closely and to draw briefly such 
conclusions as appear, after careful study, to have a basis in fact, is justified. 
These, however, are very few if one does not wish to enter deeply into the 
etiology of the various diseases; a topic for which the reader is referred to 
the literature at large. 

These factors are especially concerned in the startlingly high morbidity 
which is revealed by the enormous mortality of the first few days of life. 
They are: (1) Congenital Malformations, in so far, as they affect extra- 
uterine life ; (2) Birth Injuries, and (3) -Congenital Debility. 

The first group is probably the least important, while birth injuries are 
frequently the cause of more or less serious illness, which often results in the 
death of the child. Omitting the danger of infection from the birth canal, 
hemorrhages from vital organs (the central nervous system and its cover- 
ings, the adrenals, etc.), either as a result of congestion or injury following 
the use of force in difficult labor, are apparently common to both of the 
first two groups. 

Congenital debility is not confined to premature infants alone, although 
it is much more common among them than in others. Under congenital 
debility is included functionally retarded development of a degree which 
imperils the life or development from birth, even though it be given the 
same care, in the way of suitable temperature, breast feeding and freedom 
from infection, under which children normally develop. Space will not 
permit us to enter into the pathology of congenital debility. We can only 
call attention to the fact that its diagnosis must be confined to those cases 
in which an abnormally labile temperature, a reduction of the respiratory 
rhythm and often a marked disturbance of reaction to all physiologic 
stimuli can be shown. The early death of a new-born infant as a result of 
artificial feeding, or of infection and the like, cannot be laid to congenital 
debility, if we do not wish to make this diagnosis the "catch all" of diag- 
nostic uncertainties and imperfect observations. 

That the morbidity of infancy is governed by artificial or unnatural 
feeding cannot be repeated too often. The experience of physicians teaches 
this incontrovertibly, and not only that the more or less severe disturbances 
of nutrition or gastro-intestinal diseases occur almost exclusively in arti- 
ficially-fed infants, but that this is true also of the development and the 
severity of the numerous parenteral infections of the skin, the respiratory 
system, the uro-genital tract, etc. 

As examples, which might be multiplied without end, it suffices to 
mention furunculosis and numerous other purulent infections of the skin, 
lobular and hypostatic pneumonia, cystitis and pyelonephritis. The same 
relationship appears in the cachectic types. Spasmophilia, the exudative 
diathesis, rickets, etc., exhibit much more serious manifestations in the arti- 
ficially-fed infant than in the breast-fed child. 

The frailty and low resistance of the infant, as compared with older 



96 TEXT-BOOK OF PEDIATRICS 

children, have always been proper subjects of special attention. Emphasis 
should be put, however, upon the fact that the normal healthy child with 
suitable food and care, beginning with a sufficiently long period of breast 
feeding, does not exhibit nearly so great morbidity as one might be led to 
suppose by the high mortality statistics. 

Why artificial feeding, even when the weight curve shows that it is 
conducted to good results, should increase the morbidity of the new-born 
and of older infants so markedly and should lower their immunity so 
distinctly has not yet been determined. Whether feeding with human milk 
produces a sort of passive immunity by the constant supply of antibodies 
from the mother's milk, or whether the artificial food prejudices the chemical 
integrity and consequently the functional resistance of the infant organism, 
are questions still under discussion, the solution of which, however, will 
not materially alter clinical methods. 

The infant escapes a certain number of diseases, because even with the 
poorest of care he is not exposed to certain of the dangerous injuries of 
later life. Among these may be mentioned traumatic diseases, the results 
of exposure to inclement weather and, particularly, the lesser opportunity 
of contact with a variety of infections, so long as the child lies quietly in 
his bed. After the first year, in fact as soon as the child begins to creep 
and comes more frequently into contact with his surroundings, all this 
is changed. 

Dirt and contact infections, in fact, reach their maximum in the second 
and third years. Of these, diphtheria, pertussis, contagious impetigo, 
aphthus stomatitis, various forms of angina, and tuberculosis, may be 
mentioned. Certainly it is not an accidental thing that most of these 
diseases have their primary localization or rather their port of entry in the 
mucous membranes of the mouth and upper air passages, to which the 
grimy hands and unclean toys or eatables passing from floor to mouth first 
bring their load of disease germs. Later another opportunity is freely 
given among the crowds of children in the kindergarten and the schools 
where they come into contact with one another in their play at a time when 
the prodromata of the acute contagious exanthemata may be present. 

It will be seen that there are all-important external influences which 
give a peculiar stamp to the morbidity of the run-about-age and of the 
early school years. Undoubtedly the school age, when the so-called school 
diseases appear, broadens the circle of infections which threaten the child. 
At this period, whether we have to deal with such diseases as scoliosis, 
myopia and other visual disorders, with headache, anorexia, disturbed sleep 
and the like; or with such distinct neuroses as hysteria, migraine, neuras- 
thenia, psychopathy, etc., it is always possible to find beneath the actual 
injury arising from school attendance, an existing and recognizable pre- 
disposition, or the influence of injuries traceable to home surroundings and 
training, which have played an important part. 

As the child approaches puberty, the disease groups of both sexes come 
to resemble more and more those of the adult. Early puberty shows a 
slight increase of morbidity as compared with the low morbidity of late 



MORTALITY AND MORBIDITY 97 

boyhood and girlhood. Aside from those disturbances which stand in 
direct relationship to the development of the genital organs, an increasing 
frequency of tuberculous manifestations, of certain infections, of functional 
heart diseases and psychic anomalies, are especially to be noted. These 
years are characterized, as we have already seen, by a marked increase in 
the rapidity of growth in height and by the development of various organs 
and their systemic relations. 

The relational study of the increased rate of growth and the greater 
morbidity of the years of development has suggested the theory that this 
rapid growth and the more rapid metabolism associated with it serve to 
increase the vulnerability of the tissues and organs to disease. The hypo- 
thesis is a very probable one and affords a possible explanation of many 
other observations; e. g., to cite but one instance, the localization of rachitic 
changes at the epiphyses, the point of the entire bone of by far the greatest 
measure of growth (Kassowitz). Much is still wanting by way of accept- 
able proof of this hypothesis to permit its use even as a working basis for 
the study of the relational operation of these factors in the living mechanism. 



V. GENERAL PROPHYLAXIS AND THERAPY 

REVISED BY 
ALBERT H. BYFIELD, M.D., 

Professor of Pediatrics, State University of Iowa, College of Medicine, Iowa City. 

(a) GENERAL PROPHYLAXIS - 

THE protection of the child from disease should begin before birth. The 
influence the physician can exercise in the prevention of congenital disease 
is usually very slight, even in the families of the educated classes; and 
among the uneducated there is a general want of responsibility for their 
progeny. It must be admitted, however, that rarely does the present in- 
complete understanding of the laws of heredity permit prediction, in a 
given case or with any degree of certainty, of children sound in mind and 
body. Particular attention should be called to the fact that the marriage of 
close relatives does not, in itself, endanger their offspring, and that ill 
results are observed only in cases of converging hereditary taint (Feer). 
Thus the prenatal protection of the child practically begins only after 
conception, and then only in so far as instruction and circumstances permit 
the mother to take such measures to safeguard her own health as are 
necessary to the well-being of her expected child. This volume is not the 
place in which such teaching may be given in detail; Mention might be 
made here of the possible relationship between the nutrition of the parents 
and that of the offspring, such as occurs in the animals. 

During delivery the child is in actual danger of injury by trauma and 
from infection. Further, it may be said that an injury during birth or from 
puerperal disease may so injure the mother that nursing becomes impos- 
sible and that child loses the mother's care. It is, therefore, desirable that 
infant welfare organizations consider the hygiene of maternity and espe- 
cially of the puerperium, as well as the direct care of the infant. 

It has been clearly shown in Chapter IV., that the greatest danger 
which threatens the life and health of the infant arises, directly or indi- 
rectly, from artificial feeding. Hence the most important prophylactic 
measure is a sufficiently long period of feeding with mother 's milk. 

The methods of breast feeding, even in cases where difficulties or dangers 
arise, are fully discussed in the second chapter. The spread of the propa- 
ganda for breast feeding by institutions for infant welfare will be fully 
described later. 

The avoidance of infection is an important feature of prophylaxis even 
in children. It must begin in the new-born. Even though purulent infec- 
tions of the umbilicus do not have the importance which was formerly 
assigned to them, tetanus of the new-born, which is always avoidable, 
undoubtedly has its origin in the umbilical wound. Ophthalmia neonatorum 
is equally preventable and it should therefore be made the duty of the 



GENERAL PROPHYLAXIS AND THERAPY 99 

physician and of the midwife to use the Crede instillation in all cases even 
where gonorrheal disease of the mother can be absolutely excluded. The 
physician should be careful to see that this order is carried out. 

The organisms of infection to which the infant is exposed find entry 
through the mucous membranes of the upper air passages and mouth. 
Among these infections we may mention rhinitis, tonsillitis, pharyngitis, 
bronchitis and influenza. 

Generally speaking, all of these diseases run a more severe course in 
young infants, and especially in children artificially-fed or suffering with 
disturbances of nutrition. It is therefore necessary to guard such children 
against these infections in every possible way. This is measurably and 
readily possible because these diseases are favored or induced by climatic 
influences. Obviously, this method of contagion is not of major importance. 
Usually, these infections are carried to the child by the adults of the family. 
Therefore, the most effective measure would be to keep persons suffering 
with any of these diseases entirely away from the child. This is practical 
so far as other sick children of the family are concerned and should be 
achieved as thoroughly as the circumstances of the home will permit. Of 
course it is not always possible to replace adults to whom the care of the 
infant is entrusted. Nevertheless, the danger of the spread of contagion 
by adults may be definitely reduced by proper precautions prescribed by 
the physician. Since the infection in the above diseases is spread either by 
the hands of affected persons soiled with infectious material or by particles 
sprayed into the air, not only by coughing and sneezing, but even by 
speaking, laughing, etc., it may be avoided by the exercise of due care. 
This, of course, implies that infected material must be kept not only from 
the child's person, but also from all such objects as clothing, pacifiers, 
etc., with which the child comes in contact. 

In normal children the predisposition to this group of diseases tends to 
diminish with increasing age ; so that we may fairly say that children who 
are infected every time they come in contact with an adult suffering from 
any of these respiratory disorders have a pathologic predisposition or are 
so-called susceptible children. This class will be more fully discussed later. 

Even with careful training the majority of children do not learn to use 
mouth-washes and gargles correctly before the fourth or fifth year. The 
most important prophylactic measure against infection is, therefore, to 
keep children away from any source of trouble. To carry out this measure 
successfully it will be found necessary to accustom the child, even when 
well, to refrain from unnecessary caresses and the like. 

All this is equally true of the so-called diseases of childhood; the acute 
exanthemata, diphtheria and pertussis. These diseases, likewise are 
transferred only by close contact with those suffering with them or by 
contamination from their secretions. Since, with the exception of diph- 
theria, one attack usually confers immunity, it is readily seen that adults 
spread infection only as carriers and that the greatest danger to the child 
lies in contact with diseased children. Day nurseries, kindergartens and 
schools offer the most frequent opportunities for contagion. The spread of 



100 TEXT-BOOK OF PEDIATRICS 

measles and pertussis is increased by the fact that these diseases are con- 
tagious in their prodromal stages. Danger in diphtheria lies in the fact 
that in many cases there are no characteristic symptoms. It is the duty, 
therefore, of parents, a duty which the physician should impress upon them, 
to keep children at home when they are ill or even under suspicion of disease 
in order to protect their playmates and school fellows. 1 

If any such disease makes its appearance in a family in which all of the 
children are not immunized by previous attacks, every possible precaution, 
of course, must be taken by the complete isolation of the patient, and this 
isolation should extend to the objects used by him and should include 
adults who nurse him. Under such circumstances infection is carried 
much more readily by the adult because of the frequency of exposure, than 
it is if contact is only occasional and for a brief period. For this reason, the 
physician is less often a carrier than the mother. When the question arises 
of removing other children from the home to place them in the care of 
relatives, we must consider not only any obstacles which may exist to their 
effective care and isolation in a new abode, but also the possibility that 
they themselves are in the incubation period of the disease. It is always 
best to keep such children away from other families where there are children 
who might be endangered by exposure to disease. As it is practically 
impossible to guard children, in a large city, at least, from the acute exan- 
themata, it may be as well to resort to extreme prophylactic measures 
only for those whose health would be especially jeopardized as a reason of 
their age or because of latent tuberculous foci (or other influences tending 
to lower resistance). 

A peculiar method of disease conveyance is exemplified in the so-called 
dirt infections which are most common during the second and third years. 
Children creeping about the floor and putting soiled toys and dirty hands 
in their mouths, may contract diphtheria, pertussis, impetigo, aphthous 
stomatitis, angina, and occasionally tuberculosis, in this way. The only 
means of combating this mode of infection is by training the child and, 
while the child is still too young for this, by the most scrupulous cleanliness of 
the room, toys, and utensils. This may be accomplished most successfully 
by the use of pen shown in Fig. 10. 

The prevention of tuberculosis during childhood is largely a question of 
a sanitary home and the proper hygienic care of the child and of tubercu- 
lous adults with whom the child comes in contact. Since this can be but 
partially achieved in a large population and then only with considerable 
difficulty, the most reliable method of prophylaxis lies in the absolute 
isolation of the tuberculous member of the family. This is best accom- 
plished by placing the infected individual in a sanatorium. If this is not 
possible and if the hygienic conditions in the home are not good, the danger 
of contagion is very great, as is evidenced by the high incidence of the 
infection in the children of the proletariat of the larger cities. The danger 
of tuberculosis for the child in the school is but slight. The experience of 

1 The problem of diphtheria carriers and the detection of them is more fully dis- 
cussed under "Diphtheria" in the chapter on Infectious Diseases. 



GENERAL PROPHYLAXIS AND THERAPY 101 

school physicians has shown that the number of children of school age with 
open tuberculosis is extremely small. The danger that the teacher may be 
the source of infection must be considered as much more likely. It should 
be remembered, furthermore, that the danger of infection comes not alone 
from members of the immediate family, but also from such other residents 
in the house as servants, governesses, tutors, lodgers, etc. The necessity of 
a more careful survey of the health control of these people than is usually 
made will be readily recognized. Parents have been known to actually 
take their children to visit friends or relatives suffering with advanced 
tuberculosis. It is equally evident that healthy children may be infected 
with syphilis by a luetic wet-nurse or any other servant, a danger to be 
safeguarded by careful medical examination of those employed. 

Besides these prophylactic measures, the lessening of the predisposition 
to disease by improvement of the general constitutional resistance offers 
the largest possibility of success. As already shown, children are not alike 
in their susceptibility either to tuberculosis or to the ordinary diseases 
which arise from common "colds;" an evident tendency to disease may 
entirely disappear in some children during early childhood, whereas in 
others it remains almost unchanged even through the school age. These 
latter not infrequently have parents who themselves as children suffered 
with similar catarrhal infection. It would seem that this heightened 
susceptibility of children to these respiratory troubles can be traced back to 
some unusually severe or long drawn out acute infection which occurred 
early in the child 's life, which left a locus minon's resistentice which endures 
for many years. That chronic infection may reside in the nasal accessory 
sinuses seems to have been established beyond question. In such cases it is 
necessary to try to avoid those conditions which will stir up these respira- 
tory infections or cause new ones. The method of feeding, plays a very 
important part even beyond infancy. As overfeeding is a cause of great 
danger to the infant, so diets containing an excess of protein or fat tend, in 
children with a special predisposition to catarrh, to aggravate and to 
lengthen the duration of the attacks. Czerny has laid particular emphasis 
upon this factor, often under-estimated even by the physician, in his 
treatise on exudative diathesis. He notes that such children do best upon a 
diet largely vegetarian. [It should not be forgotten that a sufficient quantity 
of milk, preferably poor in fat must be included in order to supply the 
calcium phosphate and other salts necessary for growth.] 

The aim with such children should be to develop good resistive powers 
by methods which need adaptation to the individual case. As a result of 
the theory that most of these catarrhal conditions are the result of "catch- 
ing cold, " it has been thought necessary merely to accustom the patient to 
cold or rather to temperature changes and this has led to an unbalanced 
and excessive use of cold water treatment. We know now that this method 
should be employed sparingly in susceptible children, if it is to be useful 
rather than harmful, and that any rapid cooling of the body-surface by 
douches, baths, cold sponging, etc., which is not immediately followed by a 
vasomotor reaction and a feeling of warmth, may directly provoke or 



102 TEXT-BOOK OF PEDIATRICS 

aggravate catarrh and may exercise a bad influence upon the nervous sys- 
tem. The child may be hardened more safely and more easily by accus- 
toming it to remain in the open, even in variable and cool weather. H^ere, 
also, extreme and continued cooling of the body is to be prevented by 
sufficient clothing and exercise. The clothing should not be so heavy as to 
be impermeable to air, and the head and neck, in particular, should be 
covered but lightly. It is not wise to send children out to play with bare 
legs and in thin clothing in cold weather. 

The unquestionably favorable influence of fresh air depends not alone 
upon the direct action of the cold, but also very largely upon the effect of 
air currents and the greater amount of sunlight. Both of these agencies 
produce effects just opposite to that of cold, in that they serve as stimuli to 
the peripheral circulation. A happy combination of these factors is the 
probable cause of the favorable effect of sea air even in children for whom 
cold-sea-bathing should be prohibited. Doubtless, the much greater out- 
door acti vity, the resultant muscular exercise and an increased metabo- 
lism play a combined part, scarcely to be over-estimated, in this process 
of hardening. 

In exudative children, training plays an even more important part than 
it does with children in general; 'because the frequent and inconsequential 
illnesses of these individuals may in themselves lead to errors of manage- 
ment which in their turn develop those neuropathic tendencies which are 
often latent in them. It is absolutely necessary that such training should 
be continuous. It is very important that they be not permitted to look 
upon illness as a pleasant and desirable experience because of the excessive 
care and tenderness that are lavished upon them in such events. Ma- 
lingering to avoid school attendance and other unpleasant and even hys- 
terical manifestations, may result from grave errors in training. If this 
viewpoint cannot be sufficiently impressed upon the child 's parents it may 
become necessary in extreme instances to advise a change of environment. 

Not only exudative and neuropathic but rachitic children as well, 
require special prophylactic measures to guard them against serious com- 
plications. Of these, scoliosis is the most important because of the dif- 
ficulties of its later treatment. Since this condition is due in the majority of 
cases to long continued and unchanging position, special emphasis should 
be put upon the frequent shifting of position, carrying the infant first on 
one arm and then upon the other, and supporting it so that no bending of 
the vertebral column can occur. For children in their second year, who are 
accustomed to sit without support, the rocking-chair designed by Epstein 
(Fig. 21) is very useful, because it forces the child to employ the muscles 
of the back to keep its balance while rocking and by keeping the arms 
high, to hold the back straight while at the same time the weight of the 
body is taken from the legs which may at times be necessary and it 
is impossible for the child to sit with them doubled under him. For older 
children, a rocking-horse or a swing may serve the same purpose. System- 
atic massage may be used successfully. 

The child welfare movement is of recent origin and has for its purpose the 



GENERAL PROPHYLAXIS AND THERAPY 103 

prophylactic protection of children. Interest in infant welfare has been 
aroused, on the one hand, by the well-established fact that infant morbidity 
and mortality did not show the distinct decrease recorded during the last 
few decades and, on the other hand, by the absence, at least in European 
countries, of a normal increase in population resultant upon the diminished 
birth rate. (See Chapter IV.) 

There are two problems, in particular, with which infant welfare work 
is chiefly concerned. It has been shown that the high infant mortality is 
found largely among the artificially-fed. In the course of the last decades 
a reduction both of the number of nursing mothers and of the length of the 
nursing period has occurred almost everywhere. This is due not so much 
to a lessened interest in children and their welfare as it is to a false estimate, 
among all classes of the people, of the effectiveness of artificial feeding and 
of the extent to which it may replace 
breast feeding. 

It should not be forgotten that an 
overvaluation of sterilized infant foods 
and the development of a huge indus- 
try for the manufacture of artificial 
foods (preserved, sterilized, and evap- 
orated milk and infant foods, flours, 
etc.), almost all of them heralded in 
the advertisements as the "best" or 
"perfect substitute for mother's milk, " 
have contributed their harmful influ- 
ences in lessening breast feeding. 

Those artificially-fed infants who 
are denied not only their natural food 

, , , 11 rio. 21. Epstein s rocking-chair. 

but a mother s care as well are in great- 
est danger. The increased participation of women in the various industries, 
in so far as it leads to the mother's absence from home, has developed a 
serious menace which threatens the health and life of infancy and the nor- 
mal growth and training of older children. Not only does the alarmingly 
high mortality among infants and the neglect of older children stand in 
direct relation to this great question, but domestic poverty, the abuse of 
alcohol, the development of tuberculosis and social evil in general are closely 
associated with the necessity of wage-earning by the mother with its conse- 
quent disruption of the family. 

Accordingly, the work attempted by infant welfare organizations 
should include first of all an efficient propaganda for breast feeding aided by 
the teachings of physicians in private practice, free dispensaries, the activ- 
ities of visiting nurses in the homes of the people, the distribution of 
pamphlets, public lectures, as well as direct appeal, as for example, by the 
offer of prizes to nursing mothers. It would be well worth while to offer 
special training to physicians and nurses who after all are the most efficient 
agents in this propaganda in order that they may be best fitted to carry out 
their work in this new and special field of social endeavor. 




104 TEXT-BOOK OF PEDIATRICS 

The second and, in the interim, an equally important task lies in the 
improvement of the methods of artificial feeding or, at least, in the decrease 
of its dangers. In this matter, individual and popular teaching are little 
less important than the provision of certified, bacterially pure milk for the 
poorer classes, either by milk laboratories or dispensaries, and the improve- 
ment of the general market supply of milk by careful inspection. The ad- 
visability of relying upon milk which has not been boiled is open to serious 
question. The actual work in this line is the more difficult because it must 
be so conducted that it will not discourage breast feeding, the attainment 
of which alone will insure the lasting benefits of infant welfare work in the 
economics of the nation. 

Finally, the third and most difficult task is the expansion and regulation 
of actual economic assistance in so far as it leads to the complete protection 
of the infant. Special emphasis must be laid upon the fact that the sepa- 
ration of the mother and infant must be prevented by adequate aid to the 
mother and that when this is impossible the child should be placed in an 
institution where it will receive proper and continuing care. The law 
fixing the responsibility of the father for at least the provision of food for 
his illegitimate children has proved successful. Lying-in-hospitals where the 
nursing mother and child are cared for and housed for a sufficiently long 
period serve beneficently the welfare of both. Physicians experienced in 
infant welfare work should see to it that the laws provide generous financial 
assistance, enough to amply cover all the needs of the infants and that the 
best of care be given those who are placed either in such institutions as day 
nurseries or infant asyla. Wherever there is overcrowding, babies are 
exposed to the dangers of respiratory infection. In estimating the value 
of any of these modern attempts at infant welfare work, which often rep- 
resent great pecuniary sacrifices, alike on the part of the charitable 
giver and the taxpayer, we must always remember that their aim is not 
only to preserve the lives of a certain number of infants, but also to guard 
the survivors from serious and irreparable physical and mental injury. This 
latter is probably the more important result and fraught with larger 
consequences to the nation. 

The care of children of the run-about-age has been provided for by wel- 
fare organizations, lay associations and large industries by means of day 
nurseries, schools and the like; but this aid is still inadequate in many 
respects. As we have already suggested, the lack of proper physical care 
during this period may not cause any marked increase of mortality but it 
does produce a high morbidity. The after-results of disease and of errors in 
feeding during infancy are brought out with particular prominence during 
this period. Rickets especially becomes aggravated and results in more or 
less irremediable deformities of the extremities, the spine, the thorax, etc. 
Perhaps there should be included here "bony cavities of the face " deform- 
ities which may play a part in causing chronic nasal infection. It is at this 
age that careless training produces its most injurious consequences, because 
it is a time in which the foundations of character are laid and when the 
counter influences of the school are lacking. 



GENERAL PROPHYLAXIS AND THERAPY 105 

Children of school age are provided for in many ways. In the building 
of the newer type of school-houses much more consideration is given than 
formerly to air space, heating, ventilation and lighting. Light should not 
only be adequate but should fall over the child's shoulder. Many new 
schools are indeed models from a hygienic point of view. By providing 
abundant daylight, proper fixtures for artificial lighting and large print in 
school books, myopia, a school disease, is measurably avoided. The hygien- 
ically correct arrangement of the desk, with proper distance between seats, 
with suitable backs, and writing surface should prevent incorrect postures 
from which scoliosis may arise. It should be emphasized that permanent 
scoliosis is a definite deformity, generally rickitic in origin, which may still 
be corrected at the period when the child enters school. 

To safeguard the school from the dangers of infection it is sufficient to 
prohibit the return of convalescents until the period of contagion has 
entirely passed and to exclude early all children suspected of communicable 
disease. The school physician should be the ad visor of teachers and 
parents upon questions of hygiene. He should call their attention to any 
diseases or abnormalities which he may discover in the child. Doubtless by 
this means a large number of children will receive timely medical attention 
which, but for the school examination, they might have lacked. School 
inspection is an important prophylactic measure. 

Children with defects of the sense organs and the seriously crippled 
should be cared for in special institutions. Subnormal children should 
receive training graduated to their ability in separate schools. For physi- 
cally weak school children and particularly for those who show indications 
of tuberculosis, open-air schools, or classes, have been established in many 
communities. Philanthropic associations provide for children in summer 
vacation camps in the country, in the mountains or by the sea. 

An old question, frequently leading to heated discussions, based more on 
sentiment than on actual knowledge, is that of overwork in the schools. 
It is not to be denied that children who are weak, sickly or neuropathic are 
easily tired, but it is hardly to be expected that schools for normal children 
can reduce their standards or change their methods out of consideration for 
a few abnormal individuals. The selection and classification of subjects 
taught, on the one hand, and, on the other, the grading of school children 
and the demonstration of their degrees of educational progress are naturally 
and must remain the problem of the pedagogue or of the school authorities. 
The attempt has often been made to prove overwork in the schools by an 
experimental demonstration of the children's weariness. The results so 
obtained cannot be accepted without further corroboration. Careful 
medical observation, which alone may competently decide the question, 
records no signs of overwork in the healthy child. The real cause of the 
difficulty, commonly laid to the school, is generally a matter of improper 
home training. Improper feeding of the child may also be a not insignif- 
icant cause of school fatigue. The role of actual underfeeding, unbalanced 
diets, bad eating habits is just at present being realized. When this is not 
true and when the child cannot keep up his school work in spite of suitable 



106 TEXT-BOOK OF PEDIATRICS 

home conditions, there appears no other alternative but to give him more 
time to do the required task, or to put him in lower grades where the work is 
easier. For the children of the well-to-do, who for obvious reasons decline 
these alternatives, there are numerous training institutions or schools which, 
while costly, secure good educational results by wise individualization and 
scrupulous physical care. 

With legal safeguards against abuse and industrial exploitation and 
with the work of humane societies in caring for neglected children, the list 
of agencies for the protection of the child is complete. The delinquent child 
is also coming in for his share of study and treatment. 

(6) GENERAL THERAPY 

If the well-known axiom of all therapy that we must treat the patient 
and not the disease is recognized, it means that not only do numerous 
variations in the course of disease present indications for differing thera- 
peutic measures, but that over and above all other considerations, the 
individuality of the patient must be studied. It will be readily understood 
that the therapy applicable to childhood and more particularly to infancy, 
presents special problems incident to the peculiarities of the infant organism 
and to the pathology of childhood. 

In the child certain symptoms or symptom complexes are characterized 
by their frequency or by their unusual clinical importance ; and these, with 
the therapeutic methods adapted to them, will be discussed. The question 
whether and to what extent, in a given case, a symptom may be combated 
symptomatically must be left for inquiry to the special chapters of the book. 

Fever. If fever cannot be treated locally, as by incision of abscesses, 
by paracentesis in purulent otitis media, or by the water diet in alimentary 
fever, it may be treated symptomatically by the avoidance of food to pre- 
vent heat production or by the more commonly practiced attempts to 
increase heat dissipation. 

The fact that the child is so much more easily handled than the heavy 
adult and that the bath for the child is more simply and easily prepared, 
makes it possible to use this cooling agent more freely than in later life. A 
bath at 30 C. (86 F.) or warmer, continued for a long period, is more 
efficacious than one in which the water is at 20 C. (68 F.), or colder, which 
while it produces a rapid cooling of the surface, yet on account of the con- 
traction of the skin capillaries to the point of pallor, or even cyanosis, 
secures only a minimal cooling of the deeper tissues. Even baths at 35 C. 
(95 F.) the temperature of the cleansing bath, without the addition of 
colder water, will have a cooling effect, the difference between this temper- 
ature and that of the fevered body of the child being great enough to 
produce sufficient reduction of the body-heat in five to ten minutes, a 
reduction moreover, which is lasting. Even a large clinical experience does 
not enable one to predict in a given instance the amount of the cooling 
effect of a bath; so that a definite time limit is not justified. Since the skin 
temperature while in the bath is misleading, it may be well to interrupt 
its application in order to take the actual (rectal) temperature and deter- 



107 

mine whether the bath should be continued. Frequently the general 
condition of the child, the clearing of the sensorium, the improved heart 
action, or on the other hand, the appearance of chilliness, will suggest that 
the temperature has been sufficiently lowered. 

The desired effect may be secured by moist packs or may be attained in 
a simpler manner, which in many cases is quite sufficient. With the moist 
pack it is not advisable to prescribe the exact temperature of the water 
because it is impossible to control its changes during preparation. For an 
infant it suffices to have the water at room temperature or better still, 
somewhat warmer. Only with older children should water below 20 C. 
(68 F.) be used and then only rarely. As a rule, cooling packs are applied 
only to the trunk, leaving the arms free; but, with high fever, when a full 
bath is impracticable or is contraindicated, the extremities may also be 
included in the pack. 

The sheet intended for the pack should be of six or eight thicknesses and 
should be wrung dry enough to prevent dripping. It may be covered with 
a loosely woven woolen or knitted blanket so that evaporation from the 
pack may occur gradually. The cooling effect depends chiefly upon this 
evaporation. So soon as the pack becomes dry it prevents the radiation of 
heat and therefore it should be changed at once or, if the child cannot be 
moved, it may be moistened again by carefully pouring water over it. If 
the pack is to remain in place for a long time it is well to protect the skin 
from irritation or infection by its inunction with a bland ointment. 

A very harmless, but less active form of cooling is achieved by the use of 
moist compresses to the thorax, to the abdomen, to the head, or to the 
arms and legs. Cold sponging of the skin also comes under this head. It is 
especially valuable in those cases in which the child, on account of the 
nature of its disease, must be kept as quiet as possible. In the use of the ice- 
cap, which is best avoided with infants, care must be taken that too great 
cooling does not take place. Cold water enemata have sometimes been 
recommended in the treatment of hyperpyrexia. 

In comparison with these hydrotherapeutic measures, medicinal agents 
for the treatment of fever in young children occupy a less important place. 
Such antipyretics as acetylsalicylic acid, antipyrin, dimethyl-amido- 
antipyrin, etc., are of advantage only when their use is dictated by their 
more or less specific action in certain infections, such as influenza, rheuma- 
tism, some cases of tonsillitis, etc., or when they are simply used to pro- 
voke perspiration. Preferably physicians prescribe quinine or one of its 
less bitter derivatives, a practice justified by the fact that quinine not 
only increases heat radiation but also decreases heat production. These lat- 
ter drugs are little used in this country to control fever. 

Antipyretics are more widely used for older children, but even then only 
in those who suffer from severe subjective symptoms consequent upon 
fever. In these cases it is often possible to relieve the sleeplessness, anorexia, 
headache, pain in the limbs, etc., more completely and more easily by an 
antipyretic than by the use of baths or packs. 

The use of alcohol, even though it has a cooling effect through its dila- 



108 TEXT-BOOK OF PEDIATRICS 

tion of the peripheral circulation, and although it produces a certain 
euphoria by its narcotic action, should be scrupulously avoided in children 
of every age. It may be used as a stimulant in threatened collapse and may 
be countenanced in those cases in which an increase in the volume of the 
respiration is desired; but even in these conditions, other remedies may well 
be used. It is necessary only to remind the reader that besides combating 
the fever, good care and proper feeding must be given due attention. 

Most of the medicinal agents noted, as well as the hydrotherapeutic 
measures employed against fever, have a tendency to cause sweating 
whenever the loss of heat is prevented by the clothing covering the patient. 
This is a therapeutic effect often sought in children, but with respect to it, 
two precautions must be taken. First, it is not permissible to give infants 
large quantities of milk to produce perspiration. Some form of hot tea, 
possibly sweetened with benzosulphinidum (saccharin) may be given 
instead. Plain or sweetened water is the American equivalent for the 
commonly used tea of German authors. Second, all methods of inducing 
heat production or preventing heat radiation are contraindicated in spas- 
mophilic and lymphatic children, since these measures may readily cause 
hyperpyrexia and heart lesions. Pilocarpin is used for children as a last 
resort and then only in those whose heart action is strong. 

For combating subnormal temperatures, the same methods are used as 
are designed for their prevention, viz., the incubator, the warming tub, 
hot water bottles, etc. The use of the incubator and of Crede's warming 
tub is, of course, limited to suitably equipped institutions. In the home 
any large bottle which can be securely corked may be used. The attention 
of the mother or the nurse must be called to the danger of scalding the infant 
from a leaking bottle or of burning it by direct contact with the hot bottle 
insufficiently wrapped. This accident may also occur with the various 
forms of electric heating pads. When it is necessary to warm the child rap- 
idly the hot bath is to be preferred. Such a bath may be begun at a tem- 
perature of 35 or 36 C. (95-97 F.) gradually increased by the careful 
addition of hot water to 40 C. (104 F.), or even more. During this bath 
the child should be supported with the left hand while it is rubbed energet- 
ically with the right. 

Since a subnormal temperature is usually accompanied by other mani- 
festations of collapse, and particularly by cardiac weakness and a dimin- 
ished reaction to stimuli, it is customary to counteract the analeptic action 
of the hot bath by dashing cold water over the chest or back. Slapping the 
skin with a cloth dipped in cold water serves the purpose equally well. These 
methods, like the use of the mustard bath or pack, do not lessen the bene- 
ficial effect of the hot bath, but on the contrary they stimulate the cardiac 
and respiratory activity. Subnormal temperature frequently indicates 
dehydration, demineralization or both. Saline or Ringer's solution by 
mouth or per rectum will often cause a return to normal of the temperature. 

A mustard bath is prepared by placing four or five tablespoonfuls of 
ground black mustard in a muslin sack and steeping this in hot water for 
several minutes. By this means strong mustard vapors are given off which 



GENERAL PROPHYLAXIS AND THERAPY 109 

are irritating to the mucous membranes and may increase an existing 
bronchitis. For this reason the mustard bath has been almost entirely 
replaced by the mustard pack, the use of which is described under capillary 
bronchitis. The mustard pack cannot be used with lymphatic children or 
for those with widespread eczema. In mild cases or in emergency, when 
neither the hot bath nor the mustard pack can be prepared quickly enough, 
the warmth of the skin and the resulting stimulation of the circulation may 
be promoted by rubbing the body energetically with the bare hand or with a 
dry cloth or, even better, by rubbing the surface with spirits of mustard, 
camphor, a volatile liniment, or a mixture of equal parts of alcohol and oil. 
As internal remedies, alcoholic stimulants and black coffee are readily 
obtainable. What has already been said about alcohol applies here as well. 
Its stimulating action is transitory and since it is certainly not beneficial 
to the gastric mucosa it were better avoided altogether. There is no danger 
in using coffee, as hot as possible, in the form of an enema. It warms the 
patient and at the same time has a stimulating effect. Even when given 
in large quantities, it is not followed by paralysis or by any other symptoms 
of poisoning. Free use of it, even in infancy, may be strongly recommended. 
In comparison with coffee, the stimulating action of black or green tea is 
too slight to justify its therapeutic use. 

Medicinally the circulation may be stimulated most quickly and 
effectively by the subcutaneous injection of camphorated oil. Even in 
infants not less than 0.5 c.c. (7 minims) and even 1-2 c.c. (15-30 minims) 
may be used. If necessary, these doses may be repeated every hour for 
days at a time. Care must be taken, however, when so frequent medication 
is employed, that the injections are not made too closely together lest they 
cause necrosis and, in cases of existing bacteriemia, abscesses. 

Caffein, with sodium benzoate, may be given to infants of six months, 
or over, in doses of 0.03 gm. (^ gr.); in doses of 0.06 gm. (1 gr.), during 
the second and third years; or 0.1 gm. (2 grs.), during the fourth to the 
sixth year; and in children of school age, 0.15-0.20 gm. (2-3 grs.), three to 
four tunes a day. Such doses may be prescribed in a ten to twenty per cent, 
solution in sterile water. Its action is quick but not lasting. 

For very rapid results, epinephrin, is very useful. From 0.2-0.3 c.c. 
(3-5 minims) of a 1 : 1000 solution may be used for one intramuscular injec- 
tion in infants. Still larger doses may be given older children. As an 
adjuvant to the intravenous transfusion of saline solution it meets with 
insuperable technical difficulties in young children, but Pospischill has 
succeeded in the subcutaneous injection of as much as 60 drops, in 150 c.c. 
of physiologic salt solution, as often as two to four times a day, in 
older children. 

Digitalis acts more slowly and, therefore, for a longer time. An infusion 
of digitalis 0.3-0.5 gm. (5 to 8 grs.) in 100 c.c. (3 ounces), for infants and even 
more for older children may be used within a period of three days. On ac- 
count of the cumulative action of digitalis it is necessary, if the drug is used 
for a long period, to alternate its exhibition with intervals of withdrawal. 
During these intervals the tincture of strophanthus (1-5 drops, every three 



110 TEXT-BOOK OF PEDIATRICS 

hours), or caffein may be given. Instead of the infusion of digitalis, digalen, 
digitoxine soluble or a solution of digipuratum may be used with good 
results. Of either of these preparations two or three drops may be given 
to infants, and ten or twelve to older children, three times daily. Sterile 
digalen and digipuratum, or similar preparations, are obtainable in ampules 
and may be injected intravenously or intramuscularly if more rapid 
absorption is desired. Their influence upon the circulation is decidedly 
less marked than that of the infusion but it is equaHy necessary to watch for 
its appearance and especially for the possible retardation of the pulse. The 
effect of drugs of the digitalis group is often difficult to estimate, especially 
in young children and the dosage therefore will depend on conditions. The 
quantities given above are to be regarded as average doses and more may be 
freely given usually in vain where severe cardiac collapse is apparent. 

All of the so-called heart stimulants act, also, as stimulants of respir- 
ation, but they fail in cases in which paralysis of respiration is the most 
prominent symptom, as indicated by the alternation of respiratory pauses 
and periodic breathing while the heart action remains actually or relatively 
strong. In such cases the inhalation of three litres of oxygen a minute, for 
five or ten minutes, repeated two or three times in an hour, may relieve 
the exhausted expiratory centre and by relieving it and thus increasing 
the oxygenation of the blood may interrupt a dangerous vicious cycle. 
With the exception of laryngeal stenosis, I have, however, scarcely ever 
observed a permanent result even if oxygen is given in large quantities al- 
though temporary benefit was achieved. 

If the disturbance of respiration is due to obstruction of the nasal 
breathing, often occurring in young children who experience some dif- 
ficulty in learning to breath through the mouth, relief may be obtained 
by the mechanical cleansing of the nose with a dry cotton applicator, or 
with cotton saturated with glycerin, or, if there is much swelling, with 
epinephrin. Cotton tampons, moistened with a fresh solution of epineph- 
rin 1 : 3,000 may be placed in the nostril after it has been cleaned. Seri- 
ous obstruction of respiration in the larynx may necessitate intubation 
or tracheotomy. 

In infancy the problem of preventing a dangerous loss of water from the 
body or of stopping such loss as quickly as possible often presents itself. 
The most simple method, that of permitting the child to drink large quan- 
tities of physiologic salt solution, 2 or of slightly alkaline mineral water, or of 
weak tea containing salt, is often thwarted because the seriously sick child 
refuses fluids or because of persistent vomiting. In these cases, it is often 
possible to obtain the same results by repeated rectal injections of these 
solutions, in quantities of 50-100 c.c. (13^-3 ounces) at body temperature, 
by means- of a Nelaton catheter introduced as far as possible. To prevent 
the immediate expulsion of the fluid, the nates should be gently pressed 
together for several minutes. If it proves impossible to secure the absorp- 
tion of sufficient fluid from the bowel by this method, enteroclysis, a more 
elegant method of administration, may often be employed successfully. 

2 For the explanation of the reason for the addition of salt, see Chapter I, page 18. 



GENERAL PROPHYLAXIS AND THERAPY 111 

The apparatus for enteroclysis consists of an irrigator with a long rubber 
tube, controlled by a glass stop-cock with a catheter attached to it. The 
catheter is passed as high as possible into the rectum and held in place by 
adhesive straps. The flow is regulated by means of the stop-cock, so that 
30-40 drops a minute, or 90-120 c.c. (3-4 ounces) an hour are instilled. By 
this method it is possible, without causing distension, to give 200 c.c. (6 
ounces) several times a day. Any of the solutions mentioned above may be 
used or, to avoid the pyrogenetic action of the sodium chloride, Ringer 's so- 
lution (sodium chloride 7.5 g. ; potassium chloride 0.42 g. ; calcium chlo- 
ride 0.24 g. per litre) may be instituted. The rectal application of many 
other drugs may be practiced to the advantage of the patient. Sodium 
bicarbonate in 2-5 per cent, solution and glucose are frequently used. The 
latter substance is tolerated even by the infant in surprisingly high con- 
centrations. I have given up to 25 per cent, glucose solutions to infants 
without the least sign of irritation. 

The most rapid and certain method of increasing the fluids of the body 
is by hypodermoclysis, in which either sterile physiologic salt solution 
(0.7 per cent. ) or, preferably, Ringer's solution may be used. 

A large serum syringe or a canula, attached to a funnel by means of 
rubber tubing may be employed for the purpose. In infants who have 
lost much water, from 50 c.c. to 100 c.c. (lj^-3 ounces) may be introduced. 
This quantity may be injected gradually through a single puncture of the 
skin over the chest, abdomen or back by occasionally moving the needle. 
Its painfulness has reserved this method for extreme cases in which, how- 
ever, it is often the only means of saving the patient, when it may be re- 
peated as often as four times a day. The intraperitoneal injection of salt 
solutions is also now being practiced more than in the past. 

Frequently and under varying circumstances, it is found necessary to 
induce rapid and complete emptying of the intestinal tract. Enemata or 
colonic flushings empty the large intestines only and are especially efficient 
when it is necessary to remove hardened fecal masses from the lower bowel. 

In using the small rectal syringe, which carries 30-50 c.c. (1-1/4 ounces), 
the hard rubber tip should not be directly introduced into the bowel, 
because by any unexpected movement of the child serious injury may be 
produced. The tip should be armed with a Nelaton catheter or a rectal 
tube. This is also true of the hard rubber irrigator tip.. A rectal tube, 
which, even for the infant may have the circumference of the little finger, 
should be inserted as far as possible, the pelvis being propped upon a pillow 
with the child lying on its back or side. The nates should be pressed gently 
together after the injection, in order to hold the enema in the bowel for a 
little while to permit it to dissolve the scybala. 

The enema may also serve the purposes of a flushing. For this purpose 
it is better to use a funnel attached to the tube rather than the irrigator. 
The tube should be somewhat larger than that used in gastric lavage 
(q. v.}. A tepid physiologic salt solution, or astringent, laxative, anti- 
parasitic antiseptic solutions, etc., may be used according to the desired 
effect. Enemata of 30-100 c.c. (1-3 ounces) of oil will serve to soften scybala. 



112 TEXT-BOOK OF PEDIATRICS 

Glycerin, one or two teaspoon! uls with an equal quantity of water, is said to 
act as a stimulus to the peristalsis of the lower bowel. An identical result 
may be had by the insertion in the rectum of the well-known glycerin 
suppository, small forms of which, suitable for children, are obtainable ; or 
by the similar use of the soap stick, a common domestic device, of about the 
thickness of the little finger and from 3-5 cm., (1-2 inches) long, prepared 
from any ordinary laundry soap. 

The medicinal cathartics are much more satisfactory for the complete 
evacuation of the whole intestinal tract. For decades, calomel has unde- 
servedly ranked as the most popular cathartic. A dose of 0.01-0.05 gm. 
(3^5-1 gr.) may be given to the infant, and from 0.05-0.1 gm. (1-2 grs.) to the 
child of three years, or more may be given every two hours until results are 
obtained. That calomel has the obstipating effect ascribed to it when it is 
given in small and infrequent doses is a very questionable matter, since it is 
not an intestinal antiseptic. There is, however, no doubt that it frequently 
produces an intestinal irritation far in excess of its desired result and that it 
is injurious at least in so far as it increases the intestinal secretion which is 
very prone to decomposition and putrefaction. For this reason, it is 
hardly ever given to infants by the modern podiatrist. Its place has been 
taken by castor oil, a much less harmful remedy which young children take 
readily, especially if it has been thinned by warming it in the spoon. It 
should be given in sufficiently large doses of one or two teaspoonfuls at a 
time. Older children will take it without objection if the tongue is first 
covered with sweet chocolate or if the oil is given in the form of an emulsion 
with equal parts of the aromatic syrup of rhubarb as recommended by 
Henoch. Milk of magnesia can be used for those infants and children in 
whom the mildest laxative action is desired. 

Phenolphthalein, in tablet or candy form, is very efficacious in children 
of three years or more. It produces one complete evacuation of the bowels 
and is entirely painless in action. In younger children castor oil or, if 
necessary, the compound rhubarb powder will usually be found adequate. 

In older children, the saline laxatives may be considered, particularly 
in that degree of habitual obstipation which demands medicinal treatment. 
It is best to begin with one teaspoonful of artificial Carlsbad salts in a 
wineglassful of warm water, increasing or diminishing the dose as required. 
Syrup of senna may be used, but it is somewhat objectionable on account of 
the colic which it is apt to cause. 

For the forced emptying of the stomach emetics are seldom used now- 
a-days; since the result may be attained with less injury and more com- 
pletely by gastric lavage, which is technically simple in young children. The 
child is laid upon its side, with its face slightly downward, as shown in 
Figure 22, so that any vomited matter passing along the side of the tube may 
run off and escape aspiration the only caution that needs to be observed. 
The apparatus employed consists of a funnel of 150-200 c.c. (5-8 ounces) 
capacity, to which a catheter of about the diameter of a lead pencil is 
attached by means of a piece of tubing about a yard long. This should have 
glass connections but no stop-cock. In the infant, the catheter serves well 



GENERAL PROPHYLAXIS AND THERAPY 113 

as a stomach tube. Being passed directly to the posterior pharyngeal wall 
it causes slight gagging and then swallowing movements. The catheter is 
passed very readily. There is no danger of forcing the tube into the larynx 
and the first slight gagging soon stops if the tube is quietly held in place for 
a moment. The rest of the maneuver, the extraction of the stomach con- 
tents, and the washing with water or with physiologic salt solution at body 
temperature is carried out as it is in the adult. The tube must be moved up 
or down a few centimeters so that its eye dips into the fluid, instead of lying 




Fio. 22. Gastric lavage. 

in the air space above, the so-called "gastric bubble," in order to remove the 
last remnant of fluid used. A few large curds, which occasionally form in the 
atonic stomach, may escape the lavage, but for its therapeutic purposes 
this is of no great importance. The addition of various medicinal agents in 
lavage has not been found practical. The use of the stomach tube for pur- 
pose of feeding, where food cannot be taken or where it is refused, deserves 
especial emphasis. 

Of the various astringents employed in the treatment 4 of the diseased 
intestine, tannin is still in most common use. In irrigation of the bowels a 
.25 per cent, or .33 per cent, solution is preferred, but it reaches only the 
8 



114 TEXT-BOOK OF PEDIATRICS 

lower portion of the large intestine. To affect the entire tract, tannin must 
be given by mouth. Many modern preparations which pass the stomach 
more or less unchanged and which gradually liberate tannic acid in the 
intestine, such as diacetylic tannic acid, tannigen, tannalbin, tannoform, 
tannismut and others are available. Since any excess passes through un- 
changed it is not necessary to gauge the prescribed amount carefully. Bulk 
powder is usually ordered with directions to give a small quantity several 
times a day. As the powder is insoluble and rather bulky it is best given 
stirred into a thick gruel. 

A two per cent, of aluminum acetate maybe used for irrigation instead of 
the tannic acid solution. Starch enemata (1 teaspoonful of starch, in 150- 
200 c.c. (5-7 ounces water), water heated to form a paste. Of this solution 
30-50 c.c. (1-2 ounces) may be injected at body temperature. Although fre- 
quently recommended, it has no astringent action but may be used as a 
vehicle. The starch is supposed to act as a protection to the mucous 
membrane but this effect seems to be rather doubtful. 

Beside the tannin preparations, bismuth is often prescribed as a medi- 
cinal astringent. Bismuth subnitrate or subsalicylate suspended in muci- 
lage of acacia (20 gms. to 100 c.c.) may be given to infants in doses of 
0.2-0.3 gm. (3-5 grs.) every three hours. The stools become grayish-black 
from the bismuth and sulphur compound which is formed in the intestine. 
Tannismuth, colloidal bismuth oxide (Birmon), etc., are new preparations 
of bismuth which may be used. 

The anti-diarrhoeic action of these preparations depends upon their 
astringent action and their diminution of the secretions. Kaolin (bolus 
alba) and animal charcoal (carbo animalis) given in large doses [5-10 gms. 
(45 grs. 1 dram) in 100-150 cc. (3-5 ounces) of boiled water] three times 
daily has a different effect. It is of purely mechanical influence, due to the 
fact that the fine grains of the powder, thoroughly mixed with the intestinal 
content, prevent the access of the intestinal bacteria to their nutritive 
media and thus limit their fermentative action. Unless the intestinal canal 
is at least in part cleaned of its contents or unless no food is being given, 
little is to be expected of the bolus or charcoal therapy. 

Opium as an anti-diarrhoeic measure in children demands special dis- 
cussion. Its danger to the infant organism has been generally over-esti- 
mated and evidences of disorder which really belong to the picture of 
certain severe alimentary disturbances have been erroneously regarded as 
the result of small doses of opium. For this reason the use of opium has 
been generally condemned in young children. It is true that opium is not 
often indicated for its anti-peristaltic effect, but while it diminishes peri- 
stalsis and to a certain extent absorption, it does not in any way diminish 
the decomposition going on in the intestinal contents. Just as its use is 
justified for the control of a spasmodic cough, so its symptomatic employ- 
ment is permissible to arrest too frequent evacuations, excessive loss of 
water, severe colic or repeated rectal prolapse. It is clear, however, that 
this symptomatic treatment may mask a serious basic disease, which in 
young infants clinical experience teaches is often a very dangerous thing. 



GENERAL PROPHYLAXIS AND THERAPY 115 

As to the dosage of opium, H. Neumann advises, perhaps quite too 
conservatively, the addition of one drop of the tincture or wine of opium to 
50 c.c. (1% ounces) of water of which solution infants under six months of 
age receive one teaspoonful and in the second half-year a dessertspoonful, 
(1^/2 drams), every hour, until the bowel movements have been stopped for 
three hours. With increasing age the dosage is advanced, until children of 
three to six or eight years receive three to six drops not oftener than every 
three hours. These doses are exceeded only in exceptional cases, as for 
example, in appendicitis or peritonitis. In such cases it is better to use the 
drug in the form of extract of opium given in suppositories. So prescribed, 
0.01-0.02 gm. (M-H gr-) may be used for children from three to six years 
old; and 0.02-0.03 gm. (H-^4 g r -) f r older children according to necessity, 
three or four times a day. 

Hot compresses, very hot dry packs, or poultices applied to the abdo- 
men to relieve severe abdominal pains, may be used instead of opium. 
While their action is less certain they are entirely harmless. Dry appli- 
cations must be changed frequently and at least every half or three-quarters 
of an hour; they should be very hot and covered with dry cloths. The 
favorable influence ascribed by mothers and practical nurses to the various 
kinds of herb-tea in the relief of colic is probably not specific. They are 
permissible, since when they are being given the child usually receives no 
other food a most important indication in such cases. 

Aside from the drugs noted, the use of narcotics in children should be 
confined to the relief of troublesome cough and the induction of sleep. 
The first of these objects, the more complete discussion of which is left to 
special chapters, we will treat but briefly here. The most useful narcotic is 
codein sulphate, dissolved in sweetened water. It may be given to 
infants in initial doses of 0.002 gm. (Mo gr.) three or four times a day. 
In some cases it may be necessary to increase the dose materially, 0.003- 
0.005 gm. (/^O'Ma S r -) in order to obtain results. In children of the 
run-about-age, a further increase to 0.01-0.015 gm. (K~M gr.) may be 
required. If codein in these doses does not produce the desired effect, the 
use of morphin sulphate, which in children is fully as objectionable as 
opium, is permissible, but requires careful observation. The doses should 
be about one-third as large as those of codein. 

The soporifics require more detailed consideration. Habitual insomnia, 
either a difficulty in falling asleep, which may continue for a period of hours 
or an abnormally light sleep is not at all uncommon during childhood. 
Since in insomnia we have, to deal with a general neuropathic symptom, 
therapeutic measures must be aimed at the basic disorder, or rather, in a 
given case, must be directed to the training and environment which have 
led to the disturbance of sleep. It is better to treat the case with tepid 
packs or long continued hot baths, etc., than to employ sleep-producing 
drugs, which should be reserved for exceptional cases. This, is not true, 
however, of a temporary sleeplessness, caused by severe acute disease, 
which in itself weakens the patient. The uncontrollable restlessness of 
certain infants suffering with disturbances of nutrition or the sleeplessness 



116 TEXT-BOOK OF PEDIATRICS 

which occurs with older children in the course of septic fevers, typhoid, 
miliary tuberculosis, etc., is of this order. Under such circumstances, the 
indications for procuring sound sleep are no doubt pressing. In infants the 
most common remedy employed for this purpose is chloral hydrate. Since 
this drug acts rapidly, it is well to give one teaspoonful of a one to two per 
cent, solution, every fifteen minutes or half an hour until sleep is produced. 
By this method of administration no injury is ever done and even 
though the patient be especially resistant to the drug we are usually quite 
certain to obtain the desired effect. Of course the doses required will vary- 
greatly, several decigrams being necessary in some cases. Even a single 
dose of 0.5-1.0 gm. (7^-15 grs.) given in a two per cent, solution per rec- 
tum in a case of frequent eclamptic convulsions in infancy, is wholly with- 
out injurious effect upon the heart or the blood-pressure and will stop the 
attacks within ten or fifteen minutes and produce several hours of sleep. 

Chloral hydrate is a very good soporific fer older children, but is often 
refused because of its acrid taste. As a substitute diethyl-barbituric-acid 
[veronal 0.1-0.3 gms. (2-5 grs.), for children from three to twelve years old] 
or sodium diethyl-barbiturate (sodium-veronal) which is more soluble and 
therefore acts more rapidly, is excellent. 

Since soporifics are only required temporarily, and often for a single 
dose, there is no necessity for change; these remedies, therefore will be 
found sufficient. 

The discussion of the expectorants, indicated in congestion of the smaller 
air passages, due either to the absence of the cough stimulus or to the 
viscosity of the secretion; of the narcotics, as employed for the relief of 
cough; of the diuretics, hemostatics, anthelmintics, and of the entire 
armamentarium of serum therapy may be referred to special chapters of 
this work. 

The group of tonics, however, requires general discussion, since 
children who are subject to such treatment are very common in every 
physicians ' practice. A child is often brought to the pediatrist with a lay 
diagnosis, sanctioned actively or passively by the physician of "watery 
blood" or anemia, based upon the patient's faulty nutrition, pallor and ap- 
parent weariness, or upon a series of such functional disturbances as head- 
ache, anorexia, etc. The pediatrist is then expected to relieve the condition 
by means of tonic remedies. 

The number of preparations offered for this purpose is so great that 
no physician need hesitate for a choice if he is willing to prescribe untried 
remedies without reference to their effect in any particular case. A large 
field is open to him who wishes to make more or less aimless trial of these 
innumerable combinations of nutrients and alterants, into which iron, 
arsenic, iodine, quinine and phosphorus enter in indiscriminate variation. 
It goes without saying that such methods are unworthy of the thinking 
physician and are not to be excused by the ignorance of anxious parents. 
Even if the physician wishes to employ a medicinal agent for its purely 
suggestive influence, he must nevertheless determine, through physicial 
examination and careful inquiry into the manner of life and the training 



GENERAL PROPHYLAXIS AND THERAPY 117 

of the child, the basic cause of the given disease and must attempt, as a 
physician and an educator, the removal of such cause. A large share of the 
disturbances, which lead to a demand for this sort of therapy, are of func- 
tionally nervous origin in children, as they are in adults. In early child- 
hood, suggestive therapeutics of a medicinal character have not the same 
justification as they bear when they are addressed to the adult', because 
young persons are not responsive to such measures. The empiric use of 
the so-called alterants is the more narrowly restricted on this account. 

Information concerning blood-forming remedies, with reference to 
their usefulness in hemic disease, may be found in the chapter on Anemia. 

The artificial food preparations of which, also, an extremely large num- 
ber are on the market, are used very extensively for children who are either 
well or ill. While extended study of the pathology of infancy has taught 
the podiatrist definite indications for the increase or decrease of the several 
elements of the selected dietary, older children are carelessly given these 
manufactured preparations upon the strength of preformed conclusions 
of merit or of accidental successful experience of their use. 

The feeding of artificial protein preparations is not justified for the 
purpose of increasing the deposit of fat in a lean child. Only when an 
exhausting disease has reduced the protein content of the organism and it is 
desired to increase the nitrogen retention, by an increase of the nitrogen 
intake, is such a procedure indicated. Under any other circumstances high 
intake results in an increased nitrogenous output which cannot be con- 
sidered desirable. Of food preparations consisting largely of fats or carbo- 
hydrates, the former, if they are well borne, must be given the preference. 
A justly high value has been placed upon cod-liver oil and its emulsions; 
but this cannot be extended to the substitutes for cod-liver oil, since these 
are of entirely different chemical composition. Among the carbohydrate 
preparations the numerous malt extracts, often combined with iron, io- 
dine, etc., enjoy some popularity. Several of these have a mildly laxative 
action, which dry maltose and dextrin preparations do not possess. A favor- 
ite food of high carbohydrate content and always in favor with children is 
cocoa or chocolate. 

Even physicians who permit the temporary use of alcoholics or con- 
sider them necessary in cases of acute weakness, unamimously condemn the 
daily use of alcoholic tonics or of wine, heavy beer, etc. Alcohol should 
be used only as a vehicle for other drugs and especially for the stomachics, 
as in the wine of pepsin or the aromatic tinctures (compound tincture of 
cinchona, etc.), which are given by the teaspoonful or by drops. The action 
of agents which stimulate the appetite chiefly by their taste is naturally 
very slight in young children; but in older ones is more definite. Pepsin 
and dilute hydrochloric acid, in teaspoonful doses, immediately before or 
after feeding, are occasionally useful; but it should be remembered that a 
temporary loss of appetite may dictate a wise refusal of food which may not 
be combated without harm. 

In the habitual anoiexia of children of the run-about or school age, such 
remedies as ichthyol albuminate and the like, give much less satisfactory 



118 TEXT-BOOK OF PEDIATRICS 

results than does a careful regulation of the diet. Feeding should never be 
urged. It is especially necessary to treat the frequently coexisting habit of 
obstipation. These and other influences, not infrequently chronic infection 
of the nose and throat, affecting the psychic well-being of the small patient 
should be removed. The child is often of a nervous temperament and sur- 
rounded by neurotic adults and it is sometimes necessary to place it in 
entirely new and more favorable surroundings. The surprisingly good 
results often attaching to its removal to a children 's home in the mountains 
or by the seaside are largely due to a change of environment. 

While the psychologic, factors of treatment are particularly empha- 
sized, it is not to be denied that such hygienic influences as light, air, exercise, 
bathing, etc., are largely involved in bringing about a good result. Never- 
theless, it remains true that the reputed benefits of a change of air are 
achieved less by climatic than by psychic agencies. Especial weight is to be 
given to intensive exercise in the open, which, with its variable qualities, 
does not become tedious and does much to alleviate the illness of the child. 
The action of light is only second in value, while bathing is a less important 
matter. This conclusion seems justified by the fact that sea-baths given at 
home, in the patient's habitual surroundings, have little or no effect. 
Furthermore, the strong stimulation of the skin and the nervous system 
induced by cold sea-bathing, by-the-sea, must be more carefully watched 
and adapted to the conditions of the child than is necessary in the enjoy- 
ment of the less active influences of light, air and pleasurable exercise. In 
every case the attendant should see to it that cold sea-baths are of very 
short duration, not exceeding one or two minutes, that the child moves 
about actively in the water and is warmed up as rapidly as possible after 
the bath. 

When a number of children are bathing together it is usually possible 
to make the timid among them go into the water without persuasive force. 
If this is not possible, and skilful and repeated attempts at persuasion fail, 
the repetition of force in giving the child the cold bath only increases fear 
and becomes an injury to the nervous system. 

Sea-salt and sun-baths have become widely popular in the effort to 
build up feeble and particularly scrofulous children. Experience cor- 
roborates the conclusion already reached that at best they are but ad- 
juvants of treatment and, as given in the home, are inefficient, whereas, 
when combined with other therapeutic measures at the sea-side, they seem 
more effective. 

In the matter of technique, the following may be noted: Enough salt, 
(table salt, sea-salt) is used in the bath to make a 1.5-2 per cent, solution, 
using 30-40 litres, or 7-8 gallons, of water for infants and 100-200 litres, or 
25-50 gallons, for older children. If there is much insoluble sediment, the 
salt may be first dissolved in boiling water and then strained into the bath. 
The bath temperature should be 32-33 C. (88-90 F.) for the babe, and 
about 30 C. (86 F.) for the older child, a little less than that of the ordinary 
bath. It should be given for ten or fifteen minutes. Frequently the bath is 
followed by a cool rub down in the sun, to increase the reaction of the skin. 



GENERAL PROPHYLAXIS AND THERAPY 119 

It is well to begin with two baths a week and to increase the number only if 
the patient reacts well. 

Convenient as it would be for the physician, it is impossible to give any 
definite directions for the dosage of various drugs in childhood. A very 
indefinite approximation may be made by giving that fraction of the adult 
dose which corresponds to the fraction represented by the child's ascertained 
body-weight, as compared to that of the adult, estimated at 60-70 kilos, or 
120-150 pounds. By this method, the permissible dose for the young 
infant will hardly ever be exceeded and it may more often fall below the 
amount required for a desired effect. Since the administration of drugs to 
children is usually confined to those of definite, more or less rapid and 
readily recognized action, and without dangerous qualities, it is often 
better to prescribe medicine in divided doses, repeating the small dose until 
the required result by way of bowel movement, sleep production, disap- 
pearance of fever, or active perspiration is obtained. The choice of intervals 
between doses must, of course, depend upon the rapidity with which the 
result is to be secured. With chloral, or acetylsalicylic acid, for instance, 
it may vary between fifteen and thirty minutes; with cathartics it may 
range to two or three hours. With certain drugs, it may develop only after 
a much longer period, when smaller or less frequent doses than those re- 
quired to produce the initial effect should follow. In the use of drugs having 
a cumulative effect, as with digitalis, or of those which show a diminishing 
strength of reaction or which lead to the development of tolerance, the same 
practice should be adopted with children as in adults. A generally increased 
sensitiveness to only a few drugs exists in childhood. Opium belongs in this 
class, as shown by recent experiments upon animals. It has been already 
said that its injurious action is in part, at least, due to a misunderstanding of 
the indications for its use or to a failure to recognize the supposed symptoms 
of poisoning (see page 115). Infants show an actual intolerance to phenol; 
and it is well, therefore, to avoid its use altogether wherever there is a 
possibility of its absorption in perceptible quantities. Chloroform, also, is 
dangerous for infants and it is better to use ether exclusively for purposes of 
general anesthesia. It is hardly necessary to add that such poisonous drugs 
as cocain should be especially avoided in favor of non-poisonous substitutes. 

The exhibition of medicinal substances necessitates deviations in other 
respects from the rules which govern their prescription for adults. The 
young infant, even if he be not entirely without the sense of taste, has that 
function so poorly developed that it is hardly ever necessary to disguise the 
taste of drugs. Even in the second or third year, children with disturbances 
of nutrition or rickets have a sense of taste soslight that they will take cod- 
liver oil without objection. This statement needs the more emphasis because 
advertisements of cod-liver oil preparations, wrongfully claim that children 
can be made to take the oil only by force. If at all necessary, only sweet 
substances are required to disguise its taste. The taste for other substances, 
as the aromatics, is normally wanting. A peppermint lozenge or a piece of 
chocolate, given before a medicine mil cover an objectionable taste better 
than anything else. 



120 TEXT-BOOK OF PEDIATRICS 

Powders may be given in milk or stirred into gruels. Children of five 
or six years will usually learn to take them in wafers. Tablets, pills and 
capsules, or their contents, must be dissolved or crushed before the child 
can swallow them. 

Subcutaneous or intramuscular injections are made precisely as in the 
adult. In the infant it is best to make a subcutaneous injection over the 
breast and preferably in the skin over the large thoracic muscles, rather 
than in the extremities. Intramuscular injections are usually in the glu- 
teal region. 

Intravenous infusion is very difficult or almost impossible in infants 
and young children because the veins are not-apparent beneath the skin and 
are of too small calibre to permit the entrance of the canula. For injections 
of small amounts of fluid one may with practice use the large veins of the 
scalp (temporal) and the longitudinal sinus may also be used. The method 
of subcutaneous infusion is described on page 111. 

Among medicinal agents for external use in infancy, as applications or 
ointments, of purely local action, and but an indeterminable fraction of 
which is absorbed, concentration must be relatively high. It should be at 
least half as great as for the adult and may be increased according to need. 
The greater delicacy of the infant 's skin makes greater care necessary in the 
use of counterirritants. This applies especially to the frequently pre- 
scribed tincture of iodine. 



SPECIAL PART. 

I. 
DISEASES OF THE NEW-BORN 

BY 

H. FINKELSTEIN and L. F. MEYER, 

Berlin. 

REVISED BY 

N. O. PEARCE, M. D., 

Assistant Professor of Pediatrics, University of Minnesota, Minneapolis. 

THE viability of a premature infant depends upon the degree of its 
development and the cause of it? prematurity. While disease in the mother 
greatly reduces the chances of life in the prematurely born, even though 
carried almost to term, the number and the marked prematurity of the 
viable children of healthy parents is surprisingly great. It has proved 
possible to bring children born in the sixth month of pregnancy, weighing 
only 750 gms. (26 ounces), and measuring 35 cm. (14 inches) in length, to 
normal development. It is usually possible to maintain life in the premature 
infant who weighs 1200-1500 gms. (4-5 pounds), and is born in the twenty- 
seventh or twenty-eighth week of fetal life. 

Syphilis of the parent is the most common cause of premature birth and 
impaired vitality. In syphilitic children serious structural changes of the 
visceral organs reduce the prospect of life to a minimum. Next to syphilis, 
such organic diseases as nephritis, diabetes, eclampsia, tuberculosis, etc., in 
the mother are causally Important. 

Many difficulties are encountered in rearing premature infants. Their 
relatively great body surface permits an increased loss of heat by radiation, 
which must be met by a larger intake of energy-producing food. This neces- 
sity is especially embarrassing, for the weak and torpid infant, lying almost 
lifeless and without appreciable respiration, can be roused to active nursing 
at the breast with great difficulty. Consequently, not a few premature babies 
die of starvation. Agreater number, no doubt, die of disturbances of nutrition 
and intercurrent infections to which they can offer but feeble resistance. 

1. The Care of the Premature Infant. In the treatment of the pre- 
mature child the following points must be considered. All chilling of the 
body-surface must be avoided, especially in the fiist few days of life, when, 
in face of the insufficiency of the temperature-regulating mechanism, it may 
cause marked lowering of the body temperature. The changing of clothing 
or diapers, the bathing and feeding must all be done rapidly. The bath 
should be warmer than usual, 43 C. (110 F.) or, better, may be omitted 
entirely at first. Artificial heat should be applied by means of the hot bath, 
as soon as possible, if the premature infant has been chilled. A persisting 

121 



122 TEXT-BOOK OF PEDIATRICS 

subnormal temperature narrows the prospect of life. The clothing should be 
of the usual character. Wrapping in cotton is unnecessary. 

Provision should be made first of all for continuous and uniform heat 
supply. The cheapest and most successful method, applied with proper 
care, is by the use of hot water bottles. 

A large roomy clothes basket lined with flannel and in which hot water 
bottles, sufficient to maintain the necessary basket temperature, are placed, 
is a very efficient and easily prepared receptacle for the premature baby. 
The temperature should be maintained at between 80 and 90 degrees as 
indicated by the temperature of the baby. This heat may be regulated best 
by partially covering over the top of the basket with a light blanket. It is 
important that the thermometer in the basket be placed on the baby just 
under the outer clothing so that the temperature recorded will be approx- 
imately that of the air immediately surrounding the baby. 

Four ordinary beer or mineral water bottles are filled with boiling 
water and after being well wrapped are laid in the crib so that there is one 
bottle on each side, lying parallel to the body and one at each end. Over 
these, heavy layers of bedding are placed. One of the bottles should be 
renewed every four hours, excessive heat being prevented by placing new 
layers of bedding around it. The commercial U-shaped containers or 
ordinary rubber hot water bottles are more easily handled (O. Rommel). 
The double-walled warming tubs of metal (Crede's tubs) which are filled 
every four hours with water at 50 C. (120 F.) may be used. 

Any application of artificial heat requires careful handling, for injuries 
due to either excessive or insufficient heat occur very easily. The incubator 
is a more certain device and less dependent upon the intelligence of attend- 
ants. Various models are in use and some of these are very simple in con- 
struction. It is possible to improvise a satisfactory incubator from a 
packing case. In the most simply constructed model, the source of heat, 
provided by hot bottles or stones, is in a lower compartment of the box, 
which is divided horizontally; the air entering through several openings and 
rising, warming the feet of the child in the upper compartment and passing 
out through openings near the head. 

For use in clinics, automatically regulated incubators, susceptible of 
very ready adjustment, are designed. To-day, in modern infants' hospi- 
tals, entire rooms well ventilated and in which a constant temperature may 
be maintained are reserved for the new-born. As a rule, the incubator 
should be regulated so that the temperature on the inside is 30 C. (86 F.). 
In individual cases, however, the heating must be regulated according to 
the degree of heat demanded by the body-temperature of the child. There- 
fore, the child 's temperature must be taken very frequently. Over-heating 
is to be guarded against with as much care as is chilling; for aside from the 
fever, serious disturbances, (diarrhoea, convulsions, collapse), may arise as a 
result of excessive heat. An observing nurse will note at once, from the 
perspiration and the child 's restlessness, that it is too warm. 

With increasing age, the functional capacity of the heat regulating- 
mechanism improves, until the child is able to maintain an equal body-tern- 



DISEASES OF THE NEW-BORN 123 

perature outside of the incubator. By this time, the body-weight is usually 
2200-2400 gms. (4-5 pounds). Naturally, no definite limit to the length of 
time for the use of the incubator can be set. External heat may be neces- 
sary for a shorter period for one child than for another. Too great depend- 
ence upon the heat-regulating ability of the premature infant frequently 
results in an arrest or loss of body-weight after the child has been removed 
from the incubator. Continuation of the external heat is still essential to 
its development. 

Likewise, it is not possible to state accurately when the child may be 
taken into the open air for the first time, despite of the fact that sun, light 
and ah* are important to the infant, it is better to wait until a normal 
standard of gain for its age has been reached. 

2. Feeding. The premature infant has a great task to perfoim during 
its first year of life, a task which predicates vitality rather than weakness. 
While the normal infant only doubles his body-weight 3410 to 6714 gms. 
(7 to 14 pounds), by the end of the twentieth week, the premature child, 
according to the observations of Camerer, nearly triples his weight, 1740 
to 5180 gms. (3^ to 10 pounds), in the same length of time. This he can ac- 
complish only with sufficient nourishment; in fact, all observers have deter- 
mined that such children elect to nurse very large quantities. They require 
about 120 to 130 calories per kilogram of body-weight (54 to 60 calories per 
pound), which is from one-fifth to one-third more than normal children 
demand. Hence, the conclusion has been reached that there is a greater 
need for nourishment, conforming to Rubner's law of the ratio of food 
requirement to the greater heat radiation resulting from the relatively 
large surface of the small infant. More recently, this assumption has been 
denied and it is asserted that the premature infant receives a greater 
quantity than is necessary and that his normal development can be se- 
cured with a much smaller supply. 

Most excellent results are obtained in the premature infant by the early 
feeding of relatively small amounts of breast-milk at four hour intervals. It 
is especially true of small and weak prematures that they have a limited 
ability to digest and assimilate food and that their tolerance for food is 
easily destroyed by ovei feeding. An adequate gain in weight will take 
place on amounts of breast-milk as small as from fifteen to twenty cubic 
centimeters given every four hours. The amount should be increased only 
when the weight remains stationary for forty-eight hours. 

Breast feeding is more imperative for the premature infant than for 
any other; yet certain technical difficulties are met in the attempt at natu- 
ral feeding which depend upon the limited power of the child to nurse and 
to swallow. 

These difficulties react upon the child itself, in that it gets too little 
nourishment from the breast. Weak prematures often cannot be put to the 
breast at all and must be given the expressed milk through mouth or nose, by 
spoon, medicine dropper,tube or other instruments. Even stronger children 
may overexert themselves at the breast and become faint; and therefore 
are better fed in the beginning, wholly or in part, with expressed milk. 



124 TEXT-BOOK OF PEDIATRICS 

On the other hand, arises the difficulty of establishing and maintaining 
lactation. The stimulation of powerful suckling which serves physio- 
logically to this end is absent or inadequate. Even though the mother is 
willing to nurse the infant, the secretion does not appear or appears only 
in small quantities and soon dries up. If a wet-nurse is employed, a con- 
gestion of milk in the mother's breast is threatened and again, on this ac- 
count, the secretion may fail. The breast-pump is of some assistance; but 
it is better to substitute a strong healthy child at the breast until the supply 
increases. The wet-nurse should be allowed to nurse her own child at 
times, or her excess output should be expressed or pumped. It may be well 
for the mother and the nurse to exchange children several times a day. 
Under these circumstances, of course, we must be absolutely certain that 
syphilis is not present in either the mother, the wet-nurse or one of the 
children. A child with lues or suspected of lues, on account of the history 
of the parents, may always nurse its own mother, even when she has 
remained free of syphilitic manifestations. But such a child must never be 
put to the breast of the wet-nurse, although nothing can be said against 
feeding the infant with expressed milk provided by her. 

Persistent demand on the breast is a most important factor in the estab- 
lishment and maintenance of the breast-milk supply and even where 
suckling is for a time impossible, failure of the breast-milk supply is unneces- 
sary, if the breasts are properly stimulated by correct and thorough man- 
ual expression of both breasts at least five or six times a day. The best 
method is to grasp the breast one or two centimeters back of the colored 
areola and carry the milking motion toward the nipple, but without 
massage. This is to be continued until the last drop is obtained. Mothers 
and attendants soon become very expert in draining the breasts in this man- 
ner, and the supply of milk will be made to increase rather than be allowed 
to decrease. 

In regulating the number of feedings, we must not be influenced, as we 
are in the healthy child, by the fact that the physiologic food requirement 
of the child must be met, with due respect to the periods of waking and 
sleeping. Premature infants sleep almost constantly and must be aroused 
to be fed. The artificial feeding of premature infants should be adopted 
only in cases of extreme necessity; it is always a risky undertaking. 

The life of such a child, possessed of so little reserve power, is seriously 
endangered by a disturbance of nutrition. Every diarrhoea that occurs in 
the first few weeks of its life should serve as an absolute indication for the 
interruption of artificial feeding and the substitution of breast-milk. 

It is difficult to say what method of artificial feeding should be chosen hi 
any given case. All food mixtures have occasionally given good, but far 
more frequently bad results. The usual milk dilutions do not give the 
acquired caloric value. It seems that buttermilk, with the addition of 
maltose and dextrin in carefully regulated quantities, has great advantages 
over the usual mixtures recommended. Yet, even with this food, the 
danger of disturbance is great. 



DISEASES OF THE NEW-BORN 125 

Prognosis. A fairly large percentage of premature infants readily over- 
come all of the obstacles to their development and evidence greater vitality 
than could be anticipated at birth. Even by the end of the first year, and 
certainly by the close of the second or third year, their differences from the 
normal child are equalized. There are peculiarities, however, which even 
later must be considered in relation to premature birth; such as the tendency , 
greater than in the full-term child, to rickets, spasmophilia and, especially 
to certain anemic conditions. Toward the end of the first year of premature 
life, if not earlier, a noticeable pallor appears, which is, at least in part, due. 
to the insufficient deposit of iron; which, as we well know, accumulates in 
large store during the later months of fetal life. In this event, the early 
addition of ir on-containing foods frequently produces favorable results. 
When this is unsuccessful, we have to conclude that there is a congenital, 
insufficiency of function in the blood-forming tissues. 

It has been said that idiocy, hydrocephalus, Little 's disease, and other 
central spastic paralyses, are more common in premature children than in 
others. This seems to be true, but their causation is not to be charged to the 
fact of premature birth in itself, but rather to the conditions of disease in the 
parents which caused the premature birth and are also responsible for these 
anomalies of the nervous system. Premature children of healthy parents 
can hardly be said to have a poorer prognosis, 1 in regard to these compli- 
cations, than children born at term. 

ASPHYXIA 

By asphyxia, is understood a condition produced by interference with 
the oxygen intake and the carbon dioxide output of the child. This inter- 
ference may have developed while the child is still within the uterus, so that 
it is born asphyctic, or it may arise after birth. 

1. Congenital Asphyxia. It is a recognized fact that the stimulus to 
the first inspiration is given to the respiratory centre by an excess of carbon 
dioxide and an insufficiency of oxygen in the blood, as a twin result of 
interruption of the placental circulation. If this interruption happens before 
the delivery of the child's head, respiratory movements will occur too early, 
and may cause the asphyxia. Disturbances of the circulation between the 
mother and child may be occasioned by premature separation of the pla- 
centa, by compression of the umbilical cord, etc. 

Symptoms. Two types of asphyxia are clinically distinguishable. 1 . The 
slightly asphyctic child is born with a deep bluish-red color (asphyxia 
livida) with slow heart action, developing slight respiratory movements or 
even apncea, but of good muscular tone. Active respiration is easily pro- 
duced in this child by stimulation of the skin reflexes. 

2. The severely asphyctic child with a skin color resembling death- 
pallor, (asphyxia pallida), in whom all reflexes and all muscle tone have 
disappeared. A very weak heart action alone shows that life is still present. 

1 The bulging of the fontanelle, which frequently occurs in premature children dur- 
ing the second half year, is of no particular prognostic value. As a rule, the slight 
hydrocephalus, which appears in connection with the rapid growth of the brain, dis- 
appears in a few months. 



126 TEXT-BOOK OF PEDIATRICS 

The attempted respiration has ceased and cannot be awakened by the usual 
skin stimulation. 

At autopsy the signs of suffocation are seen in congestion of the viscera, 
hemorrhage from the serous membranes and, as result of the premature 
breathing, meconium and amnionic fluid in the air passages. 

Prognosis. The prognosis is favorable in the milder form and doubtful 
in the severe form. Even in the latter, the seemingly impossible may 
sometimes be accomplished by proper methods. The claim has been made 
.that the survivors of asphyxia are predisposed to diseases of the central 
nervous system, (Little's disease and idiocy), but this has not been proved. 
Doubtless, some inherent predisposition of the central nervous system 
must be present when asphyxia has such marked sequela?. 

The recent work of Rodda and others on the hemorrhagic disease of the 
new-born throws much light upon this subject. It is now generally recog- 
nized that severely asphyxiated infants are most likely to suffer from 
cerebral hemorrhage, which we believe to be largely responsible for the 
subsequent paralysis and mental deficiency. 

Therapy. The most efficient means of stimulating the respiration is 
through frequent and powerful irritation of the skin. After the aspirated 
material has been removed from the mouth and pharynx by means of a 
catheter, the new-born should be quickly bathed in warm water and rubbed 
thoroughly dry. If this does not produce results, the child should be plunged 
into cold and then immediately into warm water; a double bowl bath. 
These methods are usually successful in the milder form of asphyxia. 

In the severer form, more energetic measures must be adopted. First of 
all, the Schultze's method of resuscitation, described in obstetrical works, the 
great value of which is generally recognized, is advised. In addition, com- 
pression of the thorax, heart-massage, at the rate of thirty strokes a minute, 
and rhythmic traction and release of the tongue, some forty or fifty times 
a minute, may be tried. 

2. Postnatal Acquired Asphyxia. When asphyxia develops after birth, 
it is due either to disease of the central nervous system or to some disorder 
of the circulatory or respiratory mechanism which interferes with the normal 
supply of oxygen. 

Such a condition actually develops in pulmonary disease, in the white 
pneumonia of syphilis and enteritis; in heart lesions; in malformations, 
(pulmonary aplasia, diaphragmatic hernia, compression of the trachea by 
goitre or hyperplastic thymus) ; in general diseases of the new-born, (lues, 
sepsis) ; in diseases or injuries of the brain (encephalitis, congenital hydro- 
cephalus, brain hemorrhage from birth trauma) ; and in weak premature in- 
fants in whom it is usually combined with pulmonary atelectasis dependant 
upon imperfect thoracic expansion. Such asphyxia occurs soon after birth. 
If a child who has developed well during the early weeks, suddenly falls sub- 
ject to asphyctic attacks, the disturbance of the respiiation is usually due to 
a grippe-like infection. In premature children and in those with severe 
disturbance of nutrition, spontaneous asphyctic seizures occur, the cause of 
which has never been definitely explained. 



DISEASES OF THE NEW-BORN 127 

Symptoms. The clinical picture differs with the disease which causes 
the asphyxia. The inspirations are infrequent, gasping, occur in irregular 
sequence or are interspersed with long pauses during which they are 
entirely absent. The skin is blue and cyanotic, the body-temperature is 
subnormal, the extremities are cold and occasionally a slight edema is seen. 
Fine crackling rales are heard, from time to time, over the lungs as a result 
of the atelectatic process. 

In forms of asphyxia which develop late, symptoms are usually pres- 
ent, such as fever, cough, retraction of the epigastrium and intercostal 
spaces, which even with negative lung findings indicate a catarrhal pulmo- 
nary disease. 

Diagnosis. In the diagnosis the cause must always be looked for first, 
because the asphyxia itself is no more than a symptom. 

Very frequently some developmental error which was not and could not 
be discovered during life is first seen at autopsy. In other cases, the findings 
are those of atelectasis, with the conditions described in the intra-uterine 
form of asphyxia. 

Prognosis. The prognosis depends entirely upon the cause. The 
anomalies named naturally give but a poor outlook. Lacking these, how- 
ever, the prognosis depends largely upon the possibilities of treatment 
and care and even then the desired result may not be attained. 

Treatment. As in the congenital form, rapid alternation from the hot 
to the cold bath, friction of the skin and Schultze's method may be tried. 
The be?t method of all is the inhalation of oxygen. 

In premature infants born with asphyctic tendencies, all causes of rapid 
cooling of the body must be avoided and special attention must be given to 
the supply of a sufficient quantity of food. 

BIRTH TRAUMATA 

EXTERNAL CEPHALHEMATOMA 

Symptoms. Cephalhematoma is the term applied to a hemorrhage oc- 
curring on the second or third day and occasionally later, over the parietal 
bone or, more rarely, over other cranial bones. Now and then it is bilateral 
and reaches its maximal size during the fifth or sixth day (Figure 23) . The 
swelling rarely exceeds the size of an egg; larger tumors are exceptional. It is 
not sensitive to pressure. Upon palpation, a hard boundary line is felt inside 
of which the palpating finger seems to touch upon a soft dough-like hollow. 

During the following weeks, the extravasate is gradually resorbed and the 
periosteum again becomes adherent to the bone and presents a thickened 
surface which remains for a long time. If the resorption occurs slowly, a 
thin plate of bone is formed over the tumor from the lifted periosteum, which 
is recognized upon palpation by its peculiar parchment-like rattle. The 
general well-being of the infant is not disturbed and the body-temperature 
is not influenced, excepting as a result of interference or of spontaneous 
infection, inflammation and pus formation. 

Etiology. The probable and generally accepted theory is that the scalp 
is displaced by pressure against the walls of the parturient canal during 



128 TEXT-BOOK OF PEDIATRICS 

delivery, so that the periosteum, which is not so closely adherent to the 
bone in the new-born as in later life, is loosened. On account of its delicate 
vascularity, hemorrhage between the periosteum and the bone occurs. The 
loosening of the periosteum at the sutures is impossible, because here the 
pericranium is more closely adherent to the surface of the skull, a circum- 
stance which limits the hematoma to the site of the one cranial bone. 
Other attempts at explanation, such as defects of ossification, decom- 
pression of the head with a resulting hyperemia and rupture of vessels, are 
less plausible. 

One must not fail to investigate the coagulation and bleeding time at 




FIG. 23. Cephalhematoma over left parietal bone (Gisela Children's 
Hospital, Munich, Prof. Ibrahim). 

frequent intervals when a cephalhematoma is present as it has been repeat- 
.edly shown to be coincident with the development of general hemorrhagic 
disease of the new-born. 

Diagnosis. The diagnosis should give no difficulty. The inexperienced 
observer will occasionally be deceived by the surrounding bony wall and will 
mistakenly suppose that he has to do with a defect of the cranial vault with 
a resulting meningocele. A cephalhematoma can always be distinguished 
from a meningocele by its location. While the meningocele usually appears 
at a suture or a fontanelle, the hematoma commonly covers the arch of the 
bone. Pulsation of the tumor, its increase in size when the child cries, and 
the possibility of its replacement, are all indicative of meningocelle rather 
than of hematoma. 



DISEASES OF THE NEW-BORN 129 

From the unimportant swelling of the scalp, the caput succedaneum, a 
diffuse edema of the soft parts which may be present even at birth and which 
soon disappears, the cephalhematoma is distinguished by its limitation to 
one cranial bone. 

Prognosis. The prognosis is good provided that infection is avoided. 
In the latter case, it becomes doubtful; for bone caries, meningitis and sepsis 
may threaten the life of the child if the pus is not immediately evacuated. 

Treatment. Usually treatment is not necessary when the process runs 
its natural course. Because of the danger of infection, it is best to await 
spontaneous recovery. Only when the resorption of the extravasate takes 
too long, may aseptic puncture be required. When symptoms of an 
infection occur, i. e., redness of the skin, fever, etc., surgical interference 
is necessary. 

INTERNAL CEPHALHEMATOMA 

In very rare cases, hemorrhage between the cranial bones and the dura 
mater occurs simultaneously with the external hemorrhage. This is termed 
internal cephalhematoma. This will occur, however, only when a fracture, 
from birth trauma, is present or when an external extravasate passes 
through the skull by way of some ossification defect in the frontal or occi- 
pital bone. Symptoms of cerebral pressure indicate the nature of the trouble. 
It may be distinguished from those manifestations of cerebral pressure 
which are caused by hemorrhage in the meninges or in the brain by the 
absence of blood in the fluid obtained by lumbar puncture. 

The prognosis of an epidural hemorrhage is doubtful. With symptoms 
of cerebral pressure, the aspiration of the extravasate may be necessary 
after its location has been determined by exploratory puncture. 

CEREBRAL HEMORRHAGE 

In difficult instrumental labors and rarely in normal labors so great a 
compression may be produced that evidences of cerebral pressure occur. 
Such children are born asphyctic, the respiratory action is weak and irreg- 
ular, the pulse is slow. If the asphyxia does not yield to proper treatment 
and if convulsions and paralyses also appear, it is improbable that the 
condition is caused by pressure alone and cerebral hemorrhages must 
be considered. 

Etiology. The trauma which causes the hemorrhage does not necessarily 
cause severe deformities, fissures, or fractures of the cranium. Frequently 
hemorrhage occurs without external injury and this even when the deliv- 
ery was not particularly difficult. The cause is rather to be found in an 
overlapping of the cranial bones with a resulting congestion, rupture of the 
vessels, etc. 

Recent work on hemorrhagic disease of the new-born leads us to believe 
that a very large percentage of cases of cerebral hemorrhage are due to this 
disease rather than to traumatism as indicated by the author. 

Symptoms. The clinical picture is caused by the excessive intradural 
pressure. Sopor, slow pulse, irregular or intermittent respiration, a bulging 
9 



130 TEXT-BOOK OF PEDIATRICS 

of very tense fontanelle, strabismus, paralyses and especially convulsions 
will be observed. The deep and continuous sleep, the sopor, and the im- 
perfect respiration, in cases in which postnatal asphyxia is increased rather 
than improved by the usual methods of treatment, justify the suspicion of 
cerebral hemorrhage. 

In favorable cases, even serious cerebral symptoms disappear, after 
several days, without leaving a trace of a brain lesion. Quite frequently, 
however, epileptiform convulsions or paralyses develop earlier or later as 
evidences of permanent cerebral injury. 

At autopsy, in those children who die with symptoms of severe asphyxia, 
we find subdural or subarachnoid hematoma on the convexity of the brain. 
Hemorrhages over the cerebellum are more rare, as are those at the base and 
in the ventricles. Hemorrhages into the brain substance are exceptional 
but probably occur more frequently than is generally believed. They 
are usually very minute in character and only discovered at autopsy by 
microscopical examination, or, in case of recovery, are either completely 
absorbed giving no subsequent symptoms or are a large factor in the later 
development of so-called "Little's Disease." 

Diagnosis. The differentiation of hemorrhage from malformation of 
the brain, especially when visible injuries are absent, is very difficult. In 
doubtful cases lumbar puncture is advisable. Cerebrospinal fluid con- 
taining blood, with a large number of broken down or crenated red blood- 
cells, is evidence favoring a diagnosis of cerebral hemorrhage. Much 
information may be obtained from a test of the coagulation and bleeding 
time in cases of suspected cerebral hemorrhage. A delayed coagulation and 
bleeding time combined with the symptoms of cerebral hemorrhage makes 
the diagnosis almost certain, and points to the immediate necessity of 
subcutaneous injections of whole blood. 

Prognosis. The prognosis should always be made reservedly, even if 
all manifestations of intracranial pressure disappear within a few days. 
The danger of some permanent effect upon cerebral function remains. 
Paralyses, idiocy and epilepsy are not infrequently the late sequelae of such 
a lesion. With symptoms of great pressure, the attempt to puncture and to 
aspirate the extravasate may be considered. 

HEMATOMA OF THE STERNOCLEIDOMASTOID 

As a result of rupture of the fibres of the neck muscles, especially the 
sternomastoid, the trapezius, or the scaleni, hemorrhage into the muscular 
sheath occurs. Such ruptures may occur as easily in spontaneous labor as in 
artificial birth. An extreme rotation of the head is enough to cause such an 
injury to the muscle. Symptomatically we notice, soon after birth, a small 
swelling of about the size of a pigeon's egg on the neck. This swelling is 
hard, is not painful and is covered by intact skin. 

The hematoma of the muscle and the scar formation which follows the 
absorption of the blood must be distinguished from a form of cicatrization 
acquired in intra-uterine life, which is probably a more common cause of 
wry-neck than this injury. 



DISEASES OF THE NEW-BORN 



131 



Therapy. Since the hematoma is, as a rule, resorbed spontaneously 
within a few weeks, gentle massage and passive motion are to be advised. 
However, the possibility of a contracture of the muscle developing as an 
after-result of the hematoma with the resultant wry-neck (caput obstipum) 
should not be overlooked. 

PARALYSES 

(a) Paralysis of the Brachial Plexus. This form of paralysis in the new- 
born is the result of pressure upon or rupture of the nerve plexus in normal 
labor and more frequently in instrumental delivery. 

It will be remembered that the brachial plexus consists of a combination 
of branches of the cervical nerves from 
the fifth to the eighth, with the first 
thoracic. It supplies the muscles of 
the shoulder, the arm and the forearm. 
Injury to the plexus occurs most fre- 
quently at Erb 's point, which lies two 
to three centimeters above the clav- 
icle. Electric stimulation at this point 
produces contraction of the deltoid, 
the triceps, the biceps, the brachio- 
radialis, the supinators and the infra- 
spinatus muscles. Accordingly, the 
paralysis is usually of the so-called 
Erb's type, affecting the muscle groups 
named, but not disturbing sensation. 

Symptoms. Immediately after 
birth, the arm lies immovable and lax 
and is rotated inward. The palm of 
'the hand is directed outward and 
backward. Reflex movement, by flex- 
ion of the arm cannot be elicited by 
pin pricks, to which the normal arm 
readily responds. The paralysis is 
especially noticeable when the child 
is lifted up, the paralyzed member hanging relaxed by its side (Figure 24). 

A second type of birth paralysis, the so-called paralysis of the forearm, 
is more rare. In this form, the muscles supplied by the seventh and eighth 
cervical and the first thoracic nerves are affected. This involves a paralysis 
of the forearm, the smaller muscles of the hand, and the flexors and exten- 
sors of the fingers. It may be accompanied by disturbances of sensation. 
Some cases also show manifestations of Klumpke's paralysis, oculopupil- 
lary symptoms, contracted pupil, narrowed palpebral fissure and retraction 
of the bulb. Frequently the muscles concerned in the first type are involved 
also in these cases and the paralysis may be equally distributed in the arm 
and forearm (Figure 25). 




FIG. 24. Birth paralysis of the arm, upper 
arm type. 



132 



TEXT-BOOK OF PEDIATRICS 



After the paralysis has existed for some time, the muscles give the 
reaction of degeneration. Atrophy, flail-joint and contractures ensue. 

The pathologic findings in children dying from concurrent diseases, who 
have come to autopsy, show hematomatas, tears, and the presence of 
scar-tissue in the brachial plexus. 

Diagnosis. The diagnosis of birth paralyses is difficult, especially in 
their differentiation from fractures and luxations occurring during delivery 
which are often characterized by similar disturbances of mobility. Sepa- 
ration of the epiphysis at the head of the humerus is especially important. 





FIG. 25. Birth paralysis, rupture 
of chords of cervial plexus. 



FIG. 26. Left sided unilateral birth paralysis 
of the facial nerve (Berlin Children's Asylum). 



Paralysis and fractures occasionally occur together. Error in diagnosis may 
be avoided by careful palpation and by an X-ray picture of the fracture or 
dislocation. Changes in the contour of the shoulder, as seen from above, 
should lead to a suspicion of dislocation. Hyperpronation and early con- 
tractures are similarly indicative. Careful general examination and the 
Wassermann reaction, will prevent confusion with luetic pseudoparalysis 
(Parrot's paralysis; see Syphilis). 

Recovery usually occurs in paralysis of the arm. Complete restoration 
of function is very frequent and in mild cases results within a few weeks; 
but it must not be expected with any too great certainty. In the forearm 
type and in complete paralysis, the prognosis is much less favorable. If no 



DISEASES OF THE NEW-BORN 133 

improvement or but partial recovery takes place by the fourth month, there 
is nothing more to be hoped for. 

Treatment. The treatment should attempt to prevent atrophy and 
contracturc. At first, gentle massage and passive movements are indicated. 
Later, faradization and galvanization may be used two or three times a 
week. If paralysis remains, recent experience has shown that operative 
interference (sutuie of nerve trunks, separation of adhesions, or tendon 
transplantation), may be efficacious. 

(6) Facial Paralysis. Facial paralysis is frequently a result of birth 
injury. 

The cause must be sought in trauma to the peripheral route of the facial 
nerve. Paralysis of the facialis is three times as common in cases of forceps 
delivery as in spontaneous birth, doubtless because of the direct pressure of 
the forceps upon the nerve. However, the pressure upon irregularities of the 
pelvic outlet, especially in contracted pelvis, must be considered. 

The symptoms are those generally seen in facial paralysis. In the act of 
crying, the mouth is drawn toward the normal side (Fig. 26) and frequently 
the eye on the palsied side cannot be completely closed. The paralysis is 
commonly unilateral. In diagnosis, a congenital nerve defect or peripheral 
or central site must be excluded. A double paralysis is peculiarly suggestive 
of this cause. 

The prognosis is generally favorable. In most cases the palsy disap- 
pears within a few days; or, in slower process, by the end of six weeks. 
Continued paralysis is rare and always arouses a suspicion of a more re- 
mote etiology. 

The treatment consists of faradization with weak currents. It should be 
used only if the paralysis shows no improvement within two or three weeks. 

DISEASES OF THE UMBILICUS 

During fetal life, the umbilical cord forms the connection between the 
mother and the fetus. It contains, besides the remnants of embryonic 
organs (the yolk-stalk and the allantois), two arteries and a vein covered 
by the amnion and imbedded in Wharton 's jelly. The anatomic structure of 
these channels differs from that of other vessels. The walls are thick, and 
well supplied with muscle fibres and elastic tissue. They contain no vasa 
vasorum, so important for the nutrition of the vessels themselves. The 
blood from the placenta passes through the umbilical vein to the body of 
the child. Here the vein divides into two branches, one of which passed 
into the portal vein, while the other, the ductus venosus arantii, opens 
directly into the inferior vena cava. The blood passes through the fetal 
circulation and is finally carried back to the placenta by the umbilical 
arteries which arise from the hypogastric vessels. 

The circulation of the umbilical vessels stops when the first respirations 
occur. On account of the opening up of the lungs the umbilical blood-pres- 
sure falls, the arteries and the veins contract by means of the large amount 
of elastic tissue present in their walls and force out the remaining blood. 



134 TEXT-BOOK OF PEDIATRICS 

Because of the absence of the vasa vasorum and therefore of all nutritive 
supply, the umbilical cord dries up. This mummification cannot be con- 
sidered a vital phenomenon, as it was once believed to be. It follows even 
when the stump is separated from the body of the child and is kept warm 
and dry. Warmth and moisture, on the other hand, produce decay of the 
stump. The physiologic drying is usually completed by the fourth day. 
Coincident with it, a circumscribed inflammation at the navel occurs which 
causes the separation of the stump, usually on the fifth or sixth day. The 
umbilical wound lies deeper than the walls of the abdomen, in a small funnel- 
shaped depression formed by the retraction of the intra-abdominal portion 
of the umbilical vessels. A period of about three weeks is necessary for 
the healing of the wound. 

As results of the cessation of the blood flow, thrombi immediately form 
in the intra-abdominal portion of the umbilical vessels. These thrombi are 
gradually organized by the growth of connective tissue from the intima 
until the vessels are completely closed (endarteritis obliterans). The um- 
bilical vein becomes the ligamentum teres extending from the umbilicus to 
the liver; the arteries become the lateral vesico umbilical ligaments, which 
pass from the navel to the urinary bladder. 

CONGENITAL ANOMALIES 

The skin navel (critical navel) is formed by the extension of the skin from 
the body over the cord, so that after the cord has fallen off the usual funnel- 
shaped depression is absent. The umbilical wound lies at the apex of a 
protrusion which, in most cases, is gradually retracted, but which may re- 
main permanently. 

The amiiion navel, on the contrary, is caused by the spreading of the 
amnionic sheath of the cord which is normally connected to the skin at the 
base of the cord. This may spread to the size of a dollar over the abdominal 
surface. The mummification and falling off of the cord leaves a skin defect 
over this area, which usually heals by granulation. Both these anomalies 
are harmless and require no special treatment. 

Hernia at the umbilical cord (funicular umbilical hernia], is more 
important. Its origin is to be traced to the normal umbilical hernia which 
persists to the second month of fetal life. A loop of intestine which should 
normally return to the abdominal cavity has remained enclosed within the 
sheath of the umbilical cord. A large tumor forms at the umbilical site. 
The covering of the tumor is so transparent that the contents may be seen, 
through it. The hernia often contains other organs than the intestine. 

The stomach, liver or spleen have occasionally been seen through it. 
Only rarely is the rupture spontaneously healed. If the condition is not 
treated, a fatal peritonitis may set in after the cord has separated. 

Error in diagnosis is possible in the case of small ruptures only. It is 
especially dangerous, because where the intestine has been tied off, gangrene 
and ileus cannot be avoided. It is necessary, therefore, to establish the 
content of the umbilical hernia by careful palpation. 



DISEASES OF THE NEW-BORN 135 

The treatment consists, generally, in prompt laparotomy, reposition 
and suture of the edges of the skin. Only in rare cases should any depend- 
ence be placed upon spontaneous healing; it has rarely been observed. 

Persistence of the Omphalomesenteric Duct. The omphalomesenteric 
duct, which passes from the intestine to the. yolk sac, is normally obliter- 
ated by the end of the^second month of fetal life. If this does not occur, a 
communication between the ileum and the umbilicus remains a patent 
Meckel 's diverticulum. 

This rare anomaly prevents the healing of the umbilical wound after 
the cord has separated. A secretion appears and close examination reveals a 
fistula from which a turbid fluid exudes. This fluid, upon investigation 
proves, by its odor and its microscopic and chemical features, to be intes- 
tinal content. Diverticulae also occur, which have been obliterated upon 
the intestinal side, but remain open at the umbilicus and which secrete small 
amounts of an alkalin fluid resembling intestinal juice. 

The treatment consists in the surgical removal of the diverticulum. 

Fistula due to persistence of the urachus. Normally the urinary bladder 
is developed from the urachus, while the remainder of the organ obliterates 
and forms the median vesical ligament. If this latter portion remains patent 
as it does in rare cases, a communication between the bladder and the umbil- 
icus is established with consequent leakage of urine from the fistula at the 
navel. The fluid may be recognized by the presence of uric acid. 

Etiologically this malformation depends upon obstruction to the pas- 
sage of the urine from the bladder, by normal means such as phimosis, 
preputial adhesions, etc. 

In the treatment, the existence of obstructions must be sought for. The 
fistula should be cauterized after the natural urinary passages have been 
opened. In some cases, the edges must be freshened and sutured. 

INFECTIONS OF THE UMBILICUS 

Any delay in the separation of the umbilical stump and in the healing 
of the wound (see page 133) should direct our suspicion to a possible infection 
of the wound, complicating the physiologic process. The distinction be- 
tween the normal and the diseased umbilical wound cannot be too sharply 
drawn. Practically, the wound should be considered infected whenever 
inflammation appears and the temperature rises after the stump has 
sloughed. The infection which is usually due to cocci, more rarely to 
bacilli, is localized in the stump or in the umbilical wound or may extend 
from either. Apparently normal healing does not predicate the absence of 
infection; for serious extensive infections often occur without the usual 
visible signs of inflammation. 

According to location, we may classify the diseases of the umbilical 
stump, e.g., irregularity of physiologic mummification, gangrene, etc.; 
localized inflammation of the umbilicus, as blennorrhea, ulcer, fungus, 
omphalitis, gangrene of the umbilicus; and finally general infections starting 



136 TEXT-BOOK OF PEDIATRICS 

from this focus as arterial thrombosis, periarteritis, venous thrombosis, 
and periphlebitis. 

Another classification in common use is dictated by the severity of the 
disease. It distinguishes: 

MILD DISEASES OF THE UMBILICAL WOUND. 

1. Delayed healing. 

2. Blennorrhea. 

3. Ulceration and fungus. 

4. Circumscribed omphalitis. 

5. Gangrene of the stump. 

SEVERE DISEASES OF THE UMBILICAL WOUND. 

1. Umbilical gangrene. 

2. Arterial and venous thrombosis. 

3. Periarteritis and periphlebitis. 

Infections of the umbilical wound, particularly of the more severe forms, 
have decreased continually during the last few years, thanks to the great 
progress in our knowledge of asepsis. The obstetrician has learned to use 
proper measures of prophylactic asepsis, especially in the care of the umbil- 
ical stump. The dry method of treatment has proved especially useful. 
The stump of the cord is wrapped in clean sterile linen or gauze rather than 
absorbent cotton, which adheres too readily, and is then held by the usual 
abdominal binder. All antiseptic fluids and ointments are avoided because 
the moist warmth delays mummification and fosters decay. The drying 
process is usefully hastened by means of such dusting powder as bolus 
alba, 1 or bismuth subgallate in small quantity. As soon as the dressing 
becomes moist or soiled it should be changed, great care being taken to 
avoid tearing the cord. 

This same dry method of treatment is applicable to the umbilical wound 
after the cord separates. Especially is it necessary, if sloughing occurs early 
and there is much exudation from the wound, to avoid anything that will 
obstruct free drainage. 

.In private practice the daily bath presents no dangers but in crowded 
institutions, where the possibility of local infection exists, it is safer not to 
bathe the child until the wound is healed. 

GANGRENE OF THE STUMP 

Gangrene of the stump, or sphacelus, recognized by the strong odor of 
decay, the discolored appearance and the moisture of the gtump of the cord, 
and causing resorption fever, develops only when the cord is not properly 
cared for and when dressing materials are used which prevent drying. 

Treatment consists in the removal of the decayed tissue by means 
of the actual cautery. If this is done soon enough rapid healing results; if 

1 Because of the danger of the presence of tetanus bacilli in the bolus alba it must be 
sterilized before use. Stearate of zinc is very successfully used as a drying powder. 



DISEASES OF THE NEW-BORN 137 

not, the possibility of septic infection or of toxemia from the gangrenous 
area threatens. 

BLENNORRHEA 

Excoriation of the Umbilicus. Blennorrhea is that condition in which 
a seropurulent or purulent secretion occurs from the umbilical wound after 
the stump has been sloughed, the depression in the skin being slightly 
reddened and indolent granulations at the base of the wound being covered 
with a mucopurulent exudate. The flow of the secretion is obstructed by 
the anatomic relations, the retraction of the wound beneath the level and 
within the overlapping folds of the skin. In consequence and often by aid 
of constricting bandages, the inflammation frequently spreads to the 
neighboring periarterial tissue and to the newly formed thrombi in the 
arteries, which become involved in a purulent decomposition for some 
distance. In this way, something resembling a fistula is formed into which a 
probe may be introduced for several inches and from which large quantities 
of pus may be expressed. 

The diagnosis depends upon the continuous flow of the secretion from 
the wound. It must be remembered that the mere formation of pus in the 
navel, even though it be extremely abundant, is insufficient basis for a 
diagnosis of general umbilical sepsis. It is necessary, therefore, when pus 
formation in the navel is associated with serious disturbance of the general 
health to look for other causes of the major illness. 

The prognosis is favorable. The infection zarely spreads to the hypo- 
gastric arteries because of the complete destruction of the thrombi. 

By way of treatment it is of first importance to provide free drainage. 
It must be remembered that strips of gauze and the free use of anti- 
septic powders rather favor the continuance of the infective process than 
promote free drainage and granulation. Sometimes the pus may be care- 
fully expressed from the fistula several times daily. Occasionally, it may be 
necessary to open the fistula by means of incision made over a grooved 
director to insure proper drainage. If this is done and if the child is pro- 
tected from disturbances of nutrition, the blennorrhea heals rapidly. 
Slight dusting with antiseptic powders may aid in the formation of granu- 
lations. The development of pyodermia around the umbilicus may be 
prevented by the use of ointments. 

UMBILICAL ULCER 

Umbilical ulcer may occur primarily or in connection with blennorrhea. 
In this condition there is loss of tissue, varying from one-half to one and one- 
half inches in diameter of circular or irregular area surrounded by a sharply 
defined infiltrated edge, the base of the lesion being covered with pus or a 
thick white exudate. In some cases, it resembles the primary lesion of 
syphilis. There are no general symptoms, excepting fever. The prognosis 
is favorable, although local or general infection of the wound may 
arise (Fig. 27). 



138 



TEXT-BOOK OF PEDIATRICS 







FIG. 27. Small umbilical ulcer. 







FIG 28. Granuloma (Fungus) of the umbilicus. 



DISEASES OF THE NEW-BORN 139 

The treatment consists in cleanliness, with the application of moist or 
dry heat, the surrounding skin being protected with petrolatum. Peroxide 
of hydrogen and antiseptic powders and, in some cases, the salts of mercury 
used in ointment or powder form give excellent results. Rapid healing is 
often had upon the application of a little calomel. 

Diphtheria of the umbilicus appears as a flat ulceration covered by a 
heavy membrane, around which there is a hard and often a widespread 
inflammatory deposit. The diagnosis should always be confirmed by 
bacteriologic examination. The prognosis in cases treated early is not bad. 
Later cases, unrecognized, may die of cardiac complications. Antitoxin, 
in combination with local applications, is indicated. 

UMBILICAL FUNGUS (GRANULOMA OF THE UMBILICUS) 

If healing is long delayed, the excessive secretion and pus formation 
may produce a granulomatous tumor, the granuloma or fungus of the 
umbilicus. This growth appears as a small red tumor the size of a pea or a 
hazel-nut, arising from the base of the umbilicus. At times the growth is 
hidden, so that it can be seen only when the apposed surfaces are forcibly 
separated (Fig. 28). 

Besides the granulomata, enteroteratomata and adenomata rarely 
occur. These arise from inverted rests of the omphalomesenteric duct 
which have been separated by a process of constriction from their point of 
origin. They are to be distinguished from fungus by their smooth surface, 
the latter being rough or papilliform. In diagnosis it must be remembered 
that a protruding fistula of the urachus or a prolapse of the persisting 
omphalomesenteric duct may simulate a tumor. (See page 135.) A mistake 
of the one for the other may have serious results, since the treatment indi- 
cated for granuloma may cause perforation of the peritoneum and the bowel. 

In the treatment of smaller granulomata, the application of the silver 
nitrate pencil or of chloracetic acid is usually sufficient to shrink the gran- 
ulation tissue. Larger tumors must be ligated and cut off with scissors or 
removed by cauterization. 

OMPHALITIS (ACUTE INFLAMMATION OF THE UMBILICAL RING) 

Omphalitis, an inflammation of the umbilical ring and the surrounding 
skin and subcutaneous cellular tissue may occur secondarily to blennorrhea 
and ulcer, as well as primarily in the normal healing of the umbilical 
wound. In the latter event it arises from small fissures at the edge of the 
ring. The skin about the umbilicus becomes reddened and infiltrated. 
The abdominal walls are tense, while to avoid pain, which is increased by 
every movement, the diaphragmatic breathing is extremely shallow or 
entirely absent and the more active costal breathing is compensatory. To 
relieve the tension of the abdomen, the legs are flexed. The temperature 
rises and with the development of symptoms of more intense inflammation 
the general health of the patient is affected. 



140 TEXT-BOOK OF PEDIATRICS 

The prognosis is favorable if the affected area is small. In cases of 
extensive infiltration it must be carefully made, for there is danger that the 
inflammation may spread into the deeper parts and that a complicating 
peritonitis may ensue. 

The treatment consists in the application of moist or dry heat. If an 
abscess forms, it must be incised at the proper time. In obstinate and wide- 
spreading infiltration, it may be necessary to open the infected area freely. 

GANGRENE OF THE UMBILICUS 

Umbilical gangrene, so frequent in bygone days is now, happily, hardly 
ever seen. It is usually secondary to some one of the above mentioned con- 
ditions. It may be primary in cachectic infants. Discolored, vile-smelling 
tissue necroses spread over large areas of the abdominal skin. In especially 
severe cases, the inflammatory process extends to the deeper tissues, causing 
peritonitis and even intestinal perforation. With fever, collapse, and 
extremely severe general symptoms, this disease, the prognosis of which is 
difficult, goes on to death. But few cases are recorded in which healing by 
granulation has occurred after sloughing of the phlegmonous areas. 

Treatment is very unsatisfactory. Beyond the local treatment advised 
for gangrene, attention must be given to the conditions of feeding and nutri- 
tion in order that the patient's resistance may be raised. 

MIGRATORY INFECTION 

A general tendency to spread and to lead to septic and pyemic infections 
is characteristic of this class of umbilical diseases. The general infection 
may be brought about by a purulent necrosis of the vessel thrombi or 
through the lymph channels as an extending lymphadenitis. 

A migratory infection of the umbilical arteries is the more common form. 
In this condition, we have to deal chiefly with a periarteritis, recognized at 
autopsy as a seropurulent infiltration of the perivascular connective tissue. 
This directly causes an inflammation in the preperitoneal space and later of 
the peritoneum, with a consequent general peritonitis (Fig. 29). In rare 
cases, the process descends in the preperitoneal space and breaks externally 
through the inguinal ring, causing funiculitis, orchitis and phlegmon of the 
inguinal region, the so-called preperitoneal phlegmon. Thrombo-arteritis 
is more rare. It differs from periarteritis, which more often follows the 
normal healing of the umbilical wound, in that it arises from pus formation 
at the terminus of the umbilical arteries and frequently accompanies 
blennorrhea. It i? probable that, favored by improper treatment which 
tends to keep the wound open, the purulent necrosis of the thrombus 
spreads, until it finally reaches the hypogastric arteries and thence causes a 
general pyemia. Arterial thrombosis and periarteritis may occur together. 

In disease of the umbilical vein, lymphangitis alone is hardly ever 
observed, because of the slight development of the perivascular tissue. In 
this vessel, thrombophlebitis, or a combination of thrombo- and peri- 



DISEASES OF THE NEW-BORN 



141 



phlebitis is more frequent. The disease of the vein leads to peritonitis or 
hepatitis or both, resulting frequently in multiple abscesses. 

Of the symptoms of this disease, fever, only, is first observed; the cause 
of which is the more obscure because the umbilical wound, hi even cases of 
venous infection, is usually completely healed. But as soon as the peri- 
tonitis or pyemia develops, the picture is one of severe general septic 




Fig. 29. Arteritis and periarteritis of the umbilical, vessels. Mucopurulent infiltration 
of the arterial walls and the periarterial connective 'tissue extending to the urinary bladder. 
Beginning peritonitis. 

infection, often showing pyemic metastases. Icterus, as is well known, is 
common in venous disease. This complication, if the disease spreads 
slowly, may occasionally occur during the second, third or even the fourth 
month. Abscesses of the liver may also be postponed to so late a period. 

The prognosis is bad in almost all cases. Exceptionally the purulent 
process may be arrested and encapsulation may ensue before the appear- 
ance of general infection. 

The treatment is that generally indicated in septic infection. 



142 TEXT-BOOK OF PEDIATRICS 

TETANUS NEONATORUM 

Etiology. Tetanus in the new-born is distinguished from that in the 
adult only by the peculiarity of its port of entry. Almost invaiiably the 
umbilical wound is responsible for the invasion of the micro-organism. The 
soiled hands of those who care for the child and especially hands soiled with 
garden earth or floor dust, the normal medium for the tetanus bacillus, 
carry the .infection. Occasionally the materials for the dressings (bolus 
alba) may come under suspicion as carriers of the infection. 

The demonstration of the bacillus is possible. For this purpose, the um- 
bilical wound is scraped with a sharp curette and the material so obtained 
is- injected into a mouse. The organism doefe not cause local inflamma- 
tory changes in the wound. If inflammation does occur, we have to deal 
with a mixed infection (pyogenic organisms). 

The pathologic findings are those of congestion in the central nervous 
system. Occasionally, extensive hemorrhages are present. 

The incubation period is sometimes very short, symptoms appearing 




FIG. 30. Tetanus neonatorum. Typical facial expression. 

as early as the first or second day. Most cases appear by the end of the first 
week; but a few in the second and third week. 

Symptoms. The earliest symptom is trismus, first recognized by the 
difficulty in introducing the nipple. The rigidity soon spreads to the face 
and graduaUy appeals in the muscles of the trunk and of the arms and legs, 
so that the whole body eventually becomes stiff. The child's face is 
characteristic; the tetanic facies, with wrinkled forehead, closed eyelids, 
taut cheeks, hardened by the contraction of the masseters, slightly puckered 
and firmly compressed lips, with the angles of the mouth drawn down pro- 
ducing the risus sardonicus (Fig. 30) , completing the picture. In the further 
course of the disease, lightning-like tetanic spasms passing over the whole 
body like a flash, occur. In the interval, the patient lies silent, perfectly 
rigid, frequently in opisthotonos, with distended legs and rigidly flexed 
arms. With the extension of the tetanus to the respiratory muscles, disturb- 
ances of respiration and cyanosis appear. The more severe the type, the 
more frequent the spasms. In extreme cases rises in temperature are 
observed, which occasionally show most peculiar variations and may reach 
a stage of hyperpyrexia. 



DISEASES OF THE NEW-BORN 143 

Diagnosis. The diagnosis may always be made from the clinical pic- 
ture. The demonstration of the bacillus is not necessary, since a negative 
result is of no value. Of course, the differentiation from similar diseases is 
not always easy. Tonic contractions in the new-born are also seen in such 
birth injuries as cerebral and meningeal hemorrhages, in encephalitis and 
other cerebral processes. In the latter, the involvement of the ocular mus- 
culature is a valuable point of differentiation; it is absent in tetanus. 

Prognosis. In general, the prognosis is very unfavorable; from seventy 
to eighty per cent, of cases die. In individual instances, the prognosis will 
depend upon the length of the incubation period and the severity of the 
infection. Long periods of incubation, relatively infrequent spasms, ab- 
sence of respiratory impairment and cyanosis and of excessive temperature 
permit a more favorable although guarded outlook. 

Treatment. The treatment consists chiefly in measures for the relief 
of the convulsions. Absolute quiet and removal from all possibility of ex- 
ternal shock is to be advised. Light moist or dry packs reduce the irritating 
influence of air currents and of temperature changes. 

Chloral hydrate 0.5 gm. (7 grs.), at a dose, up to 3.0 gms. (45 grs.) 
per day has been used, in most cases in combination with the bromides, 
preferably calcium bromide, 1-2.0 gms. (15-30 grs.) per day in aqueous 
solution, or veronal, 0.075 gm. (1 gr.) per dose. These are best given 
by rectum. The antispasmic action of an injection of a salt of magnesium 
(20 c.c. of an 8 per cent, solution of magnesium sulphate), may be tried. 

Great difficulty is encountered in feeding on account of the trismus. 
Expressed breast-milk or artificial food is to be given from a spoon, and, if 
necessary, through the nose. In severe cases, it is preferable to avoid 
repetitional excitement and to feed only three times a day through a 
catheter. The required quantity of water may be given in small enemata 
or by enteroclysis (see page 111). 

Serum therapy cannot, as yet, show absolute results. One-half of a tube 
of antitetanic serum, containing 250 units, should be injected subcutane- 
ously around the umbilicus and the other half into the spinal canal by 
lumbar puncture. 

Since the above was written the value of antitetanic serum has been 
definitely proved. The physician is justified in giving it even before the 
bacteriologic diagnosis is established. Much larger quantities up to 1000 to 
2000 units, may be given and repeated. 

UMBILICAL HEMORRHAGE 

Umbilical hemorrhage may come from the arteries, either before or after 
the separation of the cord, or it may come from the parenchyma (idiopathic 
hemorrhage). Hemorrhage from the vessels indicates a failure of their 
physiologic closure, while an idiopathic hemorrhage shows a local or general 
decrease of the physiologic coagulability of the blood or an abnormal per- 
meability of the vessel walls. 



144 TEXT-BOOK OF PEDIATRICS 

Hemorrhage from the vessels while the cord is still attached should never 
be laid to unsuccessful ligation of the cord, since the physiologic sequel of 
birth, in the way of constriction of the vessels and reduction of blood-pres- 
sure through the expansion of the lungs suffice, under normal conditions, to 
stop the bleeding even without ligation. Hence, it is always well to search 
for more remote causes of umbilical hemorrhage (pulmonary atelectasis, 
asphyxia, heart lesions, etc.). 

In the rare cases of hemorrhage which occur after separation of the cord, 
the formation of thrombus and the closure of the vessels by the organization 
of the clot are delayed by causes as yet unknown; possibly by a reduction of 
the coagulability of the blood incident to infection. 

Parenchymatous bleeding is the result either of general sepsis, which 
reduces the blood coagulability or, more rarely, of local infection which 
prevents the formation of solid thrombi. 

In the treatment of hemorrhage from the vessels of the umbilical cord it 
is necessary to tie off the cord with special care and for this purpose elastic 
bands are to be recommended. The respiration should be persistently and 
carefully watched. Hemorrhage after the separation of the cord is stopped 
by painting with epinephrin solution (1 : 1000), by touching with the thermo- 
cautery or by taking sutures around the navel through the abdominal 
walls. In parenchymatous hemorrhage all these measures are useless. In 
this, as in all other hemorrhage uncontrolled by such measures, the attempt 
must be made to overcome the bleeding by local applications and by sub- 
cutaneous injection of 10 to 20 c.c. (2-4 drams) of sterile gelatin solution. 
The injection of human serum, obtained as fresh as possible a method 
recently used with success, may be considered. 

Experience has shown that hemorrhage from the umbilicus is very fre- 
quently a manifestation of idiopathic hemorrhagic disease of the new-born. 
Coagulation and bleeding time should be tested in every case and when 
they are found to be prolonged, subcutaneous injections of whole blood 
should be given in the amount of 30 c.c. once or twice daily, until the hemor- 
rhage is controlled, and the bleeding and coagulation time becomes normal. 

SEPSIS 

While septic diseases of every grade, from the mildest to the most severe, 
were formerly common in institutions for children and in lying-in hospitals 
where they are still observed, yet, they have now, thanks to the advance of 
hygiene, become much less frequent. 

In their etiology many forms of micro-organisms are concerned. The 
ordinary pyogenic bacteria, the staphylococci and the streptococci and the 
pneumococci, are particularly observed, but other varieties, as the bacillus 
coli, Friedlaender 's bacillus, the bacillus of hemorrhagic septicemia, the 
bacillus pyocyaneus and certain strains of proteus, are occasionally among 
their causative factors. 

The fetus may become infected, even in utero, by the passage of germs 
from the diseased placenta. A second possibility of infection before birth 



DISEASES OF THE NEW-BORN 145 

occurs between the rupture of the membranes and the end of delivery. 
Such occasions of disease transmission are, of course, rare as compared with 
those which develop postpartum. After birth, the umbilicus is the chief 
port of entry for pathogenic organisms; but the general surface of the skin is 
the subject of so frequent and so numerous wounds erosions, rhagades, 
intertrigo, etc., during the early days of life, that many other opportunities 
of infection are offered. Usually, only local disturbances, such as furuncles, 
abscesses and phlegmons, occur; to which, later, general septic or pyemic 
developments maybe added. The mucous membrane may also offer a route 
of invasion for micro-organisms. From injuries to the buccal surfaces, 
usually caused by the meddlesome care of the mouth, formerly in so common 
vogue, stomatitis, and Bednar's aphtha may be traced and general septic 
disease may take origin. More frequently however, the primary septic focus 
is to be found in the pharynx, in the nasal mucous membrane, the con- 
junctiva, the tonsils, the ear, or the intestine. The possibility of general 
infection from the lung and from the urinary tract must also be considered. 

The transmission of the infection results from numerous forms of con- 
tact (fomites, hands, utensils, lochia, etc.). The theory, occasionally 
advanced, that infection comes by way of the mother's or cow's milk, 
containing germs, is not tenable. Undoubtedly, disturbances of nutrition 
increase the liability to infection to a great degree by reducing the immun- 
izing forces of the body and therefore, infective disease is more common in 
artificially-fed children. 

The structural basis of sepsis varies widely with the numerous clinical 
pictures which present themselves. In the more acute cases, the autopsy 
findings are often very indefinite and are confined to parenchymatous 
degenerative lesions. In cases of longer duration, more marked visceral 
changes may be seen. Hemorihages from the serosse are especially frequent. 
Evidences of pneumonia, gastro-enteritis, and numerous metastatic, serous, 
sero-hemorrhagic or purulent foci of inflammation (embolic abscesses, septic 
infarcts, osteomyelitis, empyema, synovitis, etc.), are associative. 

With its greatly varied etiology and with the large number of entry 
ports of septic infection, the disease-picture is also extremely variable, as 
regards alike the severity of the general toxemia and the localized disease in 
individual organs. However, the majority of cases are similar in so far 
as the symptoms of general intoxication are concerned and these are usually 
more marked than is common in older patients, Fever, restlessness, alter- 
nating with apathy, a tendency to collapse, and disturbances of conscious- 
ness are usually present. Disorders of the digestive tract in the foim of 
diarrhoea, with rapid losses of weight, are almost always observed and these 
often appear in so pronounced a form that the sepsis runs its course mis- 
takenly diagnosed as a gastro-intestinal disease. The similarity of the 
picture of severe primary dyspepsia with toxic conditions, as it develops 
frequently in the course of a pure disturbance of nutrition, will be readily 
understood. In fact, the septic process usually develops in such a way that 
the parenteral disease becomes the cause of severe alimentary disturbance. 
10 



146 TEXT-BOOK OF PEDIATRICS 

Sometimes, the sepsis develops within a very brief period and the diag- 
nosis is possible only by bacteriologic examination. In other cases, the 
process covers a longer time and various other symptoms may be observed. 

Symptoms. Fever is usual; high and irregular rises of temperature 
especially at the beginning of the disease are often followed, earlier or later, 
by a marked fall and collapse. At times, every rise in temperature from the 
very beginning is succeeded by collapse. Chills, so common in older 
patients, are never seen. 

In the urine, albumin, casts and epithelial cells are always found as 
an expression of the toxic effect upon the kidneys; at times a hemor- 
rhagic nephritis or cysto-pyelitis may develop. Enlargement of the spleen 
and liver is common, but is of diagnostic value only when it appears 
during the course of the disease. Numerous changes in the skin are indica- 
tive of toxemia. Septic erythemata, which resemble either scarlet fever, 
measles or erythema multiformi, occur. Hemorrhages, in the form of small 
petechise or large ecchymoses, are characteristic and of diagnostic signifi- 
cance. The color of the skin is at times grayish, as in anilin poisoning. 
Often the skin and mucous membranes become yellow because of a com- 
plicating icterus. 

It is customary to distinguish a hemorrhagic, a gastro-intestinal and a 
pneumonic form of sepsis according to the prevalence of certain groups of 
symptoms. 

A true pyemia characterized by metastatic abscesses is not very common 
in the new-born, nor at any period of childhood. Probably the low degree 
of resistance at this age does not favor the slow course of the disease neces- 
sary to abscess formation. Nevertheless, it does occur now and then and 
runs a course showing special tendency to metastases in the skin and to 
embolic abscesses in the internal organs, to pyemia of the joints or to osteo- 
myelitis. Endocarditis and pericarditis are comparatively rare. 

Buhl's and Winckel's disease are to be regarded as forms of sepsis 
having a peculiar course. Their etiology has not been explained. The Buhl 
type produces a fatty degeneration of the heart, liver and kidney resembling 
that of phosphorus poisoning, together with hemorrhages in various organs 
and in the skin. The children affected by these very rare diseases are born 
asphyctic and severe manifestations of disease soon appear, such as diar- 
rhoea, loss of weight, hemorrhage and sopor. Most cases die and death 
occurs early with extreme cyanosis and icterus. 

The chief symptoms of Winckel's disease are hemoglobinemia and 
hemoglobinuria. The disease runs its course with cyanosis, icterus, dysp- 
noea and gastro-intestinal manifestations and usually results in death in a 
very short time. 

The diagnosis is based upon the recognition of a port of entry, upon the 
existence of metastatic foci, which may, however, be hard to demonstrate, 
and upon the appearance of petechiaB, icterus, etc. The chief difficulty lies 
in its differentiation from alimentary intoxication, a distinction which is all 
the more important because parenteral infections in the young infant tend 



DISEASES OF THE NEW-BORN 147 

to cause secondary disturbances of nutrition. In alimentary cases, the 
effect of dietetic treatment upon the fever, the toxic symptoms and the 
diarrhoea make the primary cause clear. The bacteriologic examination of 
the blood cannot be undertaken outside of the hospital, because it is not 
always possible to obtain the required amount of blood, which should be, 
at least, 2 c.c. (% dram). 

The prognosis is always grave. The more abrupt the onset and the more 
rapid the course of the septic process, the less prospect is there of keeping the 
patient alive. In the pyemia of gradual development and slow course the 
hope of successfully combating the disease is better justified. Occasion- 
ally, cases in which hope is apparently lost may recover if nutrition is 
well sustained. 

Prophylaxis. The experience of hospitals and infant homes has taught 
us that much may be accomplished in combating sepsis by proper prophy- 
lactic measures. It has been shown, first of all, as already noted, that the 
sources of infection may be reduced and the number of entry ports for 
infective organisms may be decreased by proper care of the skin and the 
umbilicus, by frequent changing and by the avoidance of meddlesome 
cleansing of the mouth. In the home, also, it is necessary to guard the 
new-born infant with the greatest possible cleanliness and asepsis. 

Special care must be taken when the mother has a puerperal infection. 
In this event, it is better that the mother and the child should be cared for 
by different persons. If this is impossible, the child's toilet should always 
be attended to before the mother 's, in order to protect it from contamina- 
tion. This is advisable even when the puerperal mother is well, because 
even the normal lochia may contain pathogenic organisms. On the other 
hand, the danger that threatens the child from the milk of a puerperally 
diseased mother is much overrated. It has never been demonstrated that 
septic infection is introduced in this way. In cases where there is any 
anxiety on this score the expressed milk may be fed. Not even the milk of a 
woman suffering with mastitis seems to be dangerous to the infant, in so far, 
at least, as the defensive measures of the intact mucous membrane of the 
mouth are concerned. 

Treatment. In the treatment of sepsis, suitable feeding is the first 
requirement; since it has been shown beyond a doubt that the formation 
of immune bodies is favored in the greatest degree by proper diet, while 
Improper feeding definitely lessens immunity. It is often possible to 
maintain the bodily strength of the child at so high a stage with mother's 
milk that the infection may be overcome. In fact, those methods of feeding 
which determine the general well-being of the infant in health are similarly 
beneficial in sepsis, so that the mother's milk is the main reliance. Particu- 
larly in those cases in which intestinal disturbance become prominent 
much may be expected from proper feeding. They should be treated by the 
identical methods that obtain in similar conditions arising from alimentary 
causes. (Compare Disturbances of Nutrition.) Local pus formation must 
be treated according to surgical requirements. Strong antiseptics, espe- 
cially phenol and iodoform, are to be avoided. 



148 TEXT-BOOK OF PEDIATRICS 

For the rest, it may be necessary to stimulate the heart by the use of 
camphorated oil (7 minims, subcutaneously, several times a day 2 ) ; or with 
citrated caffein or caffein sodio-salicylate 4 c.c. (1 dram) of a 0.5 to 1 per 
cent, solution, four or five times a day, or with a solution of epinephrin 
(1 : 1000), 7-15 minims. In high fever, tepid baths are useful. If there is a 
tendency to collapse, hot baths, carefully applied may be employed. Neither 
collargol, by enema or in form of an ointment, nor antistrepticoccic serum 
have given any definite results. 

HELENA NEONATORUM 

The passage of large quantities of pure blood from the gastro-intestinal 
tract has customarily been called melena. The blood is voided either by 
vomiting or by stool. A form of pseudo-melena (melena spurid), occurs, in 
which the vomited blood is of different origin. It may arise from an epis- 
taxis or be derived from a wound in the nipple of the nurse. In true melena 
the gastro-intestinal tract of the patient is the direct source of the hemorrhage. 

Under this proper designation, however, a symptomatic melena and a 
true melena may be distinguished. Symptomatic melena is a result or 
manifestation of some other disease. It sometimes occurs in diseases of the 
liver (lues), or in other processes causing severe congestion. The most 
common causes, however, are septic and septo-hemorrhagic infections, in 
which the melena occurs only as one form of other and multiple hemor- 
rhages. In many cases, such infection is introduced by specific hemorrhage 
producing organisms. 

The origin of true melena (melena verd) is still wholly obscure. Nothing 
more is known than that the blood usually comes from small ulcers in the 
stomach or duodenum and, more rarely, in other parts of the tract. But it 
may be possible that even these are absent and that in autopsy only hemor- 
rhage from the mucous membranes or a simple hyperemia is found. Nothing 
definite can be said about the mode of origin of these ulcers. The once 
accepted theory that they are caused by embolisms from thrombi of the 
umbilical veins, does not seem plausible. At present, thrombosis of small 
intestinal vessels with consequent hemorrhage and resulting tissue digestion 
is considered more probable. This thrombosis may be caused by a vaso- 
motor-ischemia. The significance of concurrent disturbances of nutrition 
may be understood from the frequent occurrence of duodenal ulcers in 
severe atrophic conditions (decomposition). The theory is also advanced 
that conditions of central nervous irritation may cause hemorrhages from 
the intestinal mucosa and that the hemorrhagic areas are then converted 
into ulcers by action of the digestive fluids. 

The hemorrhages usually begin by the second to the fourth day, although 
occasionally they appear earlier or later. Unimportant, at first, they soon 
reach the stage in which tarry stools are passed, or clotted masses of blood 

2 Recently, objections have been raised against the use of camphor in severe general 
infections. 



DISEASES OF THE NEW-BORN ' 149 

vomited. The weakness and anemia resulting depend upon the severity 
and duration of the hemorrhage. Some children bleed to death rapidly; 
in others, the condition extends even to the second week. Of the untreated 
cases, more than one-half die. 

The diagnosis must determine whether it is a false or symptomatic 
melena, or a true melena. This is all important to the prognosis. The 
symptomatic form and especially the hemorrhages dependent upon sepsis 
have a very unfavorable prognosis. A prolonged bleeding and coagulation 
tune are practically always present in true melena. 

Treatment. By way of treatment subcutaneous injections of gelatin 
may be given and repeated if necessary. The gelatin may be obtained free 
from tetanus and completely sterile in ampules, 10-25 c.c. (2-6 drams). 
Many cases have been saved by this method. The subcutaneous injection 
of 10 to 20 c.c. (23^-5 drams) of serum, preferably human, has been recom- 
mended. The horse serum may be substituted if the human cannot be 
obtained. In urgent cases, whole blood may be used instead of serum. 
Recent experiences show that 30 c.c. of blood taken from the mother by 
means of the ordinary Luer syringe and injected subcutaneously is very 
efficient . The syringe may be lined with sterile petrolatum or the blood 
may be citrated (sodium citrate 2 per cent.) but these precautions are not 
essential. The injection may be repeated daily, or more often if necessary. 
All other measures (ice, liquor ferri sesqui-chlorate, epinephrin, etc.), are 
uncertain. Upon occasion, the usual treatment for collapse and, in certain 
cases, the transfusion of salt solution, must be considered. 

ERYSIPELAS 

Erysipelas of the new-born does not differ etiologically from the disease 
at any later age, but is distinguished from it by its increased tendency to 
spread and its resulting malignancy. It usually arises from either the um- 
bilicus or the genital organs and begins at the end of the first or second week. 

It begins with redness and edematous swelling of the affected part, 
which increases in diameter and spreads rapidly. High fever develops and 
in many cases alternates with collapse temperatures. The general health 
of the child is severely affected. At times, skin necroses, phlegmonous, gan- 
grenous and general septic processes develop from the erysipelas as a base. 

In the diagnosis, the differentiation from phlegmon must be especially 
considered. The prognosis is very unfavorable in the new-born; certainty 
much more unfavorable than it is in somewhat older infants, to say nothing 
of children of more advanced years. 

The treatment is that generally used in this disease ; (ichthyol ointment, 
alcohol, mercuric bichloride, 1:1000, aluminum acetate, etc., externally). 
Applications of saturated solution of magnesium sulphate are of great value. 
Special attention must be given to the maintenance of the general quality 
of resistance by the feeding of mother's milk and of the strength of the 
heart, in particular, by means of stimulants. 



150 TEXT-BOOK OF PEDIATRICS 

OPHTHALMIA NEONATORUM 

Severe purulent catarrh of the conjunctiva is frequent in the new-born; 
partly because of a special predisposition upon the part of the mucous 
membranes of early life, and partly because the passage of the child through 
the infected birth canal affords especially favorable opportunities for con- 
junctival infection. In fact, the majority of children are infected with the 
disease during labor if the mother is suffering from any form of purulent 
vaginitis. The number who acquire the disease later, by some other form 
of contact, is small. 

Etiology. The gonococcus is usually considered the most common 
agent in the production of blennorrhea. The so-called inclusion or chlamy- 
dozoa blennorrhea is almost equally frequent, however, with the gonococci 
form. Clinically it has a great resemblance to the latter, but in general 
pursues a milder course. By staining smears according to the Giemsa 
method, the inclusions of epithelium as described by Halberstaedter and 
Prowazek, may be demonstrated in large numbers, while gonococci are 
absent. Pneumococcic conjunctivitis, the catarrhal infection produced by 
the Koch- Weeks bacillus and other forms are known. 

Symptoms of the gonorrheal form, which is the most severe, appear by 
the second or third day in the form of a reddening and edema of the lids, 
while a thinsero-hemorrhagic secretion appears between them. The eyes can 
be opened with difficulty, the lids are tense and the conjunctiva chemotic. 

In severe cases, the lids may become so tense that danger of gangrene 
arises, and the conjunctiva shows a membranous exudate. After several 
days, the swelling goes down and large quantities of pus are secreted while 
the connective tissue appears slightly granular. 

The duration of uncomplicated cases is usually from six to eight weeks, 
when recovery sets in. The danger of keratitis with perforation always 
threatens. It is a generally accepted fact that about one-third of all blind- 
ness is due to blennorrhea. Gonorrheal arthritis, synovitis, dermal ab- 
scesses and exanthemata are among the complications of the local infection. 

The course of blennorrhea due to micro-organisms other than the gono- 
coccus is usually shorter and its result more favorable; but damage to the 
cornea is not always avoided. 

The value of Crede's prophylactic method of instilling one drop of a 
1 per cent, silver nitrate solution, or some less irritating silver salt, in each 
eye is recognized. The catarrhal conjunctivitis which the silver may cause 
may be disregarded in view of the great benefits of the method. 

Treatment. The treatment, during the stage of swelling, consists of 
measures to reduce the inflammation. Applications of ice are frequently 
recommended, but the extreme cold may be injurious at this stage. No 
damage will be done by dry or moist heat. In addition, irrigation with 
warm antiseptic solutions (boric acid solution, mercuric bichloride, 
1 : 5000), may be useful. After pus formation is fully established, the physi- 
cian himself should touch the averted lids daily with a 1 to 2 per cent, solu- 
tion of silver nitrate, after which the eyes should be carefully washed out 



DISEASES OF THE NEW-BORN 151 

with physiologic salt solution. Several drops of a two per cent, solution of 
protargol or argyrol (freshly prepared without heating) may be instilled into 
the eye in place of the silver nitrate. In all methods of treatment, injury to 
the cornea must be very carefully guarded. If only one eye is affected, the 
sound eye should be washed daily with a half of one per cent, solution of sil- 
ver nitrate and may be covered with a protection bandage. Involvement of 
the cornea should be treated occording to ophthalmologic methods. The 
articular metastases will heal, without opening the joint, with applications 
of heat or of Bier's hyperemia, or, at most, by puncture. In obstinate 
cases, vaccine treatment may be tried. 

SWELLING OF THE MAMMARY GLAND AND MASTITIS 

In quite a number of new-born infants of both sexes, swelling of the 
mammary gland begins two or three days after birth. It increases until the 
middle of the second week and then gradually disappears. During this pe- 
riod, the so-called " witch 's-milk, " which very closely resembles colostrum, 
may be expressed from the gland, so that we have to deal with an actual se- 
cretory function similar to that of the maternal breast. The probable cause 
of this phenomenon is to be found in the lactogen, a substance which, accord- 
ing to the latest researches, is produced by the ovaries and the uterus and 
which in gravid puerperal women stimulates the production of milk. This 
agent passes by way of the placenta into the circulation of the child and 
acts specifically upon the infant breast. Upon the invitation of this physio- 
logic activity, infection may occur and mastitis may develop, especially if, 
in line with an old and objectlonal popular practice, the fluid is expressed. 
The turgescence further increases, fever, redness and abscess formation or 
phlegmon ensue; from which source, occasionally, a general infection may 
arise. The prognosis of mastitis, however, is generally good. 

The treatment consists primarily in measures to reduce the inflam- 
mation, followed later, if necessary, by incision. Radial incision should be 
carefully done to avoid severing the ducts. 

ICTERUS NEONATORUM 

Jaundice occurs in more than eighty per cent, of all new-born infants, 
from the second to the fifth day. It appears first in the face and then de- 
scends over the body. The sclera are affected much later. Other manifesta- 
tions of disease are absent. The feces are colored with bile. The urine is light 
in color and is negative to the usual tests for bile pigment. Microscopically, 
however, brownish-yellow masses of bilirubin, either free or in epithelial or 
hyaline casts ("masses jaunes"), are found (Fig. 31). The jaundice lasts 
from a few days to three weeks; in exceptional cases only, and especially in 
premature infants, is it present for a longer time. The whole phenomenon 
is quite unimportant and is considered a physiologic one. 

No anatomic lesion is found in infants with jaundice who die from other 
causes. Bilirubin crystals may be demonstrated in the tissues. 



152 



TEXT-BOOK OF PEDIATRICS 



Of the cause of icterus neonatorum, nothing definite is yet known. The 
older theories which attempted to show that it was of hematogenous origin 
and caused directly by the resorption of the products of a catabolism of the 
hemoglobin derived from extravasated or broken-down red blood-cells, 
independently of any action of the liver, have been disproved by the demon- 
stration of bile acids in the urine and in the tissues, the presence of which 
can be due alone to a resorption of bile. Quincke 's theory to the effect that 
the bile massed in the meconium passes directly into the blood through the 
patent ductus venosus arantii has, also, many arguments against it. The 
theory of a passing anomaly of liver function, on account of which the bile 
not only passes into the bile capillaries, but is, in part, also secreted into the 




Fio 31. Urinary sediment in icterus neonatorum (Berlin Children's Asylum). 



blood, is a more probable one. Obstruction, causing the flow of the bile in 
the wrong direction, has been attributed to increased pressure in the bile 
capillary system, secondary to polycholia or to an excessive viscosity of the 
bile. But this theory, also, has to be abandoned, when Hirsch and Ylppo 
were able to show that during the last months of fetal life an increase in the 
production of bile pigment and its presence in the blood occurs normally, a 
condition which persists for several days after birth. Accordingly, icterus 
neonatorum may be considered an actually physiologic phenomenon. Ic- 
terus of the skin always occurs when the bile pigment content of the blood 
passes a certain definite limit. The explanation of this increase of the bili- 
rubin during the first few days of life still remains a problem. 

Other forms of icterus also occur in the new-born, which are all the more 
important because they are more serious. In all these forms bile pigments 



DISEASES OF THE NEW-BORN 153 

may be found dissolved in the urine and examination of the urine is, there- 
fore, very important in the diagnosis. The most common of these forms of 
jaundice is septic icterus. Infectious forms are seen in hospitals and are, 
at times, epidemic. They produce slight fever and gastro-intestinal symp- 
toms, and in some cases, are fatal. They probably depend upon an entero- 
genous invasion of bacilli into the bile passages ("maladie bronzee"). 
Congenital atresias of the large bile ducts are evidenced, during the first 
days of life, by the jaundice that they cause. 

Habitual icterus gravis of the new-born is a rare and puzzling condition. 
It affects several or all the children of a family. It runs its course with 
severe general manifestations and, later, develops cholemic symptoms. 
Usually, it has a fatal termination. At autopsy, internal hemorrhages, 
small serous exudates in the body cavities, swelling of the spleen and liver, 
together with marked icteric discoloration of the brain nuclei, are found. 

EDEMA AND SCLEREDEMA OF THE NEW-BORN 

Mild forms of edema occur so much more commonly in the feeble new- 
born, and especially in prematurely born infants, than they do in older 
children, that the term edema neonatorum has been bestowed upon them. 
Such edema is not associated with nephritis, but resembles in its course the 
idiopathic edema which is not infrequently seen in cachectic children, during 
the first and second years of life, and is dependent upon the retention and 
non-excretion of water which is, in turn, related to disturbances of salt 
metabolism. It is apt to be most severe when the diet contains much salt 
and, especially, sodium salts. While this idiosyncrasy comes, in the older 
child, in the path of disturbances of nutrition and as a consequence of infec- 
tion, in the new-born and prematurely born it represents a congenital func- 
tional insufficiency. It is possible to build up the infant by proper care and 
feeding, the edema disappears spontaneously. 

Scleredema. The hard swelling of scleredema which cannot be easily 
indented and, in extreme degree, may cause a stiffness of the limbs, is in 
direct contrast to the soft doughy swelling of edema. The skin, in this form 
of disease, has a death-like pallor or is mottled and characteristically cold. 
The general body temperature is far below normal. At autopsy, the sub- 
cutaneous tissue and the skin are saturated with a yellowish fluid, very rich 
in protein, and possessing the characteristics of serum, rather than of the 
lymph of simple edema. The skin change? usually begin in the legs and 
in severe cases spread over the entire body, leaving only the scrotum, the 
knuckles and the eyelids unaffected. The disease is always accompanied by 
evidences of extreme weakness, such as apathy, somnolence, thready pulse, 
superficial and irregular breathing, and anorexia. The prognosis, usually 
unfavorable, is dependent upon the severity of these general symptoms; 
although it is occasionally possible to save even apparently hopeless cases 
by an improvement of their general nutritive condition. 

Schlerema. The dieease must be differentiated from fatty sclerema, 
in which the swelling cannot be indented and depends upon a hardening 



154 TEXT-BOOK OF PEDIATRICS 

of the subcutaneous fat. As a rule, fever is present in this disease. At 
autopsy, no fluid appears upon section. 

The cause of scleredema has not been, as yet, fully explained. The most 
commonly discussed hypotheses are those on the one hand, which look upon 
the condition as a septic infection, complicated by vascular changes; and, 
on the other hand, as an idiopathic edema to which is added a hardening of 
the subcutaneous fat, ordinarily occurring after death, but which in this case 
is due to a lowered metabolism and to the extreme cooling of the body. In 
view of the peculiar consistency of the exudate, a condition related to a 
coagulative edema, resulting from injury to the vessels because of the ex- 
tremely low temperature, must also be thought of. 

The treatment consists of the application of external heat by means of 
the incubator, or other similar apparatus (see page 122). Heat may be 
applied more rapidly by a hot bath. All further therapy must be ad- 
dressed to the restoration of the reduced strength. Feeding with mother's 
milk is indispensable. 

ALBUMINURIA 

Albuminuria (proteinuria) , is observed so frequently in the new-born 
that it has been called "physiologic." The quantity of protein is always 
small. The greatest amount is present from the first to the third day. 
Traces are often present until the second week and occasionally later. The 
urinary sediment contains epithelia, leucocytes, and abundant urates. 

In spite of much discussion, the cause of the albuminuria, is not defi- 
nitely known. It is generally looked upon as incident to the sudden changes 
in the infant metabolism and circulation in the transition from intra- to 
extra- uterine life. Probably the physiologic congestion arising in the vascu- 
lar system, during birth, causes proteinuria, as it does in the analogous con- 
dition of orthostatic albuminuria. 

URIC ACID INFARCTS 

The peculiar change of the kidney in which yellowish-red stripes are 
seen arising from the papillae, passing into the pyramids and disappearing 
in the cortex, is called uric acid infarct. Microscopically, urates are found 
imbedded in the kidney substance. Doubtless there is an increased secre- 
tion of uric acid in the new-born. This is most probably due to the de- 
composition of large numbers of nuclein-bearing cells (leucocytes). Why 
the uric acid should be deposited in the form of infarcts is still an un- 
solved problem. 

Gradually, during the first two weeks of life, the infarct is dissolved 
without injury to the infant and gives the urine its characteristic sediment, 
a reddish-yellow, finely granular mass which stains the diaper red and is 
seen under the microscope to be made up of casts covered with urates, fine 
urate deposits and epithelium. 

VAGINAL HEMORRHAGE 

In rare cases, hemorrhage from the vagina, of slight degree, occurs in 
new-born infants during the first few days of life. The blood comes from' 



DISEASES OF THE NEW-BORN 155 

the uterus, as may be readily seen with an ear speculum. No other symp- 
tom or disturbance of the general health appears. 

Only recently has a knowledge of the cause of this phenomenon been 
gamed. It is probably incident to a physiologic congestion, resulting in 
subepithelial hemorrhages of the uterus like the process of menstruation; 
and like it, caused by a specific internal secretion which circulates in the 
maternal blood and occasionally passes into the blood of the child in suf- 
ficient quantity to become active. 

In its differential diagnosis, malignant new growths and septic diseases 
must be taken into consideration. Precocious menstruation does not need 
to be considered, because it hardly ever occurs in the first few days of life. 



n. 

PATHOLOGICAL CHANGES OF THE BLOOD 
AND BLOOD-FORMING ORGANS 



CONSTITUTIONAL ANOMALIES AND DISEASES 
OF METABOLISM 

BY 
M. von PFAUNDLER, 

Munich. 

REVISED BY 

M. D. OTT, M.D., 

Associate in Pediatrics, University of Minnesota. 

INTRODUCTION 
PHYSIOLOGY AND PATHOLOGY OF THE BLOOD 

HUMAN blood-cells, as shown in the table formulated by Schridde 
(Figs. 32 and 33) belong to two different groups or families. Those espe- 
cially interested are referred to the excellent article by the above named 
author in Aschoff's Text-book of Pathological Anatomy (5th Edition). 

1. The Myelotic Parenchyma. In embryos of less than 10-12 cm. in 
length only the primary erythroblasts are found in the blood-spaces. Only 
at a later date do the other derivatives of the cells of the vessel walls appear 
and then, extiavascularly, only in the liver but after the second month of 
fetal life also in the spleen and bone-marrow, the latter gradually monopo- 
lizing the formation of these cells. From the blood forming parenchyma, 
the white cells enter the blood stream by their own activity, while the red 
corpuscles are forced in by the rupture of the centre when the cells have 
matured. The platelets are derived from the giant cells. 

2. The Lymphatic or "Non-granular" Parenchyma. The cells of the 
walls of the lymph-vessels, together with the germinal centres of the lymph 
nodes form the lymphatic parenchyma which appears later than the 
''granular parenchyma." The genealogy of the large mononuclear leuco- 
cytes is still in dispute. 

At birth the greater portion of the myelotic parenchyma is confined to 
the grayish-red, functionally-active bone-marrow and the lymphatic paren- 
chyma is found in the lymph nodes, the spleen, and other lymphoid 
tissues of the body. In the long bones this functionally active marrow later 
changes into inactive, yellow, fatty and gelatinous marrow. Under patho- 
logic conditions a return to the phase of widely diffused blood-forming 
parenchyma is seen, accompanied by the appearance of atypical forms of 
cells. Retrograde changes of an embryonic character, especially in the 
direction of a reversion to a gelatinous bone-marrow, is also observed. Both 
of these tendencies carry with them stimuli of varying nature and intensity 
156 



THE BLOOD AND BLOOD-FORMING ORGANS 



157 



Even the ordinarily adequate, regulative stimulus, incident to the normal 
breaking down of the blood elements, may become pathologic in degree if 
this degeneration is marked. Furthermore, the development of endogenous 
and ectogenous poisons, the nature of which is not fully understood, must be 




considered productive of non-physiologic stimuli. The return to the 
embryonic type of blood formation, that is, an activation of the myelotic 
blood-forming foci outside of the bone-marrow, occurs more readily in chil- 
dren than in adults. 

The Blood in Childhood. The most important peculiarities of the child 's 
blood, as compared with that of the adult, are given in the following table: 



158 



TEXT-BOOK OF PEDIATRICS 



Cells per Cm. 
of Blood 


Reds 
(Million) 


Whites 
(Thousands) 


Percentage of various forms of whites 


Hemo- 
globin 
(Sahli) 


Polymorpho- 
nuclear 


Large 
Mono- 
nuclear 


Lympho- 
cytes 


Neutro 


Eosino 


New-born 


5-7 
4.1-5.2 
4.5-5.0 


20-32 
8-13 
6-8 


70 
27-36 
71 


2 

2-7 
3 


8 
9-15 

4 


19 
50-55 
22 


110-130 
60-80 
100 


Infant 


Adult 





The following facts may be added by way of histologic description : 
Erythroblasts, nucleated red cells, are frequently found during the first 
few days after birth and occasionally even later during the first half-year 




Cell of Lymph-vessel wall 



Lymphocyte 



Lymph oblast 



Lymph oblastic 
Plasma-cell 



Lymphocyte 



Lymphocytic 
Plasma-cell 



FIG. 33. Lymphatic tissue (representing stain with Azur II-Eosin). 
(From Schridde in Aschoff's Text-book of Pathologic Anatomy.) 

in healthy infants. An excess of the non-granular over the granular types 
of leucocytes persists until the fifth year. At this age the proportions 
existing in the adult are rapidly approached. Large forms are remarkably 
frequent among the non-granular cells in childhood. During the first few 
weeks an occasional myelocyte is found in the normal blood. Immature 
cells are frequently found in the blood of normal infants during the first 
weeks of life; as, in the event of any disturbance of hematopoiesis , they oc- 
curmorecommonlyinthe blood stream of children than in that of later years. 



THE BLOOD AND BLOOD-FORMING ORGANS 159 

Hemodynamics. The pathologic phenomena attendant upon diseases 
of the blood are much better understood than formerly as a result of recent 
discoveries and, particularly, of those of Plesch. 

The functional ability of each organ, as of the body in general, is first of 
all dependent upon its oxygen supply, which represents the most important 
function of the blood and the circulation. According to Plesch, the oxida- 
tion process in the tissues is the main and the only indication of the vigor of 
the circulation. If the oxygen requirement is increased as a result of en- 
larged functional activity, as, for instance, of the musculature in bodily 
exercise, this increased demand may be satisfied by an increase of the vol- 
ume of blood per minute. 1 This result may be attained by increase either 
of the force or the rate of the heart beat, or by increased velocity of the 
blood flow. The demand may otherwise be met by more complete oxygena- 
tion of the blood, by the increased oxygen-carrying power of the blood, by 
improved pulmonary aeration, or by the more complete interchange of 
gases between the blood and the tissues. These factors are very closely 
interdependent and the laws which govern these many-sided functions 
frequently find expression in the symptomatology of the diseases of the 
blood and circulatory apparatus. If an injury alters one of these factors, 
compensatory changes in the other factors usually appear. If, for example, 
the oxygen capacity of the blood is reduced as a result of a loss of hemo- 
globin, the volume of blood per minute will increase. When the blood 
volume is increased by added force of the heart -beat, resulting in complete 
systolic emptying of the heart and greater heart capacity, palpitation, 
anemic dilatation and hypertrophy will arise. If the increase is brought 
about by added frequency of heart action, an anemic tachycardia will 
develop; while increased velocity will result in hemic murmur ("bruit de 
diable")- The oxygen demand of the anemic patient is proportional to the 
increased amount of respiratory and circulatory work required to compen- 
sate the low hemoglobin. E. Mueller's studies have confirmed in many 
cases the application of the hemodynamic laws operative in the adult to 
the child. 

A. GROUP OF ANEMIAS 
GENERAL SYMPTOMATOLOGY 

The conditions grouped under this head are very often secondary or 
associated manifestations of other disturbances. They are characterized,, 
clinically, by a reduction in the total quantity of blood, by an absolute 
or relative decrease of the erythrocytes or of hemoglobin, with habitual 
pallor of the skin and mucous-membranes, and by compensatory and 
hemodynamic adjustments resulting from them. The reduction of the 
hemoglobin index which indicates an oligochromemia, that is, a diminu- 
tion of the total amount of hemoglobin in the blood, serves at present as 

1 By volume per minute is meant the amount of blood which enters one chamber of 
the heart in one minute, or which passes through the total area of the greater or lesser 
circulation. 



160 TEXT-BOOK OF PEDIATRICS 

a criterion which may be readily applied. It is a misleading one, however, 
when the volume of the blood is changed as in hydremia or in over-concen- 
tration. The total quantity of blood and the total quantity of hemoglobin 
can be determined in the living in only exceptional cases. 

Even though the common term anemia suggests a reduction of the total 
volume of blood, or at least a diminution of the essential constituents of the 
entire blood, nevertheless it must be borne in mind, in dealing with the 
individual case, that it is not merely a question of the quantity of the blood, 
but rather one of its functional capacity. The term "thin-blooded" more 
nearly covers the facts of such functional poverty. It is clear that even 
though it be diminished in quantity, the blood may be functionally effi- 
cient as an agent of circulation and interchange, because it can move more 
rapidly and thus increase its specific activity. In such cases we speak of 
a compensated anemia. Attention has been called, under the head of 
hemodynamics, to the various mechanisms of these very frequent adjust- 
ments. Frequently compensation is established by the fact that the anemic 
blood, in itself, has the power to stimulate the formation of red blood-cor- 
puscles. This stimulus naturally operates in those regions in which the 
myelotic parenchyma persists after birth, viz., in the functionally active 
bone-marrow. But, under certain circumstances, it may become active in 
those organs which do not participate in the erythropoietic function in post- 
natal life, as, for instance, in the lymph nodes, the spleen, and the liver, in 
which the myelotic parenchyma may be newly formed. Not only in loca- 
tion, but also in method, such a compensatory erythropoiesis may or may 
not be analogous to the normal developmental process. A postembryonic 
type of compensatory erythropoiesis may usually, in fact, be distinguished 
from the embryonic form. In the latter type, the immature cells, as megal- 
ocytes and megaloblasts, which physiologically are found only in the blood 
of the embryo, at once appear in the blood stream. In the postembryonic 
phase, however, this occurs only in extreme cases and as a final effort in the 
blood-forming function of the bone-marrow. Since an actual transition to 
the embryonic type is probably not determined by qualitative, but rather 
by quantitative conditions, and is further influenced by age, in childhood at 
least, it will hardly serve in itself to differentiate the several forms of anemia. 
The erythropoietic stimuli, activated by anemia, will not exercise any 
noticeable compensatory influence if the requirements for successful erythro- 
poietic activity are wanting from the beginning. 

Pathologic changes in the erythropoietic tissues in anemia cannot 
always be determined by the methods in use today. 

Every systematic classification of the anemias of childhood meets with 
objections in the present status of our knowledge of the subject. The di- 
dactic and practical purpose of this work, however, makes such a classifi- 
cation necessary. Such presentation of the nature of these diseases as our 
present knowledge will permit will give the thoughtful physician basis for 
a logical therapy. 



THE BLOOD AND BLOOD-FORMING ORGANS 161 

I. ANEMIA DUE TO PRIMARY INTERFERENCE 
WITH ERYTHROPOIESIS. 

This form of anemia is characterized by an insufficiency in the blood- 
forming organs incident either to hypoplasia of the matrix, external con- 
ditions unfavorable to its normal activity, or to a lack of raw materials. Its 
clinical characteristics are chiefly of a negative sort. The signs and symp- 
toms of increased destruction of the erythrocytes in the blood are not 
evident, nor are theie indications of either an excessive, an atypical, or an 
incomplete erythropoiesis. Actual changes in the total quantity of the 
blood, oligemia, hydremia, oligocytosis, oligochromemia and, occasionally, 
polychromasia, and the more marked variations in the size of the red cells, 
are alone met with. 

1. Congenital or Early Acquired Anergic and Aplastic Anemias. 
In this group, which has been little studied, insufficiency of erythropoiesis 
is the result of anomalies in the formation or function of the bone-marrow. 

Hypoplastic marrow is not uncommon in anemic infants, nor is a fatty 
marrow in the long bones of children even in the first two years. The 
latter finding is considered to be the basis of the anemia seen in congenital 
myxedema and symptomatically related conditions. 

Anemias appearing early in cases of infantilism, with hypoplasia of the 
genitalia and the circulatory system, in which the blood findings so much 
resemble those of chlorosis that they have been erroneously regarded as 
habitual or chronic chloroses, probably belong in this group. Benjamin has 
recently reported a peculiar type of anergic anemia, with hypoplastic habi- 
tus and mental weakness, in which no acquired injuries could be demon- 
strated and in which both therapeutic results and anatomic findings in the 
bone-marrow were negative. In this case, probably, the anemia may be 
considered the result of a congenital functional weakness of the hematopoi- 
etic mechanism. Similar anomalies of development, complicating such 
cases, are found in other organs. 

2. Alimentary Anemia (in the restricted sense). Experimental starva- 
tion and states of inanition, resulting, either from stenoses along the ali- 
mentary tract or from internal causes, do not produce an anemia but rather 
an atrophy of the blood which parallels that of the remainder of the body. 
In young rapidly growing animals, on the other hand, a diet poor in iron 
impairs erythropoiesis through a deficiency in the material for the synthesis 
of hemoglobin. Von Hoesslin and others have observed that children who 
have been fed exclusively upon milk 2 or other foods deficient in iron be- 
come anemic after the initial store in the liver has been exhausted. This 
is especially true in the case of premature infants, twins, and children 
born of anemic mothers. This so-called chlorotic anemia of the new-born 
described by the French authors, better termed oligosideremia, offers a good 
prognosis and responds quickly to the administration of iron. That not all 
premature infants develop this anemia can be explained by the fact that 
the initial store of iron is quite a variable quantity even in full term infants. 

2 Whole cow's milk contains 0.3-0.7 milligram Fe 2 O 2 and human milk 1.5-2 milli- 
grams per litre. 
11 



162 TEXT-BOOK OF PEDIATRICS 

As in other forms of anemia, the constitutional factor must be considered 
in the pathogenesis of alimentary anemia without, however, invalidating 
the meaning of the term. Children of this type have a higher iron require- 
ment than normal children, as Schwartz and Rosenthal have recently 
demonstrated that they have a negative iron balance. There are, of course, 
other factors to be considered, but these are discussed elsewhere. Even in 
older children who, from some psychic or other causes, subsist solely on milk 
may show a reduction of the color index without other appreciable blood 
changes. The observations of M. B. Schmidt that in pregnant animals an 
iron poor diet retards the growth of theoffspringis noteworthy in this respect. 

The form of alimentary anemia described by Czerny and his followers 
belongs in another category. According to their conception, a high milk 
diet produces in certain constitutionally predisposed children actual changes 
in the blood and blood-forming organs through the action of the milk fat, 
particularly the fatty acids. Whether these substances affect the blood 
through a withdrawal of alkalies or through some hemolytic action 
(Kleinschmidt), these anemias should be classified with those of toxic ori- 
gin. This view is supported by the symptomatology of the severe cases 
as well as to their failure to respond to ordinary iron medication. 

3. The So-called Anemia of Poverty; Tenement Anemia; School 
Anemia; Incubator Anemia. It is certain that children reared in city 
slums, that is, in overcrowded, poorly ventilated, ill-lighted, cold and damp 
dwellings, who are taken into the open but rarely, and who with poor food 
find only an ineffective stimulus to physical exercise, not only appear pale 
and weak, but often suffer from actual anemia. From the further obser- 
vation that all the objective symptoms of such an anemia disappear after 
a few weeks or, at the most, a few months of living and exercise in the 
open, either in the country, the mountains, or at the sea-side, we may 
conclude that some one of these many injurious elements, or their com- 
bination, has had an unfavorable influence upon the formation of red blood- 
corpuscles. These children, almost without exception, become rickitic 
during the first-half of the third year and are infected with tuberculosis by 
the tenth year. These forms of anemia do not, however, appear to be 
dependent upon these very common diseases or upon any disease of other 
organs or systems. 

To this group should be added the anemia of debilitated infants who are 
treated for too long a time in the incubator, a form which reacts very fav- 
orably to fresh air treatment. 

The attempt has been made several times, but without definite results 
up to the present time, to gain a clearer knowledge, by means of natural or 
artificial experiments on human beings, animals and plants, of the particu- 
lar form of injury which produces anemia and of its method of action. It is 
true that the absence of light causes a loss of chlorophyll, which is the 
analogue of hemoglobin. In a purely experimental way, however, relative 
darkness, as experienced in the polar night, in mining operations, or in 
animals kept in covered cages, does not cause any reduction of hemoglobin 
in adult human beings or animals, or at least no relative oligochromemia 



THE BLOOD AND BLOOD-FORMING ORGANS 163 

or oligocytosis. Just the reverse might rather be expected from a reduction 
of the oxygen tension and the poor decarbonization of the blood. It is 
possible that the red blood-cell formation of the growing organism responds 
more acutely to such injuries and especially to the absence of actinic and 
related stimuli (Schoenenberger). The increased circulation in the muscu- 
lature and in the skin during exercise in the open, and especially in moving 
air, with direct or indirect daylight, and the resultant breaking down of the 
erythrocytes, probably begets erythropoietic stimuli, which are never 
absent during the developmental period, especially in constitutionally weak 
children, without resulting injury. 

In these anemics a rather mild degree of anisocytosis, and oligochro- 
memia, moderate oligocytosis and, occasionally, polychromatophilia, 
combined with the general symptoms of anemia or chlorosis, such as head- 
ache, sleeplessness, anorexia, general weakness, palpitation of the heart, 
listlessness, etc., are observed. A special tendency to obstipation, indi- 
canuria, intermittent albuminuria, and vomiting is also to be noted. In- 
creased area of heart dulness and accidental murmurs are almost the rule in 
school anemias. There is no fever and the prognosis is favorable. 

4. Chlorosis, or Green Sickness, and Pseudochlorotic Conditions. 
These disturbances almost always begin during or immediately after 
puberty. They are not really children's diseases and, therefore, they will 
not be fully considered here. Nevertheless, chlorosis maybe properly 
included in the symptomatic grouping of anemias, since while many cases 
have a normal hemaglobin content and exhibit certain signs and symptoms 
common in chlorosis, that are not due to anemia (Morawitz), yet the 
absence of all evidences of an increased breaking down of the red blood-cells 
shows that there is an insufficiency of erythropoiesis and that the chief 
factor in the causation of the anemia is usually a limitation upon the pro- 
duction of new hemoglobin. 

Nature and Etiology. The characteristic blood findings of chlorotic 
anemia are confined to a reduction of the coloring matter of the blood, that 
is, to an oligochromemia, without a corresponding oligocytosis. It has been 
shown, also, that the total quantity of blood, as indicated by the total 
number of erythrocytes, where the red cell count is normal, is not reduced 
but usually increased. This increase may amount to almost double the 
normal quantity, so that the blood represents ten per cent, of the body- 
weight instead of about five per cent. It is permissible, therefore, to speak of 
a chlorotic plethora. The production of hemoglobin does not seem able to 
keep up with this increase of blood. The cause of the plethora is in doubt. 
Whether it represents a pathologic survival of the blood proportions, rang- 
ing from six to eight per cent, of the body-weight, which exist before 
puberty; whether it is dependent upon a tendency to high water retention 
in the chlorotic, or whether it may be regarded as an attempt at compen- 
sation of the reduced oxygen capacity of the blood, is not determined. 
Another viewpoint from which the nature of chlorosis may be considered is 
suggested by the fact that the disease occurs almost exclusively in females 



164 TEXT-BOOK OF PEDIATRICS 

and at puberty, and that supposedly it has a subsequent effect upon the 
generative organs. 

Symptoms. In a majority of cases the only definite blood changes are 
oligochromemia, anisocytosis, polychromatophilia, slight oligocytosis, 
general pallor, reduction of the color index of the red cells, diminution of the 
specific gravity of the blood, increased coagulability, and a decrease of the 
blood-platelets. The subjective symptoms are sleepiness, lassitude, 
migraine-like headache, dizziness, shortness of breath, palpitation of the 
heart, fainting spells, side-stitch, epigastric pain, chills, blinking, tinnitus, 
dyspepsia, anorexia and parorexia, dysmenorrhea, and leucorrhcea. The 
objective symptoms consist chiefly in a greenish or alabaster pallor, in 
slight edema and the formation of venous thromboses, both of which are 
known to occur in 'the mesentery; in increased area of heart dulness, an 
exaggerated cardiac impulse, accidental heart murmurs, venous bruit, and 
softness and frequency of the pulse; in tachypncea, gastroptosis, moderate 
hyperchlorhydria, and occasionally enlargement or descent of the spleen. 
No characteristic changes of metabolism are known. 

Diagnosis. The blood findings are pathognomonic. Certain negative 
findings and the reduction of the color index are important in differential 
diagnosis. Pseudo-anemia, is often mistaken for chlorosis. Secondary 
anemia of toxic origin or following hemorrhage may also cause confusion. 

II. ANEMIAS DUE TO LOSS OF BLOOD 

In this class of cases, in addition to the blood findings of the first group 
incident to a relative insufficiency of erythropoiesis, the evidences of stim- 
ulation, in the presence of normoblasts, of poikilocytosis and leucocytosis, 
are found. 

Post-hemorrhagic anemia, especially in traumatic cases, is a condition 
the etiology of which is considerably more clear than in other groups of 
anemias and in its purely experimental pathology is very instructive. 
Immediately after an external or internal hemorrhage has occurred, an 
actual diminution of the total quantity of blood, that is, a true oligemia is 
always found. In individual cases this is rapidly compensated, but in cases 
where hemorrhage is frequent or habitual it persists, and the proportion of 
blood per kilo of body-weight may be reduced from 60 c.c. to about 20 c.c. 
The first attempt at repair after a hemorrhage is an increase of the volume 
of the remaining blood by withdrawal of plasma from the tissues. This 
serves to refill the vascular system and to restore in a degree the blood- 
pressure. It results in hydremia, oligochromemia, oligocytosis, with normal 
color index, and to a certain extent in a swelling of the red blood-corpuscles. 
Later, a restitution of the blood-cells occurs. The loss of blood gives an 
intense stimulus to the bone-marrow which, if it is not already exhausted, 
results in putting into circulation stored up mature cells, erythrocytes, and 
neutrophilic leucocytes alike ; and also in the liberation of immature forms, 
among them cells poor in hemoglobin, nucleated polychromatic cells, baso- 
philic granular erythrocytes, mononuclear leucocytes and myelocytes. In a 
word, a blood crisis obtains. Secondly, it responds in an active hyperplasia 



THE BLOOD AND BLOOD-FORMING ORGANS 165 

of the marrow tissue and in a rapid and excessive development of erythro- 
cytes and granular leucocytes. The formation of hemoglobin is a matter of 
longer delay. A relative leucocytosis appears, although the loss of leuco- 
cytes is less than that of the erythrocytes, because the former are more 
uncommon in the rapid axial stream. A decrease of the color index char- 
acterizes this stage of post-hemorrhagic anemia. The regeneration, as a 
rule, follows the type of a postembryonic erythropoiesis. One exception to 
this, suggested by the writers' experience and by experimental hemor- 
rhagic anemia in animals, is found in severe umbilical hemorrhage of the 
new-born. The coagulability of the blood increases during and after the 
hemorrhage. Lipemia and fatty infiltration of the tissues may occur. 

Causatively, aside from the trauma, the so-called hemorrhagic dia- 
theses, Barlow's disease, melena, umbilical hemorrhage, epistaxis, rectal 
polyposis, certain intestinal parasites, and the hemorrhagic nephritides must 
be considered. 

Symptomatically, large and rapid loss of blood causes faintness, pallor, 
general weakness and sometimes convulsions. Repeated small hemorrhages 
may produce cachectic conditions. Hemorrhages are more dangerous in 
children than in adults. The rapid loss of from one-fourth to one-third of 
the total quantity of blood, that is to the extent of two per cent, of the body- 
weight is dangerous to life. 

III. HEMOCYTOLYTIC AND MYELOPATHIC ANEMIAS 

In this, the largest group of anemias, we have to deal with acquired 
conditions, which affect, first, the mature blood in the circulatory system, 
and, second, the blood-forming organs. A strict classification of cases, 
dependent upon the point of attack of the agent of injury, is neither 
practically possible nor theoretically justified. For when a hemic poison 
enters the circulation it not only prejudices the mature circulating cells, but 
it is likely to extend its influence to the blood-forming parenchyma. Thus 
a combination of myelogenous and hematogenous injuries is formed. 
Chemical poisons, such as lead, which have a recognized specific toxicity to 
the erythrocytes, have been shown, also, to damage the bone-marrow. 
Further, signs of blood degeneration, by way of the too early, as well as the 
increased break-down of the circulating blood-cells, are particularly notice- 
able whenever weak cells appear in the circulation as the result of a myelo- 
genous injury. Finally, it may be supposed that a hematoplastic stimulus, 
such as a marked degeneration of the mature cells would give to the blood- 
forming organs, after it has exceeded certain limits, must become patho- 
logic and harmful. It is a hopeless task, indeed, to search the pathologic 
blood for criteria which will make a definite differentiation between myelo- 
genous and hematogenous anemia possible. Basophilic granulation of the 
erythrocytes, poikilocytosis, crenation, hemosiderosis, or the deposit in the 
tissues of increased blood-pigment from broken down cells, and the evi- 
dences of reversion to the embryonic type of erythropoiesis, are all impor- 
tant characteristics of the forms of anemia under consideration. They do 



166 TEXT-BOOK OF PEDIATRICS 

not, however, invite conclusions as to the localization of the injury, whether 
in the mature blood or in the immature cells. 

Theoretically, a large part of the anemias of this class may be consid- 
ered, in the broadest sense, as toxogenous anemias; that is, they are caused 
by more or less well recognized ectogenous or endogenous blood poisons. 
In the light of their action two classes of these may be distinguished. 

(a) Hemocytolytic poisons are those which cause the intravascular 
dissolution or disintegration of a large number of red blood-cells, with cer- 
tain definite results. The coloring matter passes into the plasma, a hemo- 
globinemia. A part of it is changed in the liver into bilirubin and urobilin; 
another part is stored in the liver, spleen, and bone-marrow as hemosiderin ; 
and some is excreted by the kidneys, giving a hemoglobinuria or methemo- 
globinuria. The erythrocytic debris is taken care of in the spleen, giving a 
spodogenous enlargement of the organ, and in the blood by the phagocytes. 
This cleaning up process does not always take place without disturbance, 
by way of destruction of the leucocytes, intravascular clotting, so-called 
hematogenous icterus, anuria, etc. 

In children the ectogenous substances which are to be considered in this 
relation are certain sera, the primary toxic action of which is to be distin- 
guished from anaphylaxis; snake venom, the poison of bee stings, and vari- 
ous vegetable poisons, such as aspidium, the several members of the 
species of solanum, and mushrooms. Among the endogenous hemolytic 
poisons are the poison arising from burns, the biliary constituents which 
enter the blood, causing cholemia, and particularly the microbic toxins of 
sepsis, Winckel's disease, malaria, typhoid and scarlet fever. 

Paroxysmal hemoglobinuria is a peculiar disease caused by endogenous 
hemolytic substances in the nature of autolytic amboceptors. These ambo- 
ceptors are peculiar in that they attach themselves to the erythrocytes, both 
in vivo and in vitro, only at low temperatures, when the natural complement 
of the blood, which is liable in these subjects to unusual variations, completes 
the chain and permits the hemolysis. This explains the occurrence of repeti- 
tional attacks of the disease. These attacks are brought on by exposure to 
cold. They begin their course with chills, cyanosis, pain in the back, hemo- 
globinuria, oligocytosis and relative leucocytosis; and they occasionally go 
on to embolism with gangrene. They usually last from one to two hours 
and are followed by jaundice, enlargement of the spleen, and urobilin- 
ogenuria. The repeated appearance of these abnormal amboceptors may 
be closely related to a lessening of the resistance of the red blood-cells. In 
almost all of the children so affected there is a question of the existence of 
some congenital or parasyphilitic poison. 

Hemocytolysis, with the formation of methemoglobin, occurs with 
many medicinal agents, among which are potassium chlorate, the phenol 
derivatives, as acetphenitidin, lactophenin, phenocoll, and phenolphthalein; 
the anilin derivatives, antifebrin and acetanilid, and pyrogallol. Chemical 
changes in the hemoglobin, involving its oxygen content, are caused by 
carbon monoxide, hydrogen sulphide, and hydrocyanic acid. 



THE BLOOD AND BLOOD-FORMING ORGANS 167 

(6) Other hemic poisons may cause early destruction of the erythrocytes 
without involving their solution in the blood to any great extent. These 
injurious agents doubtless act, in part, through the liver, spleen, and bone- 
marrow upon immature forms of cells. Hemosiderosis, the phagocytosis 
of red cells, and the excretion of uiobilin and urobilinogen are observed in 
these cases. Of the ectogenous poisons, lead, mercury and arsenic belong 
in this class. Among the endogenous poisons of similar action are those 
excreted from the body-substance of such animal parasites as tenia, bothrio- 
cephalus, ascarides, anchylostomata, and trichocephalus, as well as lipoid 
substances arising from degenerated body tissues. To these may be added 
the hypothetical toxins of acute intestinal disease and the nephroses, and, 
finally, the bacterial poisons and the reaction products they excite in latent 
as well as manifest tuberculosis and syphilis. 

It was thought, because normally erythrocytes are destroyed in the 
spleen, that hypertrophy of this organ led to an increased destruction of 
these cells. It is probable, however, that the hemolytic activity of the 
spleen pulp is confined to those erythrocytes which originally were or have 
become defective. According to Frank, the reticular endothelial cells of the 
spleen and lymph nodes elaborate a hormone which is inhibitory to the 
bone-marrow, and which in case of hypertrophy of the spleen is capable of 
producing anemia. 

The pathologic effects of the action of such poisons upon the blood and 
the bone-marrow are shown, in part, in retrograde changes as the atrophy 
of the marrow in tuberculosis and chronic nephritis, in part by chronic 
inflammatory changes and by progressive nutritive disorders, by way of 
hypertrophies and new tissue formation in the active bone-marrow. These 
new growths may revert in type to the most primitive marrow germ cells, 
which are really in the nature of capillary endothelium. This metaplastic 
formation may be no longer confined to the bone, but may appear in widely 
diverse parts of the body. It is most common in the liver, spleen, and 
lymph nodes. The stimulation of these reserves may repair the blood 
injury. This is certainly true in the most common forms. 

1. The ordinary mild type of chronic toxogenous anemia includes the 
so-called secondary or complicating anemias accompanying tuberculosis, 
lues, and the chronic nephroses. 

The clinical picture consists essentially of the symptoms recited and of 
those of anemia in general, described under chlorosis and post-hemorrhagic 
anemia. 

The prognosis and course depend upon the extent of the injury done by 
the toxic agent and upon its recognition, avoidance, and removal. 

The pathologic effects of the action of such poisons upon the blood and 
the bone-marrow are shown, in part, in retrograde changes, precisely as the 
appearance of diffuse metaplastic foci of blood-forming parenchyma, 
already described, resembles the embryonic hematopoiesis. 

2. Biermer or pernicious type of anemia is recognized clinically by the 
appearance of large numbers of megalocytes and megaloblasts. At times, 
these giant erythrocytes are so numerous that the reduced hemoglobin 



168 TEXT-BOOK OF PEDIATRICS 

content of the ordinary red cells is over-compensated and the color index 
runs higher than one. 

The exhaustion of the myeloid parenchyma may be recognized by 
leucopenia, that is by polynuclear leucopenia, relative lymphocytosis, 
extreme oligochromemia and oligocytosis, poikilocytosis, anisocytosis and a 
reduction of the protein content of the blood-serum which is of a deep yellow 
color. The marked loss of coagulability which underlies a hemorrhagic 
diathesis, indicated by hemorrhages of the mucous membranes, skin, and 
retina, is a fact of great importance. 

Another condition very rare during childhood and because of that 
probably often overlooked is the: 

3. A regenerative (or aplastic) type of severe anemia. This type of 
anemia may occur in children of school age, rarely before and pursues a 
progressive and rapidly fatal course extending only over a period of a few 
months. There is a very definite hemorrhagic diathesis but usually little 
impairment of the nutrition. While the clinical picture resembles that of 
pernicious anemia, the blood picture is entirely different. There is a com- 
plete and constant absence of all signs of blood regeneration such as erythro- 
blastosis, megalocytosis, anisocytosis and polychoromatophilia in spite of a 
profound reduction in the hemoglobin and the number of erythrocytes and 
platelets. Furthermore, there are no findings on examination of the liver, 
spleen and lymph nodes, and the urine is normal. 

From the rarity of the pernicious type of anemia in childhood and from 
certain peculiarities of this disease, such as enlargement of the spleen in 
younger individuals, it may be inferred that the blood and the bone-marrow 
of small children react differently from those of the adult to these poisons. 
This fact has been determined by the experiments of Reckzeh and others, 
and by observation of members of the same family with xeference to the 
effects of essentially similar blood injuries in individuals of different ages. 

4. The v. Jaksch-Hayem form of disease, which is closely related to the 
leucanemic type, seems to be a more frequent form of reaction in the 
youthful organism. 

V. Jaksch and Hayem contemporaneously described, clinically, this 
fairly definite form of disease, occuring quite frequently in children of one- 
half to two years, under the name of pseudoleucemic infantile anemia. 
It resembles Biermer's anemia in that it also presents evidence of intense 
stimulation of the blood-forming organs, associated with the signs of a 
breaking down of the blood-cells and hemosiderosis. As in Biermer's 
anemia, too, the stimulation leads to the extension of the erythroplastic 
parenchyma of the bone-marrow to new formations of intra- and extra- 
vascular hemopoietic foci in the liver, spleen, lymph nodes, and kidneys. 
Qualitative reversion of erythropoiesis to the embryonic type also occurs. 
It differs from the pernicious form, however, in the fact that the myeloid 
foci in the liver, and more particularly in the spleen, develop to so great an 
extent that the size of these organs is largely increased and an intensive 
leucopoietic activity, marked by added numbers of white cells in circula- 
tion, takes place. 



THE BLOOD AND BLOOD-FORMING ORGANS 



169 



The Symptoms may be anticipated from the foregoing description The 
examination of the blood usually shows oligocytosis, with from one to three 
million red cells, and oligochromemia. The reduction of the hemoglobin may 
be proportionately in excess of the diminution of the number of the red cells 
a normocytotic regenerative type with reduced color index or it may be 
relatively less. The latter condition obtains when the regeneration of 
megalocytes is a prominent feature ; that is, when these and the megaloblasts 
appear in the circulation, the color index often ranging to one hundred or 
more. Poikilocytosis, polychromasia, basophilic granulation, and indica- 
tions of the breaking down of cell nucleii are characteristic. An associated 




FIG. 34. Sixteen-month-old boy and fourteen-montri- 
old girl with rickets and Jakach's anemia. Both children 
recovered after several weeks of treatment. 

leucocytosis of varying degree and type may, or may not, be present. The 
number of leucocytes is supposedly indicative of the severity of the disease 
and is usually about 20,000. At times and particularly in inflammatory con- 
ditions the granular forms predominate, but usually the non-granular are the 
more numerous. The eosinophilic cells and sometimes the myelocytes are 
increased. In some cases the large number of mononuclear cells, running up 
to twenty per cent, is a very noticeable feature. 

The rest of the clinical picture of the disease is that of rickets accompa- 
nying the high grade anemia. A dull yellow pallor, a general listlessness, 
and a wilted appearance are very apparent. The persistence of a certain 
amount of cutaneous adipose tissue gives a pasty look. Numerous .small 
hemorrhages into the skin and mucous membranes occur. The enlarged 
spleen, hard and with a sharp edge, but not tender, always extends below 



170 TEXT-BOOK OF PEDIATRICS 

the costal margin and may frequently reach to the level of the umbilicus or 
even lower, greatly distending the abdominal wall. There is marked swell- 
ing of the liver, which is soft and also has a sharp, thin edge. There is slight 
enlargement of all the lymph nodes. Accidental heart murmurs are rare. 
The pulse is full and soft. 

Occurrence, Course and Prognosis. Jaksch-Hayem 's anemia begins 
between the seventh and the sixteenth months of life. It is almost entirely 
confined to artificially-fed children and especially to those of the poorer 
districts of large cities. Gradually, and at times rapidly, it reaches a severe 
degree. It persists for months, but rarely until the third year or later, 
after which spontaneous recovery takes place in a certain per cent, of cases. 
No other form of anemia which, judging by the general symptoms and the 
blood picture, is equally severe offers so good chances of favorable termi- 
nation. Rickets is responsible for most of its fatal complications, in the form 
of intestinal disturbance, broncho-pneumonia, and muscular degenerations. 
Hydrops and hemorrhages occur but rarely. 

Etiology. From the clinical viewpoint, tuberculosis, syphilis, typhus, 
other infectious diseases, intestinal parasites, chronic disturbances of nutri- 
tion, and poisoning are occasionally given as etiologic factors; but rickets 
evidently stands in much closer relationship to Jaksch-Hayem 's anemia 
than any of these. Since rickitic skeletal changes may be demonstrated at 
autopsy in almost every child of this age who succumbs (see page 196), the 
combination of this disease with pseudoleucemic anemia is not necessarily 
astonishing. So associated, rickets commonly attains at least a medium 
intensity and usually a severe degree. It remains clinically manifest and 
florid until the second or third year. 

Recently Aschenheim and Benjamin, as well as Marfan, have attempted 
to clear up the relationship between the two diseases. 

While these views are very worthy of consideration, the writer can not 
commit himself to them without reserve so long as the knowledge of the 
etiology of rickets itself is no further advanced. For the present Naegeli's 
view must suffice for the systematic classification of Jaksch's anemia. Ac- 
cording to this view, the disease represents a variety of secondary anemia 
arising from peculiar biologic conditions in the early stages of infantile 
development. The primary causes are found in repeated infections and 
faulty nutrition during the first years of life. On the one hand, it appears 
that rickets may arise as a sequel of these injuries and, on the other hand, 
Jaksch's anemia may result from them in that critical and important period 
of development, at the close of the first year, when there is a tendency to 
germinal disease. 

5. The "Alimentary Anemia" of Czerny. As previously indicated, 
Czerny believes that in certain constitutionally predisposed individuals an 
abnormal metabolism results in the elaboration of acid products from milk 
(also from starches) which are toxic to the blood-forming parenchyma. 

To distinguish it from the ordinary form of alimentary anemia pre- 
viously described and which results from a deficiency in blood-building 
material, the term trophotoxic anemia would probably be preferable. The 



THE BLOOD AND BLOOD-FORMING ORGANS 171 

clinical picture of this form of anemia as given by Kleinschmidt is so vari- 
able as to make a description of the condition difficult. Some of the chil- 
dren were thin, others fat, some had a yellowish coloration of the skin, 
others were very white, some had small, others large hemorrhages into the 
skin. Edema was occasionally encountered. Enlargement of the liver and 
spleen was often noted, though there was only slight enlargement of the 
lymph nodes. A reduction in the hemoglobin, usually 30-45 per cent, and a 
less marked oligocytosis were the only constant blood findings. In contrast 
to these mild pseudochlorotic cases were the more severe ones with oligo- 
cytosis, poikilocytosis, polychromatophilia and erythroblastosis. There 
was usually a lymphocytic leucocytosis of 15-18,000. Evidences of a 
marked activity of the bone-marrow, occasionally hemosiderosis, and a 
fatty degeneration of the heart were the pathological findings. 

The sole criterion for the nosological identity and the alimentary origin 
of this protean condition is the favorable reaction to dietary measures. 
Whatever benefit is obtained from this must, however, be an indirect one, 
as the same diet is employed in those constitutional disorders most often 
associated with alimentary anemia. (Rickets, exudative diathesis, lym- 
phatism and "milchnahrschaden".) Czerny's alimentary anemia espe- 
cially in its more severe form may be included in v. Jaksch-Hayem's anemia 
which is better defined. To discard the latter and substitute the former, 
as some desire, would not be advisable at least so long as the origin of ali- 
mentary anemia is hypothetical. 

6. A group of rare diseases in which the erythropoietic system is chiefly 
affected, caused also by toxogenous injuries, operating even in the embryo, 
is observed in childhood. Symptomatically, at least, the diseases of this 
group are closely related, as is shown by the following common changes 
which include the general manifestations of anemia, oligocytosis, or more 
rarely polycytosis, oligochromemia, embryonic erythropoiesis, with the 
occurrence of megaloblasts. They present, also, an increased destruction of 
red blood-cells, with its consequences in hemosiderosis, pigmentation of the 
skin, enlargement of the liver, jaundice, the excretion of bilirubin, urobilin 
and urobilinogen; early spodogenous enlargement of the spleen, and varia- 
tions in the leucocyte count, as in Jaksch' anemia. Leucopenia, relative 
lymphocytosis, and finally a hemorrhagic diathesis may be found. 

One of the types included in this group, described as chronic familial 
hemolytic icterus, suggests the characteristics of paroxysmal hemoglobi- 
nuria on account of its familial and early appearance, the demonstrable 
reduction of the resistance of the red blood-cells, which are broken down 
particularly after exposure to cold, its paroxysmal character, and its favor- 
able course; and, finally, its relationship to lues and other toxic infections. 
Autolytic hemolyses, however, have not been found in this condition. 

The cases belonging to the Banti-Senator symptom-complex appear at 
a later period of life, and usually after the fifth year. They follow a chronic 
course and terminate fatally in spite of treatment. Ascites, icterus, enlarge- 
ment, followed by contraction, of the liver, commonly appear late. In the 
final stages of the disease fibrosis, an enormous spleen, and cirrhosis of the 



172 TEXT-BOOK OF PEDIATRICS 

liver are found. The author has never seen an actual case of Banti 's Disease 
going on to recovery, with a negative nitrogen balance, after the operative 
removal of the spleen as the primary seat of the disease. Nor has he been 
able to establish, in the cases which havo come under his observation, the 
alleged fact that this symptom-complex always belongs to late syphilis. 
A very significant sign of disease in these cases, and often the first to be 
noted, is a profuse, repeated, and even fatal hemorrhage from the gastro- 
intestinal tract, \\fhen in doubt this condition should be treated specifically. 

In Gaucher's splenomegaly the early enlargement of the spleen to 
enormous size is the most important feature. Its course is similar to that of 
Banti 's Disease and it is looked upon as a peculiar disease of the lympho- 
erythropoietic system. 

Attention should be called to the curative effect of splenectomy in the 
last two types. 

THE TREATMENT OF ANEMIA 

In those forms of toxic anemia in which the poison is known and its 
source recognized, a successful therapy aims at the removal of the cause. 
Examples are found in parasitic or luetic anemias. 

The therapy is quite clear in those cases in which there is a deficiency of 
certain hygienic factors. Exercise in the open air, stimulation of the skin, 
the influence of sunlight, etc., are indicated. Treatment is self-evident 
when there is an actual poverty of iron in the food. This, as already sug- 
gested, is a very rare condition and the iron supply required should be 
prescribed from the garden and not from the pharmacy. The natural 
combinations of iron in food-stuffs are absorbed more completely and in 
more acceptable form than is the iron of the customary preparations 
(Krasnogorski). Most of the green vegetables, cereals, legumes, potatoes 
and fruits have sufficient iron content; they are taken without objection and 
are comparatively cheap. It is not necessary to be guided by tables as to 
their iron content, since an excess of iron is readily obtainable. If the 
child refuses vegetables it is either a question of serious defect in training or 
of overfeeding with eggs and milk. In that event the quantity of these 
items may be reduced, or they may be entirely eliminated from the menu in 
order to force the child to accept vegetables. Both milk and eggs may be 
readily dispensed with during the second year and may be omitted, if 
necessary, at the end of the first year. They would appear to have an 
unfavorable influence upon the results of a vegetable diet. When carefully 
prepared, mashed vegetables, especially spinach and carrots cooked in their 
own juices, are usually borne very well at this age. The appearance of 
green or red stools, containing undigested particles of these vegetables, is 
no contraindication. 

The diet prescribed by Czerny in alimentary anemia is as follows: 

First Meal. 100 c.c. milk diluted with an equal amount of cereal water, 
a little softened zwiebach or bread with a little butter or preferably 
marmalade. 



THE BLOOD AND BLOOD-FORMING ORGANS 173 

Second Meal. Fresh fruit with biscuits, zwiebach or a little bread 
and butter. 

Third Meal. Broth thickened with cereals, rice, oat or potato gruel. 
In addition puree of vegetables, meat, also liver (minced, 1-2 teaspoonfuls). 

Fourth Meal. The same as No. 3, or in the case of older children, bread 
and butter with meat or sausage and fruit in addition. 

It may be possible in the anergic-aplastic and trophotoxic foims of 
anemia to stimulate the hemopoietic function, and especially a new forma- 
tion of hemoglobin in unknown foci, by means of artificial stimulating 
substances. Such a stimulating property has been ascribed to iron. It 
cannot be tested by animal experiments because these foims of anemia 
cannot be produced artificially. Experiences gained at the bedside, showing 
that medicinal iron may be depended upon to a certain extent in diseases 
coming under the group of chlorosis, and probably as well in chronic post- 
hemorrhagic, anemias, 3 which are in some respects similar, would seem to 
indicate that the action of iron is related to these especial conditions. 

For chlorosis, iron is prescribed in the form of pillulse ferri carbonatis 
(Blaud's pills) 1 to 3 after each meal. In Czerny's anemia Feer, contrary 
to the views of the former, recommends ferrum reductum (0.05-0.1 gram, 
2 to 3 times daily) in addition to a limitation of the amount of milk. Of 
numerous other preparations including the ferruginous mineral waters none 
are as useful as Blaud 's pills. Proprietary synthetic preparations of organic 
iron and the wines and liquors are, to put it mildly, not indispensable. 
Because of their low iron content very large doses would be required to 
obtain the same effect. When assimulation is sought, the natural foods 
suffice, and the so-called stimulating effects are obtained from the simple 
and inexpensive preparations of inorganic iron. 

Another method of treatment is to take advantage of the adequate 
natural erythropoietic stimulation. These natural stimuli are loss of blood 
and increased destruction of red blood-cells. The former is secured by 
blood-letting; the latter usually by the use of arsenic in Fowler's solution 
(liquor potassii arsenitis)'. Arsenic is also supposed to cause an increased 
output of erythrocytes into the circulation from the reservoirs of the bone- 
marrow. In pernicious anemia in the adult, arsenical therapy has been 
justified in a purely empirical way. In v. Jaksch's anemia, occurring in 
weak children during the first year or so, this form of treatment is hardly 
ever indicated. However, Fowler's solution, diluted, in divided doses of 
from 2 to 12 drops daily, may be tried. It is very important to treat the 
rickets if there is any present. 

Attempts at organotherapy in anemia rest upon the theory of a hor- 
mone stimulation of the blood-forming parenchyma. Huebner feeds small 
amounts of fresh bone-marrow with bread and butter. It should be quite 
unnecessary to say that from active red marrow alone, may results be ex- 
pected, and not from the ordinary fat marrow. Freshly expressed meat 
juice given in spoonful quantities is to be recommended. The transfusion of 

3 A single loss of blood in itself acts as a sufficient stimulus to erythropoiesis. The 
circulatory system may be more rapidly filled by the addition of water in various ways. 



174 TEXT-BOOK OF PEDIATRICS 

blood, which has been mentioned again lately, has an organotherapeutic 
effect beyond that of merely compensating blood loss. In post-hemorrhagic 
anemia, 3 to 5 intramuscular injections of 15-20 c.c. of fresh human blood 
at intervals of several days may be given, as well as injections of normal 
saline. Autotransfusion by the use of tight bandages may also be employed. 

The treatment of chlorosis and secondary anemias by "physical," 
meaning by this hydrotherapeutic measures, is the vogue in private hospi- 
tals and sanatoriums. In the case of chlorosis, depletive sweat baths (a hot 
bath followed by a hot pack every five days) are possibly of value. Even 
here, one recommends cold sponges, cold rubs and even cold baths and 
douches, the other hot applications and hot water and hot air baths. Such 
differences of opinion do not awaken special confidence. Probably, the 
stimulation of the skin is the important feature, and if this is true, the 
method of producing it is of minor importance. In the enthusiasm over 
artificial sunlight, the beneficial effects of natural sunlight are apt to be 
overlooked. (Sun-baths on warm, quiet days, one-half to one hour twice 
daily, at first only the limbs, later the trunk followed by cool, wet rubs are to 
be recommended.) The value of high altitude lies in the therapeutic appli- 
cation of oxygen-poor air (David). 

For older children the most effective measure is a visit to the country, 
with suitable outdoor or fresh air camp life at an altitude of 1500 to 4500 
feet, the elevation to be governed by the child's condition and by the 
altitude at which he has been accustomed to live. A sojourn in such a place 
gives opportunity of recreation and of intelligent and instructive physical 
exercise in the open. Climates which experience shows to have a bad effect 
should be avoided. Tedious walks on the sanatorium promenade and the 
constant contact with convalescents should be avoided. When a southern 
sea-shore resort is chosen, the baths should be carefully watched. In some 
instances, it will be necessary to keep the child out of school for a long time, 
or at least to eliminate the less essential studies. Fresh air cures of a less 
intense nature than those carried out in the mountains and on the seacoast 
can be pursued at home, and with certain precautions in the large cities of 
the north and south. Sleeping in the open with ample protection should 
be tried. 

Changes in the spleen noted by Banti in the syndrome bearing his name 
and by Eppinger in the Biermer type of pernicious anemia raises the ques- 
tion of the value of splenectomy in these and related conditions. Even 
though these changes may not be causal (as some believe), nevertheless, 
the value of this procedure is borne out by clinical experience. Whether 
exposure to the Roentgen rays can be effectively substituted for this oper- 
ation is still questionable. 

APPENDIX 
PSEUDO-ANEMIAS 

In many children, superficially adjudged to be anemic, or thin-blooded, 
either by the laity or by physicians, other conditions present themselves 
which warrant description in this connection, even though they are properly 



THE BLOOD AND BLOOD-FORMING ORGANS 175 

classified elsewhere. If pallid infants or older children be examined indis- 
criminately their hemoglobin index and their red cell count will be found, in 
the major number, within physiologic limits. These children are either not 
in any degree anemic, or are really oligemic, that is, the vascular system 
contains a diminished quantity of a blood which has a normal pigment con- 
tent and a normal cell content. Until recently it has been impossible to 
determine which of these two conditions is really present, since the oppor- 
tunity of autopsy is rare and since the technical difficulties which surround 
the in vivo determination of the quantity of blood are great. However, 
the gap has been bridged by Erich Mueller. By the methods of Zuntz and 
Plesch it has been found possible to determine the total volume of blood, the 
total hemoglobin content, and the oxygen capacity of the blood of pale 
children over six years of age. Children with chronic nephritis or tubercu- 
losis, and those living under especially unfavorable hygienic conditions, 
were excluded from these studies. No differences were found in these 
pallid children as compared with healthy-looking specimens. In such cases, 
therefore, one has to deal, not with an oligemia, but with a pseudo-anemia. 
The existence of such conditions has been suspected for some time (Sahli, 
Strauss and others). A reduced transparency of the epidermis or a lessened 
fulness of the skin capillaries have been considered as causes of the con- 
dition. The ischemia may be due to a decreased development of the capillary- 
net- work of the skin, or to a dilatation of the blood-vessels of other organs, 
or to a contraction of the skin vessels a cuticular angiospasm. The last 
two of these factors are especially associated in the occurrence of the marked 
color changes to which such children are liable. 

Plumbism and chronic nephroses, usually responsible for the pseudo- 
anemia of adults, can be considered in only a small percentage of cases in 
childhood. An association of phenomena suggests a consideration of cause 
in still another direction. A group of sickly children, the subjects of hered- 
itary taint and of errors in physical development, with a marked tendency 
to the lymphatic diathesis, includes many of these infantile pseudo-anemias. 
Psychic traumata of various types, for example, states of fear and depression 
associated with school duties or unpleasant home conditions play a great 
role. It is obvious that a correction of these conditions rather than iron, 
arsenic and the other forms of treatment so often employed, are to be rec- 
ommended. A careful analysis by the family physician of these conditions 
as well as the intelligent cooperation of the parents are necessary, all of 
which of course requires greater effort than the mere feeding of pills. 

B. GROUP OF LEUCEMIAS AND PSEUDOLEUCEMIAS 

Pathologic research is sufficiently advanced to offer a reliable basis for the 
scientific classification of this group. The confusion into which the purely 
hematologic study of the group has been thrown by the variety of clinical 
findings, particularly as to relations between true and pseudo-leucemias, has 
been composed by pathologic researches alone. In a degree, the clinical pic- 
ture worked out at the bedside still fails of likeness to the features which 
the autopsy presents and fuller conformity must be left to the clinician. 



176 



TEXT-BOOK OF PEDIATRICS 



The several forms of disease included in this group are due to marked 
and more or less widely disseminated changes in the lymphoid or, the 
myeloid system and, taken in their entirety, may be likened to a progres- 
sive disturbance of nutrition. The following scheme will serve the purpose 
of eliminating a didactic presentation and will suggest the great impetus 
which an effective clinical terminology gives toward the association of 
heterogeneous conditions and the differentiation of homogeneous types. 



Structural 


Affections of the 


Affections of the 


Clinical 


Basis. 


Lymphoid System. 


Myeloid System. 


Terminology. 




(Lymphadenoses.) 


(Myeloses.) 




General hyper- 
plasia with ex- 


1. Lympho- 
cytomatosis. 


3. Myelocy- 
tomatoses. 


With in- f Lymphatic 
crease of 1 and myeloid 


pansive, but 






cells in the ] leucemia and 


not aggressive 






blood stream. [ chloroma. 


growth. 














Without 


True pseudo- 










increase of 


leucemia 










cells in the 


(Pinkus- 










bloodstream. 


Cohnheim). 




Hyperplasia 
with aggressive 


2. Lympho- 
sarcomatoses 


4. Myelo- 
sarcomatoses. 




Lympho- 
and myelo- 


Pseudo- 
leu- 


tumor-like 


(Kundrat.) 






sarcomata. 


cemia. 


growth, and 












atypical 












proliferation. 












Pseudo-hy- 


5. Granulo- 






Steinberg's 




perplasia; 


matoses. 






disease. 




metaplastic 








proliferation, 








especially in 








the connective 








tissue cells of 








the stroma. 









Distinctly localized leucemic and pseudoleucemic affections, that is the local 
lympho- and myelosarcoma of a particular organ, which have the distinct characteristics 
of a malignant tumor, and solitary granuloma are not included in this classification 
of more or less generalized diseases. 

1. LYMPHOCYTOMATOSES 

This group of leucemias presents, from the outset, generalized systemic 
disease conditions of all the lymphoid tissues. The lesions consist in the 
proliferation of preformed lymphatic tissue and in the adventitious growth 
of similar new tissue in the several organs. 

Since under these conditions the elements of the non-granular system of 
blood-cells appear in the blood in increased number, these disorders have 
been designated as: 

LEUCEMIC LYMPHADENOSIS OR LYMPHATIC LEUCEMIA 

In lymphatic leucemia the parenchyma of the lymph nodes, the spleen, 
the tonsils, the lymph follicles of the tongue, and of small, disseminated 
masses of lymphoid tissue in other organs, as the thymus, bone-marrow and 
kidneys, is increased to a varying and often irregular extent by a process 
of atypical proliferation. Surrounding the blood-vessels widespread, 



THE BLOOD AND BLOOD-FORMING ORGANS 



177 



semicircular, and newly formed adventitious collections of lymphocytes are 
found. Usually the proliferation results in an enlargement of the affected 
organ which may reach a marked degree, with consequent obliteration of 
the normal architectural lines. Abnormal forms of cells, probably of an 
embryonal type, consisting of large mononuclears, atypical lymphocytes and 
"Rieder V cells, appear. The infiltration of the surrounding parts often 
suggests malignancy; but the elements of neighboring tissues do not actually 
contain new cells, although they may be choked by their expansive growth. 




FIG. 35. Eight-year-old boy with acute lymphatic leucemia, 
showing swelling oi lachrymal glands. 

Onset, Course and Symptoms. The course of lymphatic leucemia, to 
which childhood shows a special predisposition is almost always acute, that 
is, it has a duration of several weeks, averaging about two months. It is 
always fatal. The new-born and young infants are similarly affected. The 
clinical picture resembles that of a sudden infection, with the prodromes of 
anemia. Its general symptoms are those of high fever, languor, headache, 
dizziness, pain in the extremities referred to the bones, numbness, vomiting, 
diarrhoea, and later, edema. Indications of a hemorrhagic diathesis appear 
in the form of petechise of the skin and mucous membranes, and of foul, 
12 



178 TEXT-BOOK OF PEDIATRICS 

ichorous ulcers resulting in the breaking down of lymphomata. Hyper- 
plasia of the tonsils and a variable degree of swelling of the lymph nodes at 
the angle of the jaw, in the neck, and, more rarely, in the groin occur. The 
thymus, liv^r, and spleen are enlarged and hard. Albuminuria and casts 
are common, together with an increase of the endogenous purin bases and 
the phosphates, due probably to the breaking down of cell nuclei. In 
advanced stages the clinical picture is further complicated by inflammation 
of the serous membranes. Leucemic infiltrations in the skin, mesentery, 
salivary and lachrymal glands, etc., are of less frequent occurrence. 

The diagnosis is established by the typical blood findings. These consist 
in the light color of the blood, its slow coagulation, the moderate to high 
grade increase, both absolute and relative, of the non-granular leucocytes, 
among which are found undeveloped and atypical forms, and, in particular 
large lymphocytes and weakly staining polymorphonuclear cells (Rieder's), 
in excess. Large numbers of lymphocytes of normal size are found less 
commonly. An absolute and relative reduction in the number of cells 
which have their origin in the myeloid parenchyma is indicative of changes 
in the bone-marrow and may resemble the findings in severe toxic anemia, 
in the way of oligocytosis, poikilocytosis, anisocytosis, basophilic granu- 
lation, normoblasts, megaloblasts and myelocytes. If the lymph anemia ie 
retarded because of the not infrequent occurrence of septic infection the 
condition may be mistaken for so-called glandular fever, for hypertoxic 
diphtheria with psuedomembranous deposits in the mucous membranec, or 
for typhoid fever. A leucemic infiltration which is said to cast a character- 
istic paravertebral shadow, lateral to the descending aorta, has been noted 
in Roentgenograms by Goett. 

For reasons yet unknown, the numbers of lymphocytic elements in the 
circulation in such lymphadenoses may be very small. They may appear 
only in the later stages or they may be absent throughout the entire course. 

The so-called true pseudoleucemias (Cohnheim-Pinkus), are sub- or 
aleucemic lymphadenoses. They must be differentiated from Werlhof's 
disease, from fulminative purpura, and sepsis. The more chronic and afeb- 
rile affection is quite rare, however, in childhood. 

Furthermore, the physiologic lymphocytosis of early childhood may be 
increased to such an extent by infectious conditions (typhoid, pertussis, 
scarlet fever, syphilis), or by the common inflammatory diathesis, as to 
resemble a lymphemia or lymphadenosis. 

2. LYMPHOSARCOMATOSES 

Lymphosarcomatoses occur, particularly, in young individuals. They 
resemble malignant tumors in that their origin is not diffuse, but rather a 
gradually spreading affection of the lymphatic system of aggressive quality, 
with the formation of metastases. They represent an apparently slow 
transitional stage from the lymphocytomatoses (the lymphatic leucemia and 
pseudoleucemia of Cohnheim-Pinkus), to the true lymphosarcomata. 

The most common form is the lymphosarcomatosis arising from the 
mediastinum. It follows a chronic course and produces a cachexia. The 



THE BLOOD AND BLOOD-FORMING ORGANS 



179 



mediastinal lymph nodes, frequently including the thymus, enlarge to form 
a densely compacted tumor mass. This mass, on account of the limited 
space in the thorax, soon produces the 
signs and symptoms of compression, in 
the way of dulness, shadows, pressure 
upon blood-vessels, nerves, and bron- 
chi; thromboses, paralyses, stenoses, 
compression of the lung apices and the 
pericardium. Later, other groups of 
lymph nodes lying in the immediate 
neighborhood, and at even more dis- 
tant points, become involved. The 
spleen and the liver usually remain 
unaffected, both clinically and anatom- 
ically. Toward the close of the disease 
the evidence of a hemorrhagic diathesis 
may appear. 

The blood findings may be fairly 
normal for a long while. In contrast to 
the findings in lymphocytomatoses, the 
non-granular cells are never increased, 
but rather very frequently decreased. 
The consequence is a relative granular 
leucocytosis which may become abso- 
lute in consequence of the formation of 
metastases in the bone-marrow. In 
such cases the development of anemia 
is to be expected 

Lymphosarcomatosis of the ab- 
dominal lymph nodes produces similar 
manifestations. 




FIG. 36. Six-year-old boy with so-called 
pseudoleucemia (Cohnheim-Pinkus). Upon 
admission the blood contains 5000 leucocytes, 
4.2 million reds, no marked oligochromemia, 
74 per cent, polynuclears, 18.5 per cent, large 
mononuclears and 2.5 per cent, eosinophiles. 
The swelling of the lymph nodes had persisted 
for nine months and had caused venous con- 
gestion. Intrathoracic lymph tumors com- 
pressed the trachea. Von Pirquet negative. 
The tumors began to disappear when the 
arsenic treatment was instituted and contin- 
ued to diminish in size spontaneously. 



3. THE MYELO-CYTOMATOSES 

The myelo-cytomatoses are systemic diseases of the myeloid tissues of 
the body. They are characterized by proliferation and increased functional 
activity of the preformed myelotic tissue in the bone-marrow and by 
diffuse adventitial new formations of such tissue in the various organs. 
Besides the bone-marrow, the spleen, the lymph nodes, and the liver 
are especially affected by these intumescent new growths. In these organs 
the lymphoid parenchyma is choked and replaced by myeloid tissue. 
The mucous and serous membranes are not affected as they are in the 
lymphocytomatoses. 

Because of the increased number of cells of the granular system which 
appear in the circulation in the myelo-cytomatoses the terms leucemic 
myelo-cytomatosis or myeloid leucemia are employed. 

Cases of this rare form of disease have been definitely diagnosed after 



180 



TEXT-BOOK OF PEDIATRICS 



the sixth year. 4 Almost all of them have a chronic course extending over 
several months or years and have proved fatal. 

Symptoms. The first definite symptoms are usually those of mechanical 
origin, resulting from the size of the tumor and the pressure of the hard, 
rough spleen, which gradually grows to an enormous size. Even then, the 

general well-being and the appearance of health 
may continue for a time. Later, as a result of 
hemorrhage, symptoms of cachexia and signs of 
anemia, such as pallor, lassitude, dyspnoea, palpi- 
tation, anorexia, and loss of weight appear. 
Coincidently, spontaneous, and pressure pains in 
the bones develop and alterations of hearing and 
a hemorrhagic retinitis are observed. The urine 
shows protein, casts, and increased output of uric 
acid. Moderate swelling of the superficial and 
deep lymph nodes often occurs, but only after the 
long continuance of the disease. Irregular rises 
in temperature are frequent. 

If the blood is highly leucemic, its increased 
viscidity and diminution of color, together with 
the formation of a grayish-white sediment upon 
standing, and its slow coagulation, may be noted, 
but less distinctly than in lymphemia. The 
anemia is usually of a simple normoblastic type; 
less commonly it may be megaloblastic. The 
degree of the anemia varies greatly. The number 
of white cells is usually between 100,000 and 
400,000. All forms of cells of the granular system 
take part in the absolute increase, so that the 
blood looks as though bone-marrow had passed 
into the circulation. Myelocytes of the most vari- 
able types of granulation are relatively numerous, 
ranging to about fifty per cent. Occasionally, the 
eosinophilic and basophilic granular leucocytes are 
also relatively increased. The neutrophilic granu- 
lar polymorphonuclear cells are usually present in 
but slight excess. The appearance of myeloblasts 
and abnormal cells toward the end of the disease 
is a noteworthy fact. 

Diagnosis. Difficulties in diagnosis are encountered when the blood 
picture and the splenic enlargment have been affected by complicating con- 
ditions or by therapy. A high leucocytosis in anemic patients, arising from 
such causes as sepsis and granulomatosis, is to be considered. In these 
cases, however, the blood picture is less varied and the increase of the 

4 In younger children, in whom a diagnosis of myeloid leucemia has been accepted, 
the process was probably always that of Jaksch's anemia. Reports in recent literature 
seem to indicate that this form is more common than was formerly believed. 




FIG. 37. Myeloid leucemia, 
boy of twelve years; Intermis- 
sion with disappearance of all 
symptoms under treatment with 
arsenic and X-Ray. 



THE BLOOD AND BLOOD-FORMING ORGANS 



181 



eosinophiles and the mast cells is also wanting. For practical purposes the 
disease may be differentiated from Jaksch 's anemia (which, both clinically 
and pathologically, differs only in quantitative degree from myeloid leu- 
cemia), by the minimal age limit in the occurrence of the former to five years. 
Occasionally, at least, myelo-cytomatoses may take a sub- or aleucemic 
course, and hence the use of the term myeloid pseudoleucemia. 

4. MYELOSARCOMATOSES 

The myelosarcomatoses, or multiple aggressive myelomata, developing 
both within and without the bone-marrow, are of a type of disease which 
does not occur in childhood 

CHLOROMATA 

The chloro- lympho- and chloro- myelosarcomata, which maybe regarded 
as deviations from the lympho- or myelo-cytomatoses, or as forms of the 
latter pursuing a peculiar course, are 
relatively common in early life. They 
present, at times, the characteristics of 
leucemia, but occur more often without 
them. Most of the cases of chloroma 
observed have been in young males 
ranging from two to thirty years. One- 
half of these have been in children. 

The chloromata are distinguished 
pathologically from the corresponding 
leucemias and pseudoleucemias by ex- 
tensive, generalized, subperiosteal cell 
proliferation. For some, as yet un- 
known reason, these proliferations are 
often of a yellow or grayish-green color. 
They are most commonly found in the 
flat bones of the cranium, especially in 
the orbital region, the temporal bones, 
and the zygoma, and in the bones of 

the thorax. Similar proliferation occurs, less frequently, in the skin and 
serous membranes. 

Clinically they are distinguished by the formation of symmetrical 
tumors, growing within the cranial cap, the spinal canal, the mouth, and 
the mastoid cells; and causing such pressure symptoms as protrusion of the 
optic bulb, paralyses of cranial nerves, etc. These characteristic clinical 
signs develop early. Their aggressive character gives the chloromatous 
diseases a position between the cytomata and the sarcomata. In other 
respects their clinical and pathologic findings correspond closely to those 
of the common forms of lymphocytomatoses or myelo-cytomatoscf?. Their 
course is always acute and very severe. The duration of the disease is, at 
least, a matter of a few months. 




FIG. 38. Three and one-half-year-old boy 
with chloromatous tumors on the flat cranial 
bones, vertebra, and orbits, with hyperplasia 
of the lymph nodes and anemia. 



182 



TEXT-BOOK OF PEDIATRICS 




5. GRANULOMATOSES 

Granulomatoses are formed 'by chronic inflammatory processes which 
gradually develop hard, compact, granulation tumors of the lymph nodes, 
with a tendency to necrosis, induration, and scar formation, without lym- 
phocytic proliferation or aggressive growth. Essentially they consist of 
endothelial and epithelial cells, of giant, spindle, and round types, mixed 

with fibroplastin and fibrin. The 
granulomata may be genera- 
lized from the beginning, or 
persistently localized. The lym- 
phatic tissue of the spleen and 
the liver is usually affected dur- 
ing the course of the disease, 
while that of other organs, as 
the bone-marrow is but rarely 
involved. 

Symptoms. At first, soft, 
grape-like enlargments of the 
lymph nodes appear in the neck. 
These may be unilateral or 
successively bilateral. Signs of 
pressure in the mediastinum are 
soon apparent. In the diffuse 
form, enlargement of the spleen 
and liver follows the gradual 
hardening of the enlarged lymph 
nodes. Periods of severe inter- 
mittent fever, occurring even 
in tuberculous individuals, are 
characteristic. The suspicion of 
granulomatosis is definitely 
sustained by a persistent diazo- 
rcaction of the urine. The diag- 
nosis is fully established in the 
living by the histologic exam- 
ination of an excised gland. 
The diffuse type of the disease 
runs a chronic course, unaffected by treatment, producing anemia and ca- 
chexia, and always ends fatally. 

The localized forms, and especially those occurring in luetic patients, are 
amenable to treatment. In contradistinction to scrofulous lymphadenitis, 
the granulomata do not tend to form epidermal scars or perforations, and 
have no relation to regional diseases of the skin and mucous membranes. 




FIG. 39. Seven and one-half-year-old boy with granulo- 
matosis, most marked in the cervical nodes. Confirmed 
by histological examination. 



THE BLOOD AND BLOOD-FORMING ORGANS 183 

PATHOGENESIS or LEUCEMIA AND PSEUDOLEUCEMIA 

Myelo-cytomatosis occurs physiologically in the embryo in practically 
the same manner as does myeloid leucemia. It develops after birth by a 
metaplasia due to the action of infectious, toxic, or actinic stimuli. This is 
equally true of embryonic lymphocytomatosis, which differs only quanti- 
tatively from lymphoid leucemia. Upon these facts (Naegeli), our knowl- 
edge of the pathogenesis of the leucemic diseases is based. Their etiology 
is entirely obscure. Some forms of pathologic leucopoiesis, as initially noted 
hi the evolution of myelocytes in osteosclerosis, may be considered purely 
compensatory. In others, as in the formation of myelocytes in post-hemor- 
rhagic, toxogenous or infectious anemia, the increased requirement or 
demand may be a factor. In still others, a direct, specific stimulative action 
of endogenous or ectogenous substances, serving as specific excitants, may 
play a part. 

The granulomata are, in some cases, directly dependent upon syphilitic 
poison and, in others, upon a tuberculous infection (Sternberg). The 
granular form due to the tuberculous virus (Much-Romer), is especially 
common. In another group of these cases the malignant granulomatoses 
however, neither a syphilitic nor a tuberculous infection, nor any other 
known cause, can be demonstrated. 

THERAPY 

There is no specific treatment for the leucemias of childhood. It is 
possible, especially in myelo-cytomatosis, to cause a direct destruction of the 
white cells in the circulation and to combat their excessive formation and 
appearance in the circulation by limiting the cytogenesis. In the early 
stages of the disease it is, strangely enough, not uncommon to note, not 
merely the remarkable disappearances of blood symptoms, but improve- 
ment in other manifestations of the disease and in the general well-being. 
Relapses always occur. These temporary results, which serve to prolong 
life, are in all probability similar, in all essentials, to the beneficial action of 
intercurrent infectious diseases. Benefit is quite certainly and directly 
secured by the use of arsenic in the form of the liquor potassii arsenitis 
(Fowler's solution), in doses up to twelve drops a day, continued for months. 
More recently benzol has given good results. Similar improvement has been 
obtained by the use of the Roentgen rays, applied in from two to six treat- 
ments, over the spleen and the region of groups of affected lymph nodes. 
A hard tube should be used, placed at least 40 cm. (16 inches), from the body, 
and the exposures should last from five to ten minutes. Symptoms of arsen- 
ical poisoning and toxogenic anemia may, of course, appear, while with the 
Roentgen method there is always danger of dermatitis. In both forms of 
treatment violent reactions may be harmful, resulting in fever and fatality. 
The most careful dosage and an extreme watchfulness will protect the 
patient absolutely against these accidents. A criterion of judgment of 
therapeutic action is to be found in a careful observation of the numbers of 
red cells and of the hemoglobin index of the blood, and in a determination 



184 TEXT-BOOK OF PEDIATRICS 

of the output of endogenous uric acid. It must be remembered, however, 
that in these cases the full effects of the Roentgen ray usually develop after 
several days. 

In cases of aleucemic lymphadcnosis and myclosis, and especially 
in cases of tymphosarcomata, every experienced observer has occasionally 
seen the most surprising results under these methods of treatment. 
Whether complete recovery ever takes place is still doubtful. The treat- 
ment of diffuse granulomata is hopeless. Local granulomata may be excised 
or treated with iodine, the internal and external application of which are 
often successful. This obtains, however, only when the luetic character of 
the tumor does not indicate other forms of treatment. 

HEMORRHAGIC DIATHESIS OR TENDENCY TO HEMORRHAGE 

In text-books it is. not customary to group diseases according to their 
symptoms, but the diseases to be discussed under this title are so grouped 
because of the greater convenience for study and for use in actual practice. 
The diseases are not necessarily related, either in their nature or general 
manifestations. The grouping followed is based upon the more outstanding 
symptoms with which hemorrhage may be combined. 

Group I. Purpura Hemorrhagica. The diseases in this group are 
limited rather narrowly to those in which the tendency to hemorrhage is 
secondary to such blood diseases as leucemia and the anergic nonplastic 
anemias. The most frequently seen is the symptom group first described 
by Werlhof and known as Werlhof 's disease. The primary conditions may 
be true blood diseases with characteristic findings, or may be of more 
indefinite and unexplained nature. In the latter cases the tendency to 
hemorrhage appears as an "idiopathic morbus Werlhoffi, " that is, it is the 
outstanding feature of the entire symptom-complex. In all the diseases of 
this group the course of the tendency to hemorrhage unless death results 
from loss of blood is dependent entirely upon the primary blood disease, so 
that it may be acute and rapidly fatal, or a relatively chronic, benign affair 
with complete recovery or with intermissions. The idiopathic form may 
also run a course of continual aggravation or of gradual recovery. 

The hemorrhages may be from the skin and subcutaneous or from 
mucous membranes or into muscles, but very rarely synovial. They occur 
as petechias, or larger spots following slight trauma, are asymmetric and 
are seen even on the head and face. The hemorrhages from the mucous 
membranes of the nose, mouth, vagina and at times of the bowel are char- 
acteristic. They may be very profuse and even fatal. There are no local 
symptoms and the general symptoms are closely interwoven with the 
symptoms of the primary affection and the post-hemorrhagic anemia. 
The bleeding time is prolonged and the contraction of the clot is incomplete. 
During the height of the hemorrhagic tendency the number of blood-plate- 
lets in the circulating blood is reduced to 30,000 or even lower. From a 
pathogenetic standpoint great stress is laid upon this " thrombopenia " in 
view of the action of the platelets in the mechanism of coagulation. Accord- 
ing to these findings, the cases of hemorrhagic purpura of the Werlhof type 



THE BLOOD AND BLOOD-FORMING ORGANS 185 

must be considered due chiefly to hematic causes. The thrombopenia may 
occur with the various intercurrent diseases and in various ways analogous 
to the origin of anemias. Its pathogenesis is probably analogous to that of 
certain primary anemias. In some cases it may be due to a crowding out 
of the platelet-forming parenchyma in the bone-marrow by leucemic 
lymphoid proliferation. In others, a marked restriction of the develop- 
ment of bone-marrow. Or again increased thrombocytolosis in the spleen 
or its associated tissue due to hyperplasia. Further, a congenital deficiency 
of the platelet-forming marrow in a condition, no doubt, related to familial 
hemophilia for which Glauzmann has suggested the name " hereditary 
thrombasthenia " may be a factor. The action of blood poison of all sorts 
may be causative. Since infectious diseases may also cause a thrombopenia 
either directly or indirectly by the action of toxins, this type of hemor- 
rhagic diathesis is also seen as a concomitant, or complication of these and 
more especially after scarlet fever and diphtheria. 

In the treatment of these conditions transfusions, injections of auto- 
serum, subcutaneous injections of horse serum and salt solution, and various 
commercial coagulation producing products are recommended. Internally, 
liquor potassii arsenitis (Fowler 's solution) in increasing doses up to twenty 
drops per day, calcium lactate or preferably chloride in large doses (6-10 
grams per day) and gelatin either subcutaneously in ten per cent, solution^or 
in large amounts by mouth are useful. The use of Roentgen treatments to 
the spleen is indicated when that organ is enlarged. 

Group II. Hemorrhage due to Multifocal Infectious Disease. This 
group is characterized, clinically, by the close relationship to obvious infec- 
tious diseases such as meningococcus meningitis, measles, influenza, sepsis, 
chicken-pox, tuberculosis and congenital lues. In these conditions we may 
have multiple, circumscribed, more or less autonomous disease foci in the 
peripheral vessels, resulting in emboli, thromboses, hemorrhagic exuda- 
tions, and erosions of the vessel walls which in turn cause bleeding. So 
that the hemorrhagic tendency in these conditions is largely due to organic 
vascular lesions. Its occurrence is in association with and dependent upon 
the basic infectious disease. 

Group HI. Hemorrhagic Arthritis (Schoenlein-Henoch). This group 
consists of diseases with a rather definite symptom picture. It occurs most 
frequently in older children, and is not fatal. They are characterized by 
recrudescences lasting several days or weeks and the entire course lasting 
for weeks or months. In definite cases a symptom triad predominates. 
This consists of cutaneous purpura, intestinal colic, and articular pains 
with or without swelling of the joints. All these symptoms are supposed to 
be due to hemorrhage or the results of hemorrhage. The subcutaneous 
hemorrhages are petechial or may become as large as small coins, super- 
ficial, and are more or less symmetrical on trunk and limbs. Actual bleed- 
ing is uncommon. Frequently skin eruptions, edema and proteinuria is 
encountered. The skin eruption may be urticarial, erythematous or mul- 
tiform in type. There may be no fever and the general manifestations are 
usually mild. The etiology is entirely unknown, but the theory of an 



186 TEXT-BOOK OF PEDIATRICS 

infectious or anaphylactic nature is generally accepted but far from proved. 
It is supposed that a functional vascular injury, that is a toxic capillary 
paralysis with dilatation and diapedesis, is concerned in the causation. 
Usually no treatment other than rest in bed is necessary. The remedies 
advised under purpura hemorrhagica may be employed. 

Group IV. Scurvy. In this group there is a distinct relation between 
the hemorrhagic tendency and food deficiency as shown by its prompt 
reaction and relief by diatetic treatment. True scurvy has been very uncom- 
mon in civilized countries, but during the World War was again quite fre- 
quent in the countries where lack of proper food occurred. Infantile scurvy, 
Barlow's disease, in children under two years is not rare at any time. 
According to recent investigations the two conditions are closely related. 
Their manifestations differ because the immature osseous system of the 
infant reacts differently to the injury than does that of older patients. It is 
still doubtful whether this injury is primarily one of the bone-marrow itself 
or whether it is due to vascular changes affecting the marrow. 

INFANTILE SCURVY (Barlow's Disease) 

This condition is of great interest to the pediatrist and requires full dis- 
cussion here. The scurvy of adults is left for text-book of internal medicine. 

Etiology. Naegeli and other authors suggest as a cause of the symptoms 
a reduced proliferation of the interstitial connective tissue of the marrow, 
with transition of marrow cells into fibrous connective tissue at certain 
points of most rapid growth as in the diaphyses, costochondral margins and 
cranial bones. This is supposed to have two results. 

First. The activity of the osteoblasts and the resulting bone growth is 
reduced at the affected points. With continuing resorption of the already 
formed bone, the wall becomes thinned resulting in localized weakness or 
myelogenous infantile osteotabes. Muscular action and slight trauma 
cause infractions and fractures of the diaphyses of long bones and the ribs. 
The growth in length is delayed. (Figs. 40 and 41.) 

The bone affection described above differs entirely from true rickets. 
The addition of rickets, however, may add to the fragility of the diseased 
ends of the diaphyses. In contradistinction to rickets, the mineral salts, 
especially calcium, are found to be retained in infantile scurvy and are 
liberated when diatetic treatment is instituted. During the florid stage, the 
mineral content of the bones and muscles is low. 

Second. The hematopoietic function of the bone-marrow suffers. The 
result of this is progressive anemia and a tendency to hemorrhage. The 
latter is especially seen, in the event of fracture, in the development of 
subperiosteal and medullary hemorrhages. The tendency to bleeding shows 
itself, also, at other points. 

Symptoms. The osteotabes causes severe pains in the affected bones; 
deformities and crepitation; distension, with dough-like swelling of the soft 
parts from the underlying blood deposits; and tenseness of the skin. Severe 
pain is localized principally at the ends of the diaphyses and is excited by 
movement or touch. As a result there may be a degrae of pseudoparalysis, 



THE BLOOD AND BLOOD-FORMING ORGANS 187 

but this is not a constant sign (Fig. 43). Deformities appear in the affected 
bones and especially in those of the fore-leg and the thigh, at the knee-joint, 
and more rarely in the bones of the arm and forearm, at the elbow or 
shoulder-joint, and at the costochondral articulations. The sinking in of 




Flo. 40. Humerus of a child of one year Fio. 41. Femur of child, infantile scurvy. Hempr- 

with infantile scurvy. The soft parts have rhage into the marrow and subperiosteal tissue with 

been dissected away in order to show the loosening of the periosteum, 
impacted fracture of the neck more clearly. 

the sternum with the costal cartilages is a good example of the deformities 
which may arise. 

In the mucous membranes the hemorrhagic diathesis is manifested 
commonly by hemorrhagic swelling and softening of the gums. These occur 
only when the teeth are present or are erupting. It is further indicated by 
conjunctiva!, nasal, intestinal and urinary bleeding; the two latter sources 
being shown by bloody stools and hematuria. Extensive extravasations of 
blood, of both subperiosteal and supraperiosteal origin appear in the jaw 
and in the long bones affected. Hemorrhage of the periosteum of the 
orbital plate is recognized by exophthalmos and by infiltration of the eye- 



188 



TEXT-BOOK OF PEDIATRICS 



lids; while. bleeding from the parietal periosteum is recognized by the forma- 
tion of ceph'alhematomata. In the skin, pallor, petechise, suffusionsand edema 
are accepted signs of anemia. In a small number of cases blood changes, 
in the form of oligochromemia, oligocythemia, poikilocytosis and relative 
lymphocytosis, may be determined by examination. Tachypncea, tachy- 
cardia, caidiac murmurs and dilatation of the heart may also develop. 
A typical fever frequently appears and is probably due to the resorption of 
extravasated blood. Food is often entirely refused. 

Scurvy usually presents itself to the observer in the following manner. 
After very slight prodromes, such as disturbances of sleep and disposition, 
marked thirst, and loss of color, and sometimes even without these, one 
notices, usually during the bath or while handling the child, that it gives 
evidences of pain upon being touched and especially in the legs. Soon after, 
swelling of the knee, on one or both sides, and of the ankles becomes appar- 

^. ent. The type of the deformity is 

different, however, from that pro- 
duced by hemorrhage into the joint 
cavity. It is clearly a disease of the 
long bones themselves. The legs 
are held motionless upon the bed, 
in external rotation, with abducted 
thighs and slight flexion of the 
knees. A few days later, a spongy 
thickening of the gums around the 
teeth, or beside the teeth which are 
erupting, is to be noticed. At the 
same time, small hemorrhages, re- 
sembling flea-bites or larger suffu- 
sions of blood are seen, here and 
there, upon the skin. The mother 
reports a peculiar red discoloration 
of the soiled diaper and a sediment, consisting of erythrocytes, appearing 
in the fresh urine. The latter may even present the characteristic findings 
of acute hemorrhagic nephritis. The general condition of the patient be- 
comes more serious, the face increasingly pallid, the restlessness more 
marked, while the immobility of the limbs consequent upon the suffer- 
ing heightens the impression of extreme debility. 

Diagnosis. The affection of the gums, the pseudoparalytic symptoms, 
the painful swelling of the limbs, together with the hematuria and hemato- 
mata are especially significant in the diagnosis of scurvy. The combination 
of the hemorrhagic diathesis with multiple lesions of the bones, associated 
with certain external conditions, is almost pathognomonic. However, 
hematuria is occasionally the only symptom. The Roentgenogram may be 
very characteristic. It shows a dark shadow strip at the border of the 
diaphyses and may also show the shadow of blood extravasates under the 
periosteum along the shaft. (Fig. 44.) 




FIG. 42. Changes in the gums in a case of in- 
fantile scurvy. 



THE BLOOD AND BLOOD-FORMING ORGANS 189 

Course and Prognosis. The onset is usually gradual and is marked by a 
certain disturbance of nutrition, its most delicate symptom. Its typical 
qualities appear successively. Untreated, the disease is chronic and is 
slowly progressive for months. Recovery may take place spontaneously 
in mild cases. The severer forms are usually supposed, however, to be fatal, 
terminating in enteritis or pneumonia. The prognosis depends upon the 
skill of the attending physician. 

Occurrence and Etiology. The great majority of cases begin from the 
ninth to the fifteenth month. Cases that develop at a late period, say, dur- 
ing the second, third or even the fourth year, or those beginning earlier in 
the third to the fifth month, are much rarer. The disease is more frequent in 




FIG. 43. Position of the thighs in infantile scurvy. 



Germany and in the north of Europe than it is in the south. In some 
southern countries it is almost unknown. This infrequency is actual and 
is not due to any want of recognition. It seems to spread from the northern 
latitudes (see Rickets). Male children are affected almost exclusively and 
especially those who are fed entirely, or to a large extent on commercially 
prepared and sterilized milk or other artificial food. For this very reason, 
scurvy is uncommon among the poorer classes. It goes without saying that 
not all children so fed are affected, but only those with a definite predis- 
position. None of the hypotheses, of course, such as injury to the milk by 
heating, by bacteria or bacterial toxins, by icing and storage, or by silicic 
acid derived from glass containers, are tenable. In fact, the attempt to 
classify scurvy among disturbances of nutrition results in stretching out 
conceptions of the disease beyond all reason. 



190 



TEXT-BOOK OF PEDIATRICS 



Therapy. Since Barlow first recognized scurvy there has been no 
disease of childhood that has proved so gratifyingly amenable to simple 
treatment. Nor is there a disease of this period upon the course of which 

pediatric ignorance has had 
more serious results. It has been 
mistaken for rickets, osteomy- 
elitis, fungus, syphilis and sepsis. 
In its treatment, natural 
foods, such as raw cow's milk, 
or human milk ; several dessert- 
spoonfuls of fresh orange, lemon, 
or grape juices, each day; ripe, 
finely divided fruits, such as 
apples in season ; mashed vege- 
tables, or raw meat juices should 
be given. Intestinal catarrh is 
no contraindication for these 
foods. The results of their use 
are truly miraculous. They are 
subjectively recognized in a 
very few days and all objective 
symptoms disappear in a few 
weeks. The repair of severe 
bone lesions requires, however, 
several months. Fractures do 
not require supporting splints, 
since the remaining periosteum 
seems to suffice to keep the 
bones in place. Baths, antiphlo- 
gistic applications, and all un- 
necessary handling of the child 
should be avoided. 

Certain mechanical disturb- 
ances of circulation may lead 
to hemorrhage as in case of con- 
gestion due to cardiac decom- 
pensation or diseases with convulsions or coughing. Besides this severe 
cachectic processes, many organic nervous disorders, even psychic influences 
may give an increased tendency to bleed. The hemorrhagic diseases of the 
new-born will be discussed in another section. 

RICKETS 

Pathologic-Anatomy. The most important pathologic changes in 
rickets are those of the skeleton. In the acute stage we find, macroscopi- 
cally a more or less general softening of the bones, which become deformed 
by swelling, decurvation and formation of callus. The periosteum and 
bone-marrow are hyperemic. Over some bones especially those of the cra- 




FIG. 44. Roentgen picture of the right thigh of a girl 
of one year with scurvy. Subperiosteal hemorrhages of 
the femur. 



THE BLOOD AND BLOOD-FORMING ORGANS 191 

nium, the periosteum may become so greatly thickened as to resemble a 
spongy exudate. 

The most important microscopic findings, also are seen in the bony 
framework and are as follows : 

1. The bone and cartilage formed during the progress of the disease are 
insufficiently calcified or entirely uncalcified, so that in acute rickets, 
non-calcified cartilage and bone tissue, the so-called osteoid tissue, of much 
greater thickness or width than normal, is found throughout the skeleton. 
This especially is seen in those parts where, normally, the growth is partic- 
ularly active, as in the periosteum and in the subchondral zones. The new 
formation of osteoid tissue occurs at an abnormal rate in these parts. At the 
diaphyses, the points where tendon insertion and muscular attachment 
constantly subject the bones to extreme flexion or extension, the mechanical 
insufficiency due to the extreme softness of the osteoid tissue leads to an 
attempt at compensation by excessive new formation of bone, or by 
decreased resorption of it. This active proliferation and mass formation is 
probably a secondary manifestation and naturally occurs as a result of 
increased vascularity. This is known as Kassowitz' inflammation, rickitic 
osteitis, or periosteitis. When this condition is most marked it is described 
as a hyperplasic osteophytic form of rickets. 

2. Bones, which at the onset of the disease were completely formed, 
become poorer in calcium salts and therefore softer (osteomalacia). This 
decalcification must not be considered analogous to that produced in the 
treatment of bone with acid, to make it easier to cut, as was once taught. 
It is not a chemical decalcification. It occurs, rather, as an actual biologic 
process, by which the physiologic resorption of the older portions of the 
bone tissue continues, while the absorbed portions are replaced by newly- 
formed tissue, poor in calcium or containing no calcium at all, so that the 
removal of the lime salts in the mature bone is actually a result of the non- 
calcification of the osteoid tissue, described in previous paragraphs. It is 
entirely comparable to the decalcification which occurs in osteomalacia. 
It is, accordingly, most pronounced in those parts in which the bone 
is normally thin, as in the craniotabetic areas on the posterior aspect of 
the skull. The loss of the salts in rickets may convert the long bones 
into rubber-like, elastic strands that are easily severed the osteomalacic 
form of rickets. 

According to von Recklinghausen this softening of mature bones takes 
place at a rapid rate in rickets. It goes on in circumscribed areas and is 
produced by the tryptic autolytic action of the osteoclasts and newly 
formed vessel shoots. 

3. The endochondral ossification is disturbed in an equally character- 
istic manner. The preliminary calcification of the cartilage is wanting, and 
under markedly increased vascularity the zone of cartilage proliferation 
becomes irregular in form and greatly extended. This extension arises 
from the delayed resorption, which in turn is due to the disturbance of 
calcification. The impairment of the endochrondral ossification, character- 
istic of rickets, is closely related to the longitudinal growth of the bone 



192 TEXT-BOOK OF PEDIATRICS 

during the course of the disease. In consequence, it is absent in the osteo- 
malacia of adults. In a word, the disturbances of ossification are due 
entirely to the non-calcification of both cartilage and bone. 

4. Occasionally, fibrous foci have been found in the bone-marrow of 
rickitic children. Recently, however, Marfan, in opposition to older 
observers, has held that the changes in the bone-marrow in rickets are 
constant and pathogenetically of great importance (see below). According 
to this observer, the first or clinically latent stage of rickets is characterized 
by an irritative, atypical and aberrant proliferation of the cells of the par- 
enchyma of the bone-marrow and of the cartilage. The second and clini- 
cally manifest phase is characterized by the formation of a fibrous marrow 
(see Scurvy). Ziegler, also, considers the proliferation of the cells of the 
bone-marrow, and especially of those which he calls endosteal cells, an 
essential change. 

In the stage of recovery, the temporary calcification of the cartilage and 
the changes of the osteoid tissue to hard, solid bone, i. e., eburnation takes 
place. 

In severe rickets, rather characteristic changes of the soft parts are also 
found and especially in the striated as well as in the unstriated muscle 
tissue. These consist in the development of slender immature fibres, 
with increased nucleation and in the modification of the longitudinal stria- 
tions. They are interpreted as specific disturbances of nutrition of a retro- 
grade character. 

The liver and spleen are often enlarged, due to hyperplasia of pulp and 
follicle. The lymphoid tissue throughout the body is markedly swollen. 
The brain is enlarged as though swollen. 

All these lesions bring about the characteristic habitus and picture of 
rickets; the large head, the short rounded chest, the pendulous abdomen, 
and the short plump extremities. 

Chemical Findings. In rickets the osseus tissue is extremely poor in 
mineral components and especially in calcium and phosphorous. The soft 
parts are less affected. The magnesium salts are reduced absolutely but 
increased relatively. The ash of the dry tissue of the ribs and vertebra may 
be reduced from sixty per cent, to as low as twenty per cent. The swelling of 
the cartilage is probably caused by the loss of lime salts, since the Ca-ions 
inhibit the process of water absorption. This plays, however, but a minor 
part in the increase of mass. It should be noted that the insufficient calci- 
fication of the bony skeleton in rickets corresponds to a reduced calcium 
retention throughout the body. The loss of salts in the rickitic infant may 
occasionally cause a negative calcium balance, which involves an increased 
calcium requirement during recovery a fact which can be proved by 
metabolism experiments. Up to the present time, no further findings of 
particular patliogenetic importance have been demonstrated. 

The calcium content of the blood in rickitic infants is subject to wider 
variations than in non-rickitic infants, both above and below the normal 
( Aschenheim) . Since this figure consists of three quotients, that is, the 
true blood calcium, the calcium of the food metabolism and the waste 



THE BLOOD AND BLOOD-FORMING ORGANS 193 

calcium, the interpretation of this variation is not too clear. Negative 
balances of alkalies, chlorides, sulphur, and magnesia are not characteristic 
of the mineral metabolism in rickets, which explains the difference from 
infant atrophy and clears up their relation to tetany. 

Pathogenesis. The anatomic study has shown that the basic cause of 
the characteristic findings in the skeleton is due to the failure of proper 
mineralization of cartilage and bone. With the recognition of this fact, a 
further study of the pathogenicity of the disease was given a definite basis 
for promising inquiry, but beyond it positive knowledge does not extend. 

Why do the newly developed parts of the skeleton take up little or no 
inorganic salts from the beginning of the disease? Three plausible possi- 
bilities present themselves: 

1. The intake of the mineral constituents of the body may be quanti- 
tatively insufficient, or the form in which they appear in the blood may be 
unsuitable. This might be due either to a scarcity of calcium in the food- 
stuffs, or to a relative inadequacy of the calcium digestion and absorption. 
Proceeding upon this theory, researches, into which obvious factors of 
error entered, were presented to sustain the surprising view that the mother's 
milk could not long fulfill the demand for lime salts put upon it by the 
growing organism of the child. This hypothesis, repeatedly advanced, but 
unsupported by pediatric authority, may be dismissed. Confirmed experi- 
ments offer no proof whatever of a primary disturbance in the calcium or 
in any other specific phase of metabolism. 

The premises upon which this teaching rests are not tenable. Bru- 
bacher, Stoltzner, Cronheim and Mueller, contradicting the findings of 
other writers, show that the alleged reduction of the calcium and other 
salts does not manifest itself in the soft parts of the body as it does in the 
bony tissue. 

Further, the consensus of judgment of numerous podiatrists indicates 
that neither an increase of the calcium intake, nor an improvement of 
calcium absorption will successfully serve as either a prophylactic or a 
therapeutic measure in acute rickets. The form of disease induced, in 
growing animals, by a calcium-free diet differs from rickets. 5 This is both 
histologically and biochemically true. Under such calcium starvation, an 
extract of the muscular, cartilaginous and bony tissues dissociates and 
takes up the calcium ion from a neutral solution of the calcium salts with 
avidity. This is not observed to so marked a degree with rickitic material. 

2. An intrinsic disease of the growing skeleton itself may interfere with 
its proper mineralization. This is not to say, of course, that rickets is an 
affection limited to the skeletal parts; but rather that an abnormality 
occasionally hindering the mineralization of the skeleton might be con- 
sidered analogous to such other disturbances, in other systemic organs, as 
myo-dystrophia, anemia, etc. 

Such prominent pathologists as Pommer and von Recklinghausen do 
not concede, as Kassowitz supposes, that actual inflammatory processes 
play any part in preventing calcification. Schmorl opposes the statement 

5 Stoltzner, Schmorl. 
13 



194 TEXT-BOOK OF PEDIATRICS 

of Stoltzner who holds- that the fundamental fact in rickets is an inhibi- 
tion of development ; that the normal metaplasia, microchemically demon- 
strable, which matures the osteoid tissue as a calcium absorber, is absent in 
rickets. Similarly, the recent experiments of Adele Hartmann show that 
pieces of rickitic cartilage placed in the abdominal cavity of the rabbit do 
not retard calcification any more markedly than do non-rickitic tissues 
similarly introduced. According to these researches, the tissues of the 
rickitic patient do not lack the power of calcium absorption. They tend, 
rather, to show that there is, in the rickitic organism, a functional limitation 
upon the mineral metabolism. 

3. This view is embodied in the third .of this group of hypotheses, which 
postulates a continuous decalcification and a consequent failure to store the 
lime salts as a result of an abnormal acidity of the body fluids. Aside from 
the fact that the condition is one, not only or merely of decalcification, but 
of actual demineralization, this theory violates Stoltzner 's finding of a nor- 
mal reaction of the blood serum in rickets. 

As a result of the discovery of primary, irritative, systemic, changes in 
the bone-marrow, Marfan has recently come to the conclusion that these 
processes affect the function of the osteoblasts arising from the bone-mar- 
row and thus hinder calcification. The proposal of this theory of the 
myelogenous nature of the disease, in spite of Zeigler's teaching as to the 
functional independence of the blood-forming and the bone-forming marrow 
seems especially noteworthy in view of the relation of rickets to scurvy and 
to von Jaksch's anemia. Ribbert finds a toxogenous necrosis of the carti- 
lage cells in rickets. 

Other hypotheses and, in particular, that which lays the cause of the 
disease to the absence of an internal secretion of certain glands, as the 
thymus, thyroid, suprarenal body or liver, lack, at present, reliable positive 
support. Erdheim claims to have produced rickitic bone changes in rats by 
the excision of the parathyroids. Animals in which rickets occurs spon- 
taneously are said to have enlarged parathyroids. 

Occurrence and Etiology. It is difficult to form any statistical estimate 
of the frequency of rickets because the subjective signs of it so closely 
simulate physiologic conditions. Systematic reports of anatomic findings 
in the large mass of unselected material coming to autopsy should be 
accepted, rather than the extraordinarily variable and but crudely oriented 
results of clinical examination. The following table is computed from the 
autopsy reports of Schmorl. This indicates that the disease never appears 
before the middle of the second month and only occasionally after the 
end of the second year, and that it affects almost every child between these 
two periods. 

It should be noted that this table includes children who have died at an 
early age; and that they were probably, in large part, of the poorer classes. 
It is also to be observed that rickets is exceptionally common in the material 
presented by this author. 

It is the experience of the author that premature infants are not affected 



THE BLOOD AND BLOOD-FORMING ORGANS 



195 



with rickets, at the same actual age as other infants, but at periods of 
relative development. 

In certain families the frequency and severity of rickets appear to be 
influenced by hereditary factors. Not only does the disease appear even 
under favorable circumstances in the children of rickitic parents, but it has 
been noted, selectively, in the progeny by different fathers of a mother who 
was rickitic. The heredity of a structural tendency to rickets is doubtful. 

The occurrence of the disease is influenced by the method of feeding. 
Severe forms are very much more common in overfed and artificially-fed 
babies than in the breast-fed. 

It cannot be said that other diseases, e, g., disturbances of nutrition and 
infections, determine the appearance of rickets. In fact the diseases which 

TABLE II. 
RICKITIC AND NON-RICKITIC CHILDREN AT VARIOUS AGE PERIODS. 



Age in months 


0-1 


1-3 


3-6 


6-9 


9-12 


12-18 


18-24 


24-36 


36-48 






















Non-rickitic children . . 


100 


39.4 


3.0 


6.0 


2.7 


1.7 


9.1 


12.3 


29.4 


Early rickets, micro- 
scopically recognized. . . 




48.5 


55.8 


32.0 


9.2 


6.8 


6.1 


























Acute rickets recog- 
nized macroscopically 
and microscopically. . . 




21.1 


20.6 


43.2 


60.0 


54.2 


30.3 


20.1 


5.9 






















Convalescing cases .... 






20.6 


18.8 


26.7 


25.4 


33.3 


21.5 


8.8 






















Recovered cases .... 










1.4 


11.9 


21.2 


46.1 


55.9 























limit growth seem rather to counteract the development of rickitic changes. 
Atrophic infants, for instance, are never severely rickitic. Nevertheless, 
the signs of rickets are not commonly seen in naturally-fed or in suitably, 
if artificially-fed children who are scrupuously cared for and are of normal or 
supernormal development and have shown no evidences of nutritional 
disturbance. If fat infants, who are frequently ill and of consequently 
lowered resistance, seem to be especially predisposed to rickets, it is possible 
that their diminished bodily activity plays a more or less important part. 
In general, the children of the well-to-do are affected as often, but certainly 
not so severely, as the children of the poor. 

Furthermore, rickets, as a disease of the masses, is influenced by modes 
of living. All those influences of domestication and civilization which 
disturb the natural and primitive habits of life; which tend to close and 
crowded housing of the poor; which favor indoor and sedentary occupations, 
and permit but limited and unbalanced physical exercise, favor the occur- 
rence and development of rickets. 6 

The most potent factor resulting from domestication, to which Kassowitz 
calls particular attention, is the element of respiratory injury. It is held 
responsible for the high prevalence of rickitic disease in densely popu- 
lated tenements. 

6 Von Hansemanri, Neumann. 



196 TEXT-BOOK OF PEDIATRICS 

Findlery's observations, of a strictly experimental order, show that in 
forms of disease identical with, or closely resembling human rickets, pro- 
duced or spontaneously incurred in young animals kept in confinement, 
the toxic, infections or nutritive injuries present were less directly causative 
of the disorder than was the enforced change from a natural mode of living 
to existence in close, dark cages. 

Numerous historical facts sustain this teaching. The geographic and 
racial distribution of rickets is in accord with it. Its gradual increase in 
frequency since the seventeenth century; its present maximal dissemination 
through all the countries of the temperate zone; its relative scarcity, with- 
out evidence of racial immunity, in the arctic circle, in the tropics, at high 
altitudes and in all sparsely populated regions, are all significant. Its 
prevalence or greater severity in the winter and spring months, and in the 
densely peopled parts of large cities; and, finally, the important influence 
of fresh air, natural feeding and intelligent management in the treatment of 
the disease, testify in support of such a rational theory. 

A factor recently added to the etiology of rickets and brought into much 
prominence is the question of the lack of certain accessory food substances 
(vitamins) . While the theories about this factor have formerly been rather 
vague, American observers in animal experiments and pediatricians in the 
central empires, during the food shortage, caused by the blockade have added 
considerable research to this view. A fat soluble vitamin (fat soluble A) 
is said to prevent rickets. It occurs in various foods in varying degree, as 
follows: whole milk, cod-liver oil, butter, egg yolk, red meat, and to some 
extent in fresh vegetables. -It is supposed to originate in green vegetables 
and germ cells of cereals. It is fairly thermostable. It does not originate 
in the animal body. It is well to await further research upon this large 
question before dropping further study of the etiology of rickets. 

Clinical observation of the disease indicates that two important factors 
enter into its pathogenesis; the first, a latent predisposition dependent upon 
a specific heredity, a rickitic diathesis or constitution, as it were, of the 
nature of which we are profoundly ignorant; and second, the infliction of 
certain nutritive injuries, arising from numberless causes and occurrent 
perhaps even in intra-uterine life. 

CLINICAL SYMPTOMS AND THEIR ORIGIN 
SKELETAL MANIFESTATIONS 

First Group: Phenomena of delayed bone development; hypogenesis ossium. 
Second Group: Phenomena of bone softening, osteomalacia. 

Third Group: Phenomena of excessive new formation of bony tissue; osteoid hyper- 
plasia and development of osteophytes. 

In thz first, group of symptoms, the delayed growth may affect any or all 
parts of the skeleton; it may cause a large number of abnormal conditions 
and may particularly disturb the symmetrical proportions and measure- 
ments of the body. The slow growth of the facial bones gives the cranium 
the appearance of being unduly large. Disease of the vertebral column and 
of the long bones affects the growth in height. Rickitic children are shorter 



THE BLOOD AND BLOOD-FORMING ORGANS 



197 



than others, even if no actual distortion of the bones occurs. During the 
acute stage, and even later, there may be long continued and complete 
arrest of growth and consequent dwarfing. The latter result is especially 
common in cases which appear late and persist for a long period. This 
retarded growth and the accompanying flaccidity of the muscular tissues, 
with the painful periosteal points at the insertion of the muscles, is apt to 
delay the acquirement of the static and dynamic functions of the child, as 




FIG. 45. Three and one-half-year-old boy with rickets. Charac- 
teristic sitting posture with legs doubled under the body and arms 
supporting the spine. Slight deformity of the head, thorax and 
limbs 

in the raising of the body, in sitting, crawling, standing and walking and in 
the general mobility of the extremities. When the disease appears late in 
infancy or in childhood, the ability to walk may be lost. When a rickitic 
child is lifted, it does not attempt to stand, but keeps its legs drawn up. 
In sitting, the legs are doubled under the body and the arms are used to sup- 
port t"he spine. The impaired ossification of the flat cranial bones is shown 
in their abnormal width and in the delayed closure of the sutures and 
fontanelles. The anterior fontanelle increases in size for a time and occa- 
sionally remains open, or membranous, until the third year. The retarded 



198 



TEXT-BOOK OF PEDIATRICS 



development is especially noticeable in the teeth. Both the beginning and 
the end of the first dentition may be delayed for as long as eighteen months, 
so that the first teeth appear at two years and the last as late as three and 
a half years. The individual teeth appear at unusually long intervals; 
erupt asymmetrically and in atypical order. Particularly in the upper jaw, 
they are frequently small, soft, easily broken and discolored by caries, to 
which they are peculiarly liable. They are often frightfully misshaped and 
foreshortened. There is occasionally an excessive formation of enamel. 
The temporary teeth show striped or circular erosions at neck and root. 
The permanent teeth, the germs of which are also affected, show these 




FIG. 46. Thigh and leg of a three and one-half-year-old 
child with severe rickets. Infraction and characteristic 
cupping at the diaphyses. 

erosions at the crown. Examination with the Roentgen rays, reveals the 
small centres of ossification and the abnormal transparency of the bone 
tissue throughout the entire skeleton, but especially in the wrist and in 
certain of the long bones. (See Characteristic Roentgenogram, Fig. 46.) 

In the second group, an important early symptom which may exist, 
temporarily, alone and may be continuously present, is the so-called cranio- 
tabes. Palpation over the occipital bone and over the posterior portions of 
the parietal bones discovers circumscribed areas of softened bone which can 
be depressed They are rarely confluent and are about the size of a small 
coin. The sensation received upon pressing one of these areas may be 
compared to that which is given in pressing upon parchment, or over the 
convex surface of an old stiff felt hat. 



THE BLOOD AND BLOOD-FORMING ORGANS 



199 



The continued pressure of the body-weight and the strain of the constant 
muscle tonus upon the persistently soft bones will inevitably produce 
characteristic changes in the way of deformities and decurvations in the 
skeletal framework. Similarly, external violence will cause breaks of con- 
tinuity much more readily than in the normal structure. Since the bony 
substance is elastic, it will bend rather than actually break. Even when 
true fractures do occur the ends usually remain in apposition by virtue of the 
thickened periosteum. Fractures and infractions are therefore easily mis- 
taken for deformities. True rickitic bone decurvations usually involve a 
pathologic excess of the physiologic curves. Space will not permit a more 
detailed description of the varying conditions and possible combinations 
which these deformities may present. 
They are of interest chiefly from the 
orthopedic standpoint. An attempt 
has been made to present pictures of 
the most common and most serious 
deformities. (See Figures 47 to 52.) 
Special attention is called to the fol- 
lowing types : The head shows enlarge- 
ment of the cranium, with softening 
of the edges of the bones. The lower 
jaw is shortened sagittally (trapezi- 
form) and the upper jaw is narrowed 
(lyraform). The lower alveolar proc- 
ess is directed inward and the upper 
ib directed outward, with such conse- 
quences to the teeth as transverse 
placement of the upper incisors and 
projection of the lower. The occluding 
surfaces are but poorly covered by 
enamel; the palatal arch is high; the 
zygoma is sharply bent. 

The spinal column is kyphotic, 
with dextroconvex, bow-like scolioses in the lumbar and thoracic regions, 
and with compensating curves in other parts. In the production of these 
deformities the flaccidity of the muscles and the manner of carrying the 
child have important influence. 

The thoracic changes consist in a flattening and inversion of the lateral 
walls, especially from the third rib down to Harrison 's groove at the level 
of the ensiform process of the sternum. Below this the costal arch is rolled 
outward; its lower margin is widened, while the upper or cervical rim is 
narrowed. The lower segments of the sternum and the costal cartilages 
are pushed outward as a result of the increased negative pressure in inspir- 
ation, the direct action of the respiratory musculature on the flexible bony 
wall, and the distention of the abdomen combining to cause chicken- 
breast, or a heart-shaped cross section of the thorax. 

The pubic angle is spread, the promontory is pushed forward and the 




FIG. 47. Two-year-old child showing rickitic 
deformity of cranium and thorax. 



200 



TEXT-BOOK OF PEDIATRICS 



conjugates are shortened, producing a flat pelvis. The neck of the femur 
is horizontal (coxa vara) to the shaft of the bone, which curves with convex- 
ity forward and outward. The tibia its curved forward in its lower third 
(Saber tibia). Genu valgum or genu varam may be either unilateral, or 
symmetrically bilateral, or the contrary. Pes valgus occurs. 

The upper extremities are usually less deformed than the lower. Multi- 
ple infractions of the clavicles, ribs, radius and femur are common. 

The Third Group. The picture of the rickitic deformities of the skeletal 
framework is finally completed by the enlargments and protuberances upon 

the flat bones which are incident 
to the excessive formation of 
new bone. 

Rounded deposits of bone, 
at first fairly circumscribed, are 
often formed symmetrically up- 
on the frontal and parietal emi- 
nences and, more rarely, at 
the edges of the cranial bones. 
Between these, the sagittal and 
coronal sutures are depressed, 
forming the so-called saddle or 
cross-bun head. Such protu- 
berances, together with a flat- 
tening of the occiput, give the 
enlarged head a quadrilateral 
form, the so-called square head, 
or caput quadratum. 

Upon the outer and more of- 
ten upon the inner surfaces of 
the costochondral articulations 
large twin nodules appear. The 
line of nodules forms a divergent 
arc, which is called the rickitic 
rosary. 

The epiphyses of the long 
bones, particularly at the wrist, 
are the seat of nodular enlarge- 
ments. As compared with these, the thickening and rounding out of the 
diaphyses is usually less noticeable. The bones of the wrist, as well as 
the phalanges, are enlarged at intervals, presenting the appearance of a 
string of beads. The severe decurvations of the bones and particularly 
the large calli forming over slowly healing infractions may be mistaken 
for rickitic osteophytes. While the decurvations, infractions and enlarge- 
ments of the various parts of the skeleton may present extreme and fan- 
tastic malformations in severe or neglected cases, they are ordinarily not 
excessive and are in part concealed by the fatty panniculus. They may 
even be entirely absent. The most common and noticeable among them 




FIG. 48. Three-year-old boy with high grade rickitic 
deformities of the extremities cranium and tho- 
racic skeleton. 



THE BLOOD AND BLOOD-FORMING ORGANS 201 

are the rosary, the disturbances of dentition, the large fontanelles with soft 
edges, and the nodular enlargements of the epiphyses at the wrist. 

The order of appearance of the skeletal changes is synchronous with the 
normal periods of rapid growth of the several bones (Vierordt). This 
development occurs earlier in the cranium and the thorax than in the ex- 
tremities. Therefore, the craniotabes and the rosary are among the first 
symptoms to appear. The depression of the walls of the thorax and the 
enlargement of the fontanelle are noticed later. The square head (caput 
quadratum), the kyphosis, and the changes in the extremities follow only at 
the end of the first year. The grosser and more permanent deformities of the 
limbs develop quite late and particularly, of course, when they are func- 
tionally employed, as in sitting, creeping and standing. Deformities of the 
thigh, however, have been found even in infants who were still in the 
cradle. If rickets occurs later in life craniotabes does not appear. 

Most of the clinically recognized changes and disturbances of function 
attendant upon rickets, appearing in other organs, may be generally inter- 
preted as complications or sequelae of the disease without compromising the 
conception that rickets is a general dyscrasia. (Glisson, 1650.) 

A direct mechanical relation doubtless exists between the thoracic 
deformity and certain respiratory disturbances. The flexibility of the bony 
chest wall limits the excursions of the diaphragm; this, in turn, impairs the 
ventilation of the lung and lessens, again, the respiratory interchange of 
gases. The contraction of the diaphragm, instead of promoting the proper 
expansion of the lungs, draws in the lateral thoracic walls and even the 
sternum. This results in dyspnoea, tachypnoea, cyanosis, expansion of the 
nares and diseases of the respiratory tract. The relation between the di- 
minished agility with the increased irritability of the rickitic patient and the 
pain developed upon active and passive motion and due to the disease of the 
skeletal framework and musculature, is quite apparent. In the acute 
stage of the disease, fear, timidity, irritability, and distrust are depicted 
upon the infant 's face. The child is afraid of everyone who approaches the 
bed and protests either by cries or by peculiar and vigorous motions of the 
hand, against being touched. 

Another group of possible complications includes anemia, marked 
enlargement of the liver and spleen and general hyperplasia and induration 
of lymph nodes, tonsils, etc. The anemia is characterized by pallor, oligo- 
cytosis, oligochromemia, poikilocytosis, erythrocytosis, lymphocytosis, and 
increase of the mononuclear cells. The liver and spleen are often displaced 
downward by the thoracic deformity, a tendency which should not be mis- 
taken for actual enlargement. It is a widely accepted view that these 
general symptoms are proportional to the severity of the skeletal disease and 
are relational to the lesions of the bone-marrow, whether primarily so, as 
Marfan holds, or in a secondary way. (See the pathogenesis of von Jaksch's 
anemia, etc.) 

Rickitic myopathy, to which reference has already been made, is almost 
always present. It manifests itself in general weakness and lassitude, mus- 
cular atony, atrophy and flaccidity, and in an abnormal mobility of the 



202 TEXT-BOOK OF PEDIATRICS 

joints. It is probably primary to a degree. The tempting hypothesis that 
this myopathy is merely a sequel to severe disease of the skeleton and is 
conservative, since it relieves the strain upon the bony framework, is sup- 
ported neither by the structural quality of these muscular changes (Bing, 
Martins) nor by the facts of their distribution. Nor is such a hypothesis 
compatible with the involvement of the entire unstriated muscular system, 
frequently observed and indicated by an abnormal dilatation of the heart 
and the arteries, by gastro-intestinal atony, obstipation and tympany. 
Furthermore, other soft parts, such as the skin, the panniculus, etc., are no 
less flaccid than the muscular tissues. 

The impaired mobility and delayed development of the rickitic child 
readily lead to a delay in its social and mental development, evidenced by a 
low grade of intelligence, imagination, and a limited vocabulary. Con- 




FIG. 49. Three-year-old girl with rickitic cross-bun 
head, protrusion of the tuberosities and defects of the 
temporary teeth. 

versely, any previously existing marked degree of feeble-mindedness which 
tends to confine the child to its bed. may be a cause of increased severity in 
the course of rickets. 

Spasmophilia, often combined with and closely relational to rickets, 
probably belongs to the group of manifestations coordinate with the skele- 
tal disease. 

The onset of rickets is usually announced by a number of premonitory 
symptoms, the nature of which Is not clear. The child becomes listless, 
restless, peevish. It bores its head deeply into the pillow and wears off all 
the hair over the occiput by a continual to and fro movement. During 
sleep a profuse, clammy, acid perspiration, especially about the head, 
appears, accompanied by numerous sudamina. Transient erythemata and 
pressure spots are further signs of vasomotor disturbance. The abdomen 
becomes distended. The urine has an unusually sharp, penetrating odor. 
The earlier evidences of disease in the skeleton and the musculature are 
noticed only after days or weeks. 



THE BLOOD AND BLOOD-FORMING ORGANS 



203 



COURSE, COMPLICATIONS, TERMINATION 

The first skeletal symptoms, craniotabes, kyphosis and the rosary may 
develop rapidly to a serious degree. Otherwise the course of the disease is 
chronic and often remittent, extending from a period of months up to two 
years. In every case that survives, spontaneous recovery eventually obtains. 
The beginning of recovery is heralded by the disappearance of general 
symptoms and by the evidences of functional progress, as in attempts at 
standing, uncertain efforts to walk, etc. The calcification of the skeleton 
becomes complete in recovered cases. In the course of years, deformities 
and especially the decurvations of the long bones are often overcome to a 
surprising degree in the process of 
growth. Dwarfism, hump-back, 
scolioses and other malformities, 
on the other hand, may persist 
throughout life. 

Rickets is never a direct cause 
of death, but it is very often a 
contributory factor. The mortal- 
ity of rickitics is especially great 
under hospital conditions. Out- 
side of hospitals, the death-rate is 
greatest among the poor. The 
most common and serious com- 
plications, induced by intercur- 
rent infections, are bronchial 
catarrh, capillary bronchitis, with 
or without broncho-pneumonia, 
severe forms of spasmophilia with 
eclampsia and laryngospasm, and 
chronic enteritis of long duration. 
The gastro-intestinai infections 
follow milk feeding injuries and 
are characterized by foul smelling, 
watery stools and pseudo-ascites, in the course of which the nutrition is 
reduced to the lowest stage. Other complicating events, as diastasis of 
the recti, hernia and nystagmus, are of less consequence. The distorted 
respiratory mechanism, involving the decurvation of the thoracic walls, the 
continued decubitus and the flaccid and distended abdomen are invitations 
to pulmonary disorders. 

DIFFERENTIAL DIAGNOSIS 

Even with the appearance of a number of characteristic skeletal and 
general symptoms which seem to insure a definite and reliable diagnosis of 
rickets, certain errors are still common. In order to avoid them it should 
be remembered that congenital forms of disease, of whatsoever type, are 
never of rickitic nature. 

Certain structural imperfections, such as the physiologic decurvation of 




FIG. oO. Two-year-old child with high grade rickitic 
deformities especially of the extremities and thorax. 



204 



TEXT-BOOK OF PEDIATRICS 



the infant leg, are sometimes mistaken for symptoms of rickets. "Fetal 
rickets" is a misnomer and under this head osteogemsis imperfecta, in 
which the lack of development of the cranial bones simulates craniotabes 
is often included. The soft bone areas in this condition differ from cranio- 
tabes in that they are situated in the temporal bone or near the sagittal 
suture, and not in the occiput. The fontanelles are sharply circumscribed 
by hard bone. The deficiency gradually disappears during the period 
within which rickitic craniotabes makes its appearance. 

Congenital myxedema and mongoloid idiocy have so many symptoms 
strikingly in common with rickets, that many distressing diagnostic errors 

have been made. In fact, a rela- 
tionship between these several 
diseases was, at one time, ac- 
cepted. The cretinoid face, the 
low mentality, the dryness of the 
skin and hair, the gelatinous con- 
sistency of the subcutaneous tis- 
sue, the macroglossia, the lower 
trachea destitute of its thyroid 
covering, are indicative of myxe- 
dema. The Mongolian face and 
the purposeless posturing indicate 
mongolism. The disturbances of 
motion in Oppenheim's congen- 
ital myatonia, in atonic infantile 
paralysis, early infantile progres- 
sive amyotrophy, Tay-Sach 's idi- 
ocy, etc., may be confused with 
rickitic myopathy. 

If rickets occurs in combina- 
tion with scurvy, quite a common 
event and probably with patho- 
genic reason, the scurvy may 
remain concealed. The manifes- 
tations of a hemorrhagic diathesis are characteristic of the latter. The 
presence of painful swellings over the ends of the diaphyses, rather than 
over the epiphyses, is not always a reliable distinction. Rapid and favorable 
therapeutic results often substantiate the diagnosis of scurvy in retrospect. 
To the expert, Roentgenography gives positive evidences. 

In cases in which severe endochondral disturbances of ossification, with 
myopathy, have caused a form of rickitic paralysis due to pain, Parrot's 
pseudoparalysis may be suggested. 

Rickitic kyphosis may be differentiated from the kyphosis of Pott's 
disease by the fact that in the rickitic the curvature is flatter, is not fixed, 
and almost always disappears when the patient is laid upon the abdomen. 

The pyriform distension of the hydrocephalic cranium may be readily 
distinguished from the rickitic tete Carre, or square head, caused by the 




FIG. 5L- 



-Rjckjtic beaded fingers, two and one-half- 
year-old girl. 



THE BLOOD AND BLOOD-FORMING ORGANS 



205 



thickening of the frontal and parietal eminences. The softness of the rickitic 
cranium, however favors, the development of the hydrocephalic enlarge- 
ment ; while venticular dropsy due to vascular congestion and lymphedema 
is common in rickets. A true cerebral hypertrophy is also supposedly re- 
lated to rickets. Periostea! processes on the rickitic cranial bones may be 
mistaken for chloromata. 

With capillary bronchitis it is often impossible to determine whether 
small lobular pneumonic foci are present. Pulmonic dulness is some- 
times simulated by scolioses, by thoracic deformities and by thickening 
of the scapulae. 

Rickets and osteomalacia, ac- 
cording to recent researches, do not 
differ in their pathology, but only 
in the period of their occurrence 
and probably in the matter of 
cause. Osteomalacia affects the 
mature bone; rickets affects the 
rapidly growing bone. In those 
rare cases in which the disease 
occurs between the third year and 
puberty, or in which it continues, 
with remissions, throughout child- 
hood, we speak either of delayed 
rickets (rickitis tarda), if the in- 
creased formation of osteophytes, 
the endochondral perversions and 
the decurvations (coxa vara, genu 
valgum, pes planus, etc.), are pres- 
ent , or of juvenile osteomalacia if the 
osteoporosis is the more prominent. 

Prophylaxis and Therapy. The 
measures of prophylaxis are those 
used in the treatment. By far the 
most important factors in preven- 
tion and care of rickets are moder- 
ate stimulation to bodily exercise and stimulation of the body as a whole. 

First, we may place the use of active and passive motion, suited to the 
condition of the musculature and of the skeletal framework. Such exercise 
cannot be obtained if the child lies continuously upon its back, wrapped in 
tight diapers infrequently changed. A good nurse may give the growing 
child sufficient stimulus for mild bodily exercise. She will, at least, give its 
natural tendency to such exercise free play while bathing and by permitting 
the child to lie naked on its abdomen. The arrangement of the bed, with a 
moderately firm flat mattress, proper mode of carrying, sufficient play 
and creeping all tend to prevent deformity. The child should be not 
encouraged in too frequent attempts to stand or walk. The Epstein rocking- 
chair may be used. (See page 103.) In the more severe osteomalacic forms, 




FIG. 52. Five-year-old girl with deformities of legs 
following rickets. 



206 TEXT-BOOK OF PEDIATRICS 

which seldom occur save in neglected or irrationally treated cases, extreme 
caution is, of course, necessary on account of the danger of infractions, even 
while changing or bathing the child. The use of salt baths and of massage 
doubtless promotes active and passive motion. It is well to begin these pro- 
cedures carefully; at first, with a gentle stroking, then by the use of a dry 
rub; later with warm sponges and finally by tepid baths with salt content 
increasing up to one per cent., continued for some ten minutes; all these 
measures being constantly controlled by the so-called "reaction" of the 
skin (Heubner). 

It is also extremely important that the little patients are continuously 
in the fresh air in sunny, sheltered places. This, of course, is accom- 
plished very satisfactorily by a visit to localities of especially favorable 
climate. Children can be protected against low temperature by woolen 
clothing. For children in the second and third years who are not severely 
anemic, high altitudes and mountain resorts may be considered. In the 
city, every sunny hour during the day should be properly used in keeping 
the child in the yard or garden, or on the veranda in an open crib or baby 
carriage. During the day the child should, if possible sleep in the open and 
at night in a freely ventilated room. During the summer months, carefully 
administered sun baths lasting at first for only two to three minuter may be 
of great value. Artificial light is said to be very efficacious and is not as 
irregular as the sunlight. Ultra-violet ray has been suggested. 

The observation that the treatment of rickets in hospitals usually 
accomplishes but little, in spite of the common use of phosphorus and cod- 
liver oil, probably turns upon the fact that these two determining factors of 
fresh air and exercise have, until recently, received too little consideration. 

As to the dietary of rickets, it is at present quite certain that no regime, 
not even rationally conducted breast feeding, is a positive prophylactic 
against the disease, even in its milder forms. Further, it is known that 
every sort of feeding, including that with breast-milk, which encourages 
excessively rapid growth, favors the appearance of the disease and increases 
its severity, suggesting a disturbed relation between organic and non- 
organic growth. It is a generally accepted fact that a limited dietary but 
slightly denaturized, moderate in quantity and of sufficiently varied quality 
is the most desirable in this condition. So that in threatened or acute 
rickets, we should vary from the rational methods of feeding for healthy 
children, suggested elsewhere in this work, only in so far that we may select 
carefully prepared additions of soup and bread and of various freshly 
boiled vegetables at an earlier date than usual. If these additions are well 
borne, which is not invariably the case, they may be given together with a 
limited quantity of milk, not exceeding one pint a day. Buttermilk fre- 
quently gives better results. The reduction of the supply of milk, together 
with careful hygienic care, is the best method of overcoming anorexia. 

In chickens and animals that are fed phosphorus, the bones become 
sclerotic. On the strength of these observations, Wagner recommended 
phosphorus in the treatment of rickets and Kassowitz found it very use- 
ful. These experiments, however, were made upon animals and upon 



THE BLOOD AND BLOOD-FORMING ORGANS 207 

non-rickitic animals at that. The effect produced in them was probably 
the opposite of osteoporosis. But this condition plays a secondary role 
among the phenomena of rickets and is one of those manifestations which 
do not suggest the etiologic character of the disease. From this point of view, 
therefore, the phosphorus therapy cannot be regarded as scientific or as in 
any way relational to the cause of the disease (Stoeltzner). 

This is true of phosphorus in emulsion of almond oil and gum acacia 
as first used by Kassowitz. Because this emulsion would not keep, it was 
replaced by the solution of phosphorus in cod-liver oil. This mixture 
has proved its value empirically but there is much question as to which of 
the two constituents is the more effective. The customary prescription is 
as follows: 

Oleii Phosphorati 2.0 (40 minims) 
Oleii Morrhuse 200.0 (8 ounces) 

The phosphorated oil is a one per cent, solution of phosphorus and the above 
prescription gives one part phosphorus in 10,000 parts of the oil. Other 
forms in which phosphorus may be prescribed seem much less active or 
otherwise less useful. The "non-purified" cod-liver oil is recommended. 
It should be protected from sunlight and other oxidizing influences. The 
dosage is four c.c. (one teaspoonful) twice daily and must be kept up for 
several months. 

During the period of recovery, the calcium and phosphorus requirement 
is naturally increased. In view of this increase, and not because of the older 
view that the rickets was caused by insufficient lime in the food, the addi- 
tion of calcium and phosphorus salts have been, recently, highly recom- 
mended. Cow's milk is a food with a high content of these salts but in 
certain cases the fat obstructs the calcium retention. The benefit of these 
salts is hardly great enough to pay their purchase price, especially if the all 
important factors of general hygiene, diet, and fresh air are neglected 
because of their use. 

Organotherapy has not proved of sufficient value to necessitate dis- 
cussion at present. 

The recent work on the accessory food substances, the vitamins, shows 
that cod-liver oil contains a large amount of the anti-rickitic element, bear- 
ing out the previously empirical use of this treatment. Numerous authors 
now recommend the use of the oil without the phosphorus. 

The use of emulsions, while it greatly facilitates the administration, is 
to be avoided because of the small percentage of cod-liver oil contained. 
Very few contain over fifty per cent, and most commercial preparations 
are even lower. 

Early orthopedic interference, to prevent deformity, is inadvisable 
because of the necessary immobilization which could only result in further 
demineralization and softening. In severe angular deformities, however, 
interference may be imperative even in infants but usually braces, etc., 
should not be applied until school age is reached. In some cases, the further 



208 TEXT-BOOK OF PEDIATRICS 

demineralization and softening produced by plaster dressings may be taken 
advantage of to soften the bone. Usually about six weeks will soften the 
bone sufficiently to permit molding by extension and massage. 

DIABETES MELLITUS 7 

The disease which is termed true diabetes mellitus occurs much more 
rarely in children than in adults. It is extremely rare in the first years of 
life, but is somewhat more frequent in the second decade. True infantile 
diabetes is commonly supposed to be of pancreatic origin and closely re- 
lated in its nature to that which develops in the adult. The observations 
of podiatrists largely sustain the view that the condition may be considered 
an hereditary endogenous degeneration. Degenerative factors, such as pa- 
rental lues and various injuries due to intermarriage and to the presence 
of certain homogeneous stigmata, frequently appear. Few of these cases 
come from parents of the middle class. 

It is commonly said that the course of diabetes in childhood is uncom- 
plicated, but rapidly fatal. That it is ordinarily under observation for a 
short period is probably due in part to the fact that the condition, because 
of its rarity in children, is not suspected and for this reason, is diagnosed 
relatively late in its course. Its severe stages may have been preceded by 
disturbances of metabolism extending over a long period, without exhibit- 
ing smy marked subjective or objective signs. The transition to more rapid 
progress may be determined by some infectious disease -or other injury. 
Only when the tolerance for carbohydrates quickly decreases or has already 
been greatly reduced, so as to cause glycosuria with a minimal absorption 
of sugar, does the disease become noticeable. Loss of weight, weakness, 
lassitude, occasional pains in the limbs, marked polydipsia and diuresis, 
often leading to enuresis and irritation of the external genitals, are its indi- 
cators. The skin is dry and irritable. Skin affections, as urticaria and pyo- 
dermia, occur less frequently than in the adult. Very often, the absence of 
any definite sign in a more or less pronounced illness calls attention to 
the possibility of diabetes and suggests an examination of the urine by means 
of which the diagnosis is established. The acetone odor may also serve as 
a guide. 

In the daily quantity of urine, which may amount to from 3 to 6 litres, 
we may find several grams of acetone and ammonia (ammonia coefficient, 
30-40 per cent.), large quantities of acetoacetic acid and oxybutyric acid 
and, at times, from 100 to 300 grams (2-8 per cent.), of glucose. In advance 
cases, protein and casts are usually found. 

Actual or pseudo-meliturias of a non-diabetic character occur much 
more frequently in children, and especially in very young children, than in 
adults. In the majority of these cases it is not a matter of glycosuria, but 
of the output, rather, of other kinds of sugar or of other reducing substances, 
the nature of which is not yet fully understood. The most common melituria 
in the infant appears to be a lactosuria ; that is, the excretion of uncoverted 
sugar of milk. Occasionally a galactosuria occurs. The common occasion 

7 For the pathogenesis of this disease, see the literature of internal medicine. Certain 
peculiarities of the symptomatology of infantile diabetes are briefly considered in this work. 



THE BLOOD AND BLOOD-FORMING ORGANS 209 

of these disorders is some disturbance of nutrition. Many children, how- 
ever, of the lymphatic type, in the course of constitutional diseases, but 
without manifest disturbance of nutrition, excrete substances which give 
reactions for the sugar group. 8 Furthermore, the acute infections predis- 
pose children to melituria, usually of an alimentary type. We are apt to 
refer the fact to a lowered limit of assimilation of sugar, failing to take into 
account the truth that in the present state of our knowledge of the renal ex- 
cretion of the various forms of sugar, whether monosaccharides or disac- 
charides, we must recognize more than one fundamental form of disturbance 
of carbohydrate-metabolism. Neither a continuance of glycosuria for 
several days or weeks, nor reliable evidences of acidosis, of which the mere 
increase of the ammonia coefficient is not adequate, justify a diagnosis of 
diabetes in these cases. Only an habitual and progressive glycosuria, a 
true excretion of dextrose with a decreasing carbohydrate tolerance, asso- 
ciated with general symptoms, are conclusive. 

The termination of diabetes in children, practically always fatal, is 
preceded by very definite signs of true acidosis, such as vomiting, acetone 
breath, jactitation, and coma lasting for two or three days. The average 
duration of the disease is given as three to six years, while its more severe 
period laets from one and a half to three years (v. Noorden). 

The treatment of diabetes in childhood cannot cure the disease, but may 
prolong life. It is essentially dietetic. Watching with the greatest care the 
most important indications, we are able to recede from that absolutely 
rigid withdrawal of carbohydrates which is instituted to prevent glycemia, 
and thus to avoid the changes of autophagic or excessive combustion of the 
body fat (acid poisoning) . In the treatment of acidosis, it is customary to 
attempt neutralization by the use of such alkalies as sodium bicarbonate or 
citrate in teaspoonful doses, in lemon juice. This treatment is not always 
successful and is purely symptomatic. In employing it, the danger of the 
occurrence of edema must be kept in mind. The dislike of the patient for an 
exclusively meat and fat diet sometimes becomes urgent. 

Oatmeal is not only better borne by diabetics than are other starches or 
sugars, but is occasionally found to increase the carbohydrate tolerance. 
Van Noorden 's dietary of oat-products is based upon this supposition. It 
consists of a diet of 100 to 200 grams of oatmeal gruel, 200 to 300 grams of 
butter, and several eggs daily for a period of one or two weeks. I have seen 
surprising results even in severe cases, but the gains are not permanent. 
The same benefit is often achieved with mashed potatoes. Inulin and 
hediosit are harmless but expensive carbohydrates. Edibles free from or 
poor in carbohydrates are meat and meat broths, ham and bacon, aspic, 
green vegetables of all sorts, cauliflower, cheese, cream, sour milk, and the 
various factorial food preparations for diabetics. The statement of the 
manufacturers concerning the carbohydrate content of these prepared foods, 
is, however, frequently open to doubt. Recently, protein milk has received 
some consideration. Relatively large doses of alcohol have been recom- 
mended (100 grams per day). 

8 Aschenheim and others. 
14 



210 TEXT-BOOK OF PEDIATRICS 

OBESITY 

Obesity is a symptom which, in extreme form, is quite rare; but in 
milder degree is very often met with among children, especially in later 
childhood. It may be produced by various causes. The most frequent 
type is the purely ectogenous or alimentary obesity caused by the use of 
excessively rich food, especially in the form of carbohydrates and fats. 
Inquiry into the child's history in this regard, shows that its food require- 
ment has been over-estimated by the parents. The child is often actually 
overfed even though the fact be strenuously denied. Special attention 
should be paid to the habit of eating between meals, to the use of milk as a 
beverage, to a dietary of sweets, artificial foods, etc. Alcoholism, to the 
frequency of which in childhood Hecker and others have testified, must also 
be considered. Both the laity and physicians, learning of the low nutritive 
value of alcohol, fail to include it as a heat-producing material in their 
caloric estimates; although beer, for instance, represents a caloric value 
two-thirds that of milk. 

In another class of cases, the quantity of food is only relatively in 
excess; that is, in proportion to the abnormally small amount of muscular 
work and bodily exercise undertaken by the child. This. may be due to 
laziness caused by heredity, training or example, etc., and is comparable to 
the fattening of the animals for market ; or it may be caused by disease 
which in its course develops myopathic or skeletal disorders, pain upon mus- 
cular contraction, etc. (rickets, paralyses). In this group the signs of 
basic disease are often hidden beneath the obesity. It may occur, for in- 
stance, in certain endogenous forms of nerve disease, as in the hereditary 
ataxia of Werdnig-Hoffmann. Such cases represent a transition to true 
endogenous obesity, which alone may be termed a true adiposis. 

These adiposes are etiologically divisible into two types; those, on the 
one hand, which constitute a phenomenon of hypo- or athyroidea; and, 
those, on the other hand, which are sequela to hypoplasias and to func- 
tional errors in the germinal organs (castration, genital infantilism, etc). 
The absence or functional incapacity of these glands of internal secretion 
leads to a retardation of the metabolism, a result experimentally proven. 
Of similar origin are those forms of endogenous obesity which, developing 
wholly without symptoms, offer no definite points of departure for etiologic 
study. With respect to the pathogenesis of these conditions clinical opinion 
has for centuries favored the idea of an hereditary constitutional anomaly, of 
a reversion of cell function due to a reduction of the total metabolic values 
of the germinal cell. For a long time, this view could not be sustained by 
experimental observation. Evidently suitable cases had failed of analysis 
those exceptional cases which maintain their excessive weight upon an 
extraordinarily small amount of food; in which, for instance, an energy 
quotient of seventeen under bodily exercise and of twelve under rest, being 
about one-third of the normal standard, persists for weeks and months. 
Very recently, however, it has been actually determined that among these 
adiposes are individuals, some of them young and without myxedema or 



THE BLOOD AND BLOOD-FORMING ORGANS 



211 



genital infantilism, who have an habitually reduced metabolism, who 
actually "use less fuel" than others (v. Bergmann). 

Finally, we must consider as a pathogenic possibility a special disturb- 
ance of fat metabolism. If it be true that certain lipolytic ferments of 
the lymphocytes are concerned in the catabolism of the body fat, the rela- 
tion of obesity to certain systemic diseases of the lymphatic organs, such as 
hypoplasia and hyperplasia would be explained in accord with clini- 
cal observations. 

The treatment of obesity in children must take this factor into account. 
Therapeutic measures addressed to cause are effective in many cases in 
which the condition is brought on by overfeeding, alcoholism, irregular 
living, or hypothyreosis. In the matter of 
diet, caution must be exercised to avoid the 
loss of nitrogen. For this reason, the use of 
preparations of the thyroid gland, when the 
gland is functionating normally, is generally 
contraindicated. According to Hellesen it is 
more difficult to prevent loss of nitrogen in 
the dietetic treatment of obesity in children 
than it is in adults. The total food supply 
estimated by its energy value, should never 
be reduced below fifty calories per kilogram 
of net body-weight when at rest. The body- 
weight to be reckoned in such estimates 
should be the mean of the individual 's pres- 
ent weight and his normal weight for his 
given height. A bulky diet generous enough 
to satisfy the appetite and containing ample 
nitrogen, water and cellulose, but poor in 
fats and carbohydrates, should be selected. 
It is not necessary to curtail the quantity of 
water, as the obese person loses more water 
during exercise than the normal individual. 

., , ., . ,, . . boy. (University Children s Hospital, 

For older children the following regimen Bfesiau, Prof. Tobier.) 
may be suggested. At noon, an abundant 

allowance of broth; later a meal consisting of meat and vegetables (cabbage, 
spinach, turnips, etc.) and for the rest of the meals skimmed or preferably 
separated milk, or tea sweetened with benzosulphinidum (saccharin), bread, 
a little honey and fruits. Water may be given freely. Active, but regulated 
physical exercise should be prescribed. In individual cases an exact esti- 
mate of the food taken should give its caloric value. 

UNDER-NOURISHED OR FRAIL CHILDREN 

The question of persisting leanness or even emaciation in children is 
frequently met with in practice. A discussion of the causation of this con- 
dition must, however, take innumerable factors into consideration. In the 
first place, the persisting leanness may be the result of a long wasting disease 




Fio. 53. Obesity, twelve-year-old 
y. (University Child 
Breslau, Prof. Tobler.) 



212 TEXT-BOOK OF PEDIATRICS 

from which the patient has recovered but never got back to his full robust 
energy. Chief among such conditions is tuberculosis with its variable mani- 
festations and its slow recovery. Then chronic toxic infectious injuries to 
the nutritive apparatus may be rated. In the second place, the cause of 
emaciation may be due to the food itself. The starved looking urchin may 
never have had enough to eat or the food may have been poor in quality and 
wretchedly prepared. Then again, there may be certain mechanical inter- 
ferences with the assimilation of the food. Among these we may have 
pyloric stenosis, cardiospasm, and esophageal obstruction, with persistent 
vomiting and wreching. 

Inanition occurs frequently in infants, not by any fault of the mother, 
but as a result of poorly functioning breasts, or of insufficient artificial food 
at times on the advice of the physician or commonly upon following the 
directions on the box of some patent infant-food. 

However, all of the above factors, which really require no further discus- 
sion, cover only a small percentage of the large number of children that can 
be classed as "under-nourished." Indeed it can easily be shown that these 
children do not react to food as one would expect of a hungry child. Addi- 
tions to the diet do not result in any marked increase in weight. Nor do 
they present the characteristic objective signs of inanition. 

Even this class of lean or frail children is not an entity. After eliminat- 
ing those cases in which the leanness exists only in the imagination of the 
mother whose ideal of childhood is the fat pasty infant, or who interprets 
the period of growth in height as an abnormal phenomenon, we still have 
those children in whom there is a true lack of fat (lean in the narrowest 
sense), those who are poorly muscled, and those that are especially small 
boned (asthenic). 

In our present system of education and training, the development of the 
musculature by proper exercise is often sadly neglected, especially in chil- 
dren from six to twelve years of age. This, naturally, results in boys and girls 
with small legs and arms even though the panniculus is fairly abundant. 
This child, because of insufficient exercise, requires little food and is sup- 
posed to be sick. Others are lean because of actual anorexia. In such, the 
anorexia may be due to a vitiated taste, spoiled by highly flavored candies 
and desserts, spiced foods and carbonated drinks. Protracted anorexia 
brings with it other unpleasant symptoms such as dulness, restlessness, 
disobedience and lack of concentration at lessons. Grouped together these 
manifestations are often called "school sickness." 

Still another group of the so-called "frail" children is found in the high- 
strung, fretful, restless, neuropath. They may be individuals of distinctly 
abnormal bodily and mental excitability, born as such or brought up in this 
way by the constant association with members of the family similarly 
afflicted. Of weak will-power, they are urged on physically and subjected to 
outbursts of temper, etc., until they 'themselves become neuropathic. 
These stimuli can often be traced into early influences. 

A certain stress must also be laid upon heredity. It is not at all uncom- 
mon to find that the father or mother presents the same characteristics of 



THE BLOOD AND BLOOD-FORMING ORGANS 213 

growth as does the child. Or one of the parents may have been of a similar 
build at the same age. There is no doubt that the failure of panniculus, 
etc., is as transmissible as obesity. In connection with this, attention must 
be drawn to the fact that the association of hereditary leanness, with vary- 
ing degrees of stigmata of degeneration, is not at all uncommon. We may 
indeed speak of a "degeneration form of frailness. " 

Remembering the discussion under obesity concerning children who are 
fat because of a lower metabolism (slow oxidation) it may be assumed that 
there are individuals who have a habitually more active metabolism and a 
resulting leanness. This, of course, has not been shown by metabolism test. 

Finally, it is definitely known that there are children that do not thrive 
upon a diet upon which others of the same age and in the same surroundings 
grow at the accepted normal rate. 

TREATMENT 

The frail children of the well-to-do regularly become the sacrifices of the 
rather " hypertrophic " industry of advertised foods. The discussion of the 
causation of the condition is really quite enough to lead the physician into 
proper therapeutic paths. Careful scrutiny of the dietary with corrections, 
giving simple but sufficient nourishment, should not be neglected. 

PECULIAR PREDISPOSITIONS TO DISEASE (DIATHESES); 
AND CONSTITUTIONAL ANOMALIES 

In certain children a remarkably frequent appearance of peculiar dis- 
turbances of health is observed and this in the face of the exercise of the 
greatest care in the avoidance of injuries which are recognized as standing 
in causative relation to such disorders. In view of this evident fact, we are 
forced to conclude that in such children some organic peculiarity exists, 
a special disposition or a favorable soil, as it were, for the agents of disturb- 
ance. Instead of the phrase " predisposition to disease," the Greek term 
diathesis has come into common use. The abnormalities to which the 
organism may show such predisposition are of varying character. They 
may belong, for instance, to the group of catarrhal affections of the mucous 
membranes and the skin, or to forms characterized by swelling of the lymph 
nodes ; or to the type of neuropathic disorders. We may speak, therefore, of 
a catarrhal diathesis, of a lymphatic diathesis or of a neuropathic diathesis 
without standing committed to any hypothesis, but expressing simply fact* 
supported by numerous observations. Such a diathesis is not a disease, but 
merely a state of predisposition to certain forms of disease. The principle 
of this conception has been often disputed, but never logically disproved. 
The elements which determine the diathesis induce manifestations which 
often differ but slightly from, or are closely identical with, those which 
figure in the diseases of individuals not so predisposed. In other cases, 
again, these manifestations represent not only quantitative, but qualita- 
tive reactions of the organism to pathologic irritation which are essentially 
abnormal or illegimate. They exhibit, indeed, certain stigmata, which call 



214 TEXT-BOOK OF PEDIATRICS 

the attention of the experienced observer to constitutional peculiarities 
which may underlie the condition. 

All diatheses, however, are not definitely latent. There are predis- 
positions to disease which are continually manifest, whether as persistent 
sequelae to distinct attacks of disease, or as externally recognized deviations 
of structure or quality from the normal habitus. The term constitutional 
anomaly is often applied to this type of cases. 

A further diathetic fact is that different predispositions to disease may 
be combined in one individual. Thus we frequently find the predisposition 
to catarrhal disease associated with the tendency to involvement of the 
lymphatic tissues. In these cases, moreover, the swelling of the lymph nodes 
cannot be regarded as a consequence of the catarrhal condition of the skin 
and mucous membranes. The two states are rather in large measure co- 
ordinate to each other; and the fact justifies us in recognizing a combined 
catarrhal and lymphatic diathesis. Frequently another member of the 
diathetic group may be associated, viz., the predisposition to nervous 
disease giving a combined neurolymphatic diathesis. Desirable as it may 
be to make advances in this difficult field by distinct classifications and 
divisions, it must not be forgotten in the desire for a schematic presentation 
of the subject, that as every observer knows from his own experience, that 
combined diatheses are frequently met with in practice. 

THE INFLAMMATORY OR EXUDATIVE DIATHESIS 

For the podiatrist this is the most important of all the abnormalities 
belonging in this group. The condition was described by Theo. White, 
among others, in 1782 ar d has recently been reviewed by Czerny. 

Occurrence. The exudative diathesis is a widely distributed condition 
and in frequency can be compared with rickets. It is recognized more of- 
ten than rickets by the physician because its manifestations continue for 
a longer period. The tendency is familiar. Heredity, especially through the 
mother, plays an important part; exhibiting itself chiefly in homologous, 
but, also, in heterologous types. 

Initial Appearances. The condition is not discoverable usually in the 
new-born. Apparently the maternal organism exerts a sort of protective 
influence, as it does in certain disturbances of the organs of internal secre- 
tion, for example, in aplasia of the thyroid. The smallness and delicacy of 
the child are no more indications of the diathesis than is a long lock of hair 
standing on end over the coronal suture. Suspicion may, however; be 
aroused by delayed reaction from the initial weight-loss following birth, 
or by an early flattening of the weight-curve in spite of an adequate sup- 
ply of natural food. This may suggest a combination of the diathesis with 
disturbances of growth and development. Such a diagnosis must be made, 
however, with exceeding care. 

Characteristic evidences of this predisposition to inflammatory disease 
and to changes in the composition of the body as a whole usually appear 
only after the first few weeks. 



THE BLOOD AND BLOOD-FORMING ORGANS 



215 



1. The habitus of the diathesis is variable. Two types are recognized; 
that of the delicate, weak, exudative patient and that of the large, appar- 
ently strong and fat, but muscularly weak child. The latter type is fre- 
quently met with in a singular variety, to which A. Paltauf has applied the 
term: status thymico-lymphaticus. This type tends to become patho- 
logically fat and shows a pallor due rather to ischemia than to true anemia, 
and in part due to the increased water content and the reduced turgor of 
the subcutaneous tissues. This form is also called the "pasty" habitus. 

2. A more or less constant hyperplasia of the thymus and of the lymph 
nodes is usually associated with the latter habitus. Its clinical signs are as 
follows: moderately hard, palpable tumors of the lymph nodes in the neck, 
over the inner aspect of the joints and perhaps, in the abdomen; an enlarge- 
ment of the spleen, a visible hyperplasia of the faucial and pharyngeal 
tonsils, with a redundancy of the circumvallate papillae. 

Infantilism is of less frequent appearance and is usually first noticed in 
older children. It consists in delay of the development of the body in point 
of size and in the secondary sexual characteristics. 

3. Certain manifestations of the diathesis appear upon the surfaces of 
the body and are apt to have certain sequelae and complications. The follow- 
ing table gives an outline of these tendencies. 

MANIFESTATIONS OF THE EXUDATIVE DIATHESIS 



Seat 


Primary forms 


Secondary forms 


Sequelae and complications usually 
of "nervous" quality 


The skin. 


Seborrhoea cap- 
itis, crusta lac- 
tea, intertrigo, 
prurigo. 


Eczema, impe- 
tigo, abscesses. 


Severe itching,- great restlessness, 
distybed sleep, readily induced 
frigh . 


The mucous 
membranes. 


Transient des- 
quamation and 
turgescence in 
various regions 


Exudative proc- 
esses. Palatal 
angina, phar- 
yngitis. 


Hyperpyrexia, cough, vomiting, 
anorexia. 








Gastro enteri- 
tis. 


Vomiting, pylorospasm, colic, 
obstipation, mucomembranous 
diarrhoea. 








Coryza, laryn- 
gitis, bron- 
chitis, bron- 
chiolitis. 


Hay fever, 
pseudo cough, 
convulsive cough, 
bronchial asthma. 








Conjunctivitis, 
phlyctenuUe, 
blepharitis. 


blepharospasm. 








Balanitis, vul- 
vovaginitis, 
cystitis. 


dysuria, ischuna. 




The lymphatic 
organs. 


Hyperplasia of the faucial and pharyngeal tonsils. 
Hyperplasia of the palpable lymph nodes in the neck and 
the joints. 


at 



216 



TEXT-BOOK OF PEDIATRICS 



The appearance of milk-crusts, seborrhoeic deposits, and intertrigo is 
usual in the first year. Prurigo 9 may occur later. Anemic catarrhal affec- 
tions and the hyperplasia of the lymph nodes which occur throughout in- 
fancy and childhood may also be present, to a degree, in the nursing infant. 

The milk-crust or vesicular eczema of the scalp appears as an exudate in 
the form of dark gray or brown scales which become firmly attached to the 
epidermis. The skin beneath them is of bright red color and moist. EC- 




FIG. 54. Pasty habitus, especially in the face. Beginning eczematous eruption. 

zema rubrum with a white bran-like desquamation occurs in sharply cir- 
cumscribed triangular areas of reddened and thickened epithelium upon 
the cheeks. 

Intertrigo or chafing, which in healthy but neglected children occurs 
around the anus and the genitalia, develops in others also behind the 

9 Prurigo occurring in lean children, forms diffuse, hard yellow itching nodules 
(lichen'); which, in fat children, are preceded by red papules (urticaria rubra). These 
lesions develop chiefly on the nates, the body, the legs and arms, but hardly ever on the 
face. The term lichen urticatus or strophulus is often confused with the quite different 
prurigo of Hebra. 



THE BLOOD AND BLOOD-FORMING ORGANS 217 

ears, in the wrinkles of the neck and in the folds of the joints. In any of 
these skin conditions, scratching and uncleanliness may cause infection, 
and the appearance, in consequence, of a severe, obstinate, wet, impetig- 
inous eczema 

Geographical tongue is caused by exudations occurring in striae, over 
the upper surface of the tongue. Prominence of the papillae and desquama- 
tion of the epithelium give the characteristic white color to these lines. 

Primary disorders of the skin and mucous membranes are probably of 
identical nature. The process consists essentially of a superficial desquama- 
tion and an accompanying exudation. The definite localization of these 
lesions, suggestive of local injury or dystrophy, and their appearance as 
distinct attacks without any apparent external cause are especially char- 
acteristic. The lesions appear singly or in the most variable relation. 
Eczema rubrum, prurigo and especially the geographical tongue are trans- 
itory and change their appearance daily. 

Czerny claims that the catarrhal manifestation of the diathesis are 
analogous to the eczemata and may also be laid to infections for which 
the soil has been prepared by the irritable condition of the mucous mem- 
branes. Numerous observers note catarrhal affections of the mucosa of the 
digestive tract which are quite different and of early occurrence. They are 
indicated by diarrhoea, muco- and sanguine-purulent stools with eosino- 
philic cells. They are not attended by severe general symptoms. Obsti- 
pation and a fetid breath usually accompany the throat conditions. In half 
of the "exudative infants" Lust finds an organized urinary sediment, con- 
sisting of epithelial cells and leucocytes, arising from a desquamative proc- 
ess which runs a definite course and increases the disposition to infectious 
catarrhs. (Colon pyelocystitis.) 

These infectious processes in the skin and mucous membra.nes increase 
in a degree the hyperplasia of neighboring lymph nodes and of the tonsils ; a 
hyperplasia which in these diatheses may be produced, also, by alimentary 
injuries, etc. The marked and permanent hyperplasiae of the faucial and 
pharyngeal tonsils and their sequelae, discussed in detail in other parts of 
this work, arise in this manner. 

4. An increased liability to disease and a heightened reaction to causes 
of irritation, which the exudative diathesis carries with it, may be mani- 
fested also in other functional systems. Children so affected are commonly 
prone to disorders of metabolism; they are disposed to disturbances of 
nutrition of varying degree, to spasmophilic phenomena and to functional 
and structural changes in the vascular mechanism, in the way of palpitation, 
cardiac dyspnoea, and dilatation and hypertrophy of the heart. 

In the status thymico-lymphaticus sudden death, primarily due to heart 
failure, often occurs. It may follow immediately after birth or happen at a 
later period without any evident cause or upon such slight provocation as 
overfeeding, anesthesia or the excitement attendant upon a slight operation, 
especially when this involves the throat, or upon the application of band- 
ages, the use of baths or other hydrotherapeutic procedures. 

In all cases in which death occurs without preceding illness, the thymus 



218 TEXT-BOOK OF PEDIATRICS 

is found to be relatively large. It is an organ especially affected in all the 
retrogressive changes of infancy. It has been suggested that the measure- 
ments of the thymus taken in event of thymic death were normal and that 
they were counted abnormal only because they were compared with the 
measurement of the organ taken from cachectic bodies. This error may 
have entered into the estimate occasionally, but, nevertheless, in the con- 
dition under discussion of enlargement of the thymus is definitely estab- 
lished by accurate observations. The organ may be said to be enlarged 
when it weighs more than twenty grams in infancy and more than thirty 
grams in early childhood. 

Where very young children have suffered from tetany and laryngo- 
spasm for a time, or when they have gradually developed symptoms resem- 
bling intoxication, death comes less unexpectedly. 

The ultimate cause of death in cases of status thymico-lymphaticus has 
not been determined. The presence of a thymic tumor has been especially 
considered. It appears, however, that the mechanical pressure of the 
enlarged organ involving the trachea, bronchi, nerves, blood-vessels, or 
esophagus, does not often play an important part. We are inclined to look 
upon the result, as one arising from a pathologic secretion from the thymus, 
a hyper- or hypo-thymusation, which is not necessarily associated with 
enlargement of the organ. The more recent view is that enlargement of the 
lymphatic glands or of the thymus is not the actual cause of this sudden 
death, but rather that it is a coordinative consequence of a severe, even 
though latent general disturbance. 

All of the manifestations of the exudative diathesis continue, usually, 
but with longer or shorter interruptions, up to the tenth to the fourteenth 
year. Early childhood is the most severely affected period. Toward puberty 
a recession of symptoms is usually noticeable. Continuance or relapse after 
puberty is rare. 

Diagnosis. The experienced observer is often able to make the diag- 
nosis of an exudative diathesis instantly from the habitus of the patient, 
or from the characteristic tendency to illness arising spontaneously or from 
a very slight injury. 

Possible findings in the body fluids in the way of relative lymphocytosis, 
eosinophilia, dietetic hyperglycemia, and melituria are of very limited 
value from a diagnostic standpoint. This is also true of the test devised by 
Rachmilewitsch, which consists in the formation of papules when a skin 
lesion is irritated by the application of mustard paste. 

The value of findings by percussion or by the Roentgen ray, in demon- 
strating an enlargement of the thymus, either by dulness or by a shadow 
deepening to the left, must be carefully weighed. A valuable diagnostic 
point is found in inspection of the follicles at the back of the tongue. 

Ultimate Nature. The various hypotheses as to the nature of the pre- 
disposition to inflammatory disease are more or less vague. The theories 
of a primary anomaly of metabolism, of chemical malformation, of endo- 
genous food injuries, of disturbances in the regulation of the water content 
of the tissues are among them, and these have been recently attacked. 



THE BLOOD AND BLOOD-FORMING ORGANS 219 

Aschenheim and Tomono could not support the theory of Eppinger 
and Hess that the exudative diathesis is based upon a vagus hypertonia. 
The careful investigations of H. and L. Hirschfeld show, moreover, that 
the serum of exudative patients has a marked vasoconstrictive action. 
Similarly, according to Samelson, the therapeutic results obtained by 
Krasnogorski with atropin, which apparently gave support to the vagus 
hypertonia theory, are problematic. Nevertheless, there is something 
tangible in the proposed relation between the status lymphaticus and 
this condition 

The exudative diathesis has a demonstrable structural basis, in a definite 
overgrowth of the several parts of the lymphatic system. This hyper- 
plasia affects the lymph nodes of the neck, the axilla, the prevertebral 
chain, the intestinal submucosa, the mesentery, the spleen, the -follicles 
of the nasopharynx, the base of the tongue and the gums. 

Together with this general hyperplasia, there is also a new formation 
of lymph follicles in the liver, thyroid and bone-marrow, and, finally, 
an enlargement of the thymus. This enlargement, according to Schridde, 
consists of a hyperplasia of the medulla and a hypoplasia of the cor- 
tex of the organ, with atypical corpuscles of Hassal. As general mani- 
festations we note a characteristic pallor of the skin and an increase of 
the panniculus adiposus. Other, but inconstant findings, are a hypoplasia 
of the vascular system, of the chromaffin system (the suprarenal me- 
dulla and the solar plexus), of the cerebrospinal and genital systems and, 
lastly, various malformations which result from a general developmen- 
tal failure. 

According to Bartel and Stein's preliminary reports, the cause of the 
changes in the lymph nodes is a failure in the development of the lymph 
channels and of the medullary stria3 of the lymph nodes, with a prolifer- 
ation of the zone of cortical follicles in the first stage of growth and a 
secondary atrophy of their specific parenchyma. The atrophy of the 
remaining lymphoid tissue is probably compensatory. The process may be 
described as a developmental error, the first results of which appear in the 
connective tissues and directly involve the lymph nodes. These results, 
accordingly are the expression of a general hypoplastic tendency in the 
genesis of which the fiypoplasia of the vascular system, possibly, plays a 
primary and fundamental role. 

This conception agrees with that which the author had reached from a 
different point of approach. A congenital, or a true hereditary weakness of 
various organic systems reduces their capacity and their resistance. This, 
in turn, results in an increased and qualitatively different reaction to natural 
stimuli which, under ordinary circumstances, would not be pathogenic, but 
with this diathesis, provoke the manifestations of disease. According to its 
capacity to respond to demands made upon it, the weakened parenchyma 
may be strengthened by exercise or injured by excessive use. In the above 
case, we may have also accompanying the general connective tissue, diatheses, 
multiple scleroses in the various endocrine organs causing deficiency 
disturbances (plui iglandular insufficiency of Wiesel). 



220 TEXT-BOOK OF PEDIATRICS 

Exudative infants constitute a pathologic species of unnumbered 
variety. The combined diatheses break up into component predispositions, 
each of which depends upon the functional weakness of a particular system 
and results in the tendency to a definite symptom-complex. From tests of 
the functional capacity of affected organs, criteria of the component predis- 
positions may be obtained. 

The injuries which produce inflammatory conditions upon the basis of 
this existing increased predisposition to disease are very many. Irrational 
forms of dietary and particularly those which are popularly termed 
"strengthening," but are merely causative of the excessive formation of 
fat, are among the most active of these injuries and that irrespective of the 
preponderance of their protein, fat or carbohydrate components. Accord- 
ing to Czerny, the most injurious consequence of such a fattening process is 
the increased disposition it affords to secondary infections, which favor the 
development of severe and often dangerous secondary changes. It is an 
accepted fact that dietetic injuries produce disease symptoms more readily 
when they occur in patients who are subject to this complex abnormality 
which we term the exudative diathesis. Too great stress, however, must 
not be put upon the effects of overfeeding in the pathogenesis of these 
disturbances. The writer discerns a tendency to exaggerate their im- 
portance when authorities call attention to the striking and constant influ- 
ence which the manner of feeding has upon individual symptoms and 
regard this alleged fact as a criterion in the recognition of the picture of 
a diathesis. 

As factors which may convert a latent diathesis into an active process 
with characteristic signs of its presence, we must reckon with certain inter- 
current infectious diseases, as tuberculosis and measles. Even vaccination, 
the application of the tuberculin test, or the accident of an insect bite may 
serve as the spark which lights up the potential tendency. With the pre- 
disposing hypersensitivity of the body surface, mechanical, thermic, actinic 
and sensory irritants may act as the agents of injury. 

Exudative diathesis and the status lymphaticus are frequently but not 
inevitably associated. Their relationship is shown in the fact of their 
frequent reaction to similar influences, as seen in their tendency to improve 
under the dietetic measures prescribed. Czerny and others consider the 
status lymphaticus as a component element in the severer forms of exuda- 
tive diathesis. Unquestionably, the latter stands in close association with 
certain neuro and psychopathies. The irritability and instability of the 
nervous system of children of exudative diathesis, exerting, as it does, a 
distinct influence upon the severity of the disease complex, (see table, page 
215) may be in the nature of a vasomotor unbalance which serves as the 
basis of all its manifestations (Moro) and is, in certain cases, of inherited or 
congenital quality. In others the neurosis of the patient is an acquired 
feature and often results from errors in training, for the indulgence of which 
the exudative diathesis, with its repeated exhibitions of ill health, has given 
ample opportunity. 



THE BLOOD AND BLOOD-FORMING ORGANS 221 

ARTHRITISM IN CHILDHOOD 

Quite recently and contrary to preexisting beliefs, a relationship between 
the exudative diathesis of children and the uric acid diathesis of adults, is 
accepted as a probability in view of the demonstration of an infantile dis- 
turbance of uric acid excretion. (Kern, Uffenheimer.) The condition which 
forms the clinical connecting link between them is arthritism, a condition 
which Comby defines as an hereditary and habitual disturbance of nutri- 
tion. This phenomenon is a widely distributed one, but is not observed in 
all classes of society and in all places. It occurs chiefly in the well-to-do 
families of city life, among the hypercivilized and the highly intellectual 
of the people. Very few cases are seen in the free dispensaries, while private 
practice among the wealthy furnishes numerous examples. Homologous 
and heterologous types of hereditary transmission are distinctly recognized 
in this expression of disease. According to Comby, the members of an 
individual family may be subject to diabetes, gout, obesity, renal calculi, 
migraine, asthma, and the various neuropathies and psychopathies, known 
as the group of Bouchard's bradytrophy. Even though the beginning of 
the disease may be traced back to the early history of the child, most of 
these cases are first recognized at school age. 

The habitus of these children is variable. A distinct division into the 
various types, such as the anemic, erethismic, plethoric and obese, is 
neither possible nor practical. Very frequently we find cases representing 
successive transitions, or mixed cases, or even those in whom the external 
habitus does not differ from the normal. 

As we have already said, the manifestations of the exudative diathesis 
are very numerous, but from the combination of symptomatic elements 
extremely variable pictures arise. According to reports in the French 
literature these manifestations may include the entire symptom-complex 
of the inflammatory diathesis if we consider that this is not confined to the 
fust months or even years of life, excepting as to such incidents as sebor- 
rhcea, intertrigo, oradle-cap, etc. The recurring catarrhal disorders and the 
nervous conditions connected with them (see table page 215) are the most 
conspicuous. To these may be added a large number of symptoms of 
greater or less note. Definite rises of temperature, resembling those of 
malaria, but without apparent cause, with a persistent increase of the 
rectal temperature to about 38 C. (100.4 F.) especially after exercise; 
changes of color in the face, transient erythemata, cold hands and feet, 
chilblains, sweats, fainting, etc.; tachycardia, palpitation, habitual arhyth- 
mia, cardiac asthenia and dilatation, diminished blood-pressure, accidental 
heart murmur and venous bruits; affections of the upper air passages, 
as spasmodic sneezing, cough and hay fever, all of these are possible fea- 
tures of the complex. 

Referring to the intestinal tract, the condition invites anorexia, esopha- 
geal spasm, cardiospasm, gastric and intestinal atony, indicated by clapo- 
tage and distension, obstinate habitual constipation, intestinal colic, 
muco-membranous enteritis, appendicitis, nervous cyclic vomiting, with or 



222 TEXT-BOOK OF PEDIATRICS 

without acetonemia, occurring as car-sickness or as a consequence of psychic 
excitement or responsively to other marked irritation, and sometimes in the 
early morning when the stomach is empty. 10 The genito-urinary system, 
also, may be affected ard present such symptoms as cloudiness of the freshly 
voided urine, with non-organized sediments, (uric acid, urates, phosphates 
and oxalates); intermittent albuminuria of the orthostatic type; polyuria, 
cystic spasms, dysuria, diurnal and nocturnal enuresis, cystitis and ure- 
thritis, balanitis, with erections and masturbation. 

As nervous phenomena of the diathesis, may be numbered pavor noc- 
turnus, choreic restlessness, tics, the f acialis phenomenon, severe typical and 
atypical migraine, neuralgias, rheumatoid pains, arthralgias (from which 
the rather unfortunate term arthritism has been suggested), osteal- 
gia without objective cause, unusual flaccidity of the muscles and pos- 
tural errors. 

In the hyperplasia of the lymphatic system the most important involve- 
ment is that of the faucial and pharyngeal tonsils with its common sequelae. 
Next in consequence comes the hyperplasia of the bronchial and mediastinal 
lymph nodes causing anomalies in the respiratory sounds, areas of pul- 
monary dulness confirmed by Roentgen shadows, and signs of varying 
compression especially upon bending back the head. The spleen may be 
palpable and occasionally the lymph nodes in the neck and in the joint 
flexures become markedly enlarged. 

These and companion symptoms may appear singly or in variegated 
grouping. They may appear at more or less regular intervals in varying 
degrees of severity, becoming progressively more and more definite. Indi- 
vidual manifestations have often been looked upon as separate and distinct 
diseases and their appearance in orderly succession has been regarded as 
accidental. The more carefully, however, the history of the patient and 
that of his immediate family is studied, the longer the observation of the 
patient is continued and the better the observer becomes acquainted with 
his conditions, the more readily will the relation of the individual patho- 
logic elements to the special predisposition or diathesis be recognized. 

Even though rarely fatal, such manifestations of the disease as hyper - 

10 The acetonemic vomiting, a very characteristic symptom of a combined neuropathic 
and metabolic disturbance, occurs in the following manner. Children, especially boys, 
previously affected by atony of the stomach and intestines, with habitual obstipation, 
become ill every few weeks with frequent, violent and uncontrollable vomiting. This 
may follow some active voluntary exercise or may be entirely spontaneous or independent 
of any exciting cause. The attacks may last for several days, during which time all food 
is ejected. The vomitus may be bile-stained and bloody. The accompanying exhaustion 
may become alarming, but the patient usually recovers very quickly after the vomiting 
has ceased. During the attacks, there is not only acetonuria, but evident excretion of 
acetone from the lungs. The presence of acetoacetic acid, and of /3-oxybutyric acid in 
the urine and expired air may further indicate the acidosis. Icterus and enlargement of 
the liver, with elevations of temperature may be noted. Apparently the condition is a 
cataclymic eruption ot an otherwise more or less latent disturbance of metabolism. 
According to Hecker, it is an interference with the catabolism of fat due to the hypoplasia 
of the lymphatic system. The eruption is seemingly brought on by nervous influences. 
Suggestive treatment is occasionally effectual. The writer prefers an active catharsis 
once a month, with the daily use of calcium chloride or of alkalies, with physiologically 
alkaline food, for a long period. 



THE BLOOD AND BLOOD-FORMING ORGANS 223 

pyrexia without objective cause, succeeding an equally causeless collapse, 
acetonemia, paroxysmal tachycardia, pavor nocturnus, colic, enteritis, 
migraine, fainting, skin eruptions are, to say the least, very distressing and 
unpleasant complications. 

Often, as a result, the child is unable to attend school and the diathesis 
is harmful from the social standpoint while such injuries as impairment 
of hearing, aprosexia in adenoid disease, enuresis, masturbation, etc. have 
an ethical or moral bearing. 

Treatment. The treatment of the exudative diatheses cannot, perhaps, 
be directed against the fault in the germ or the resulting perversions of 
metabolism, but only against those certain external influences which excite 
its manifestations, such as the frequent intercurrent infections and those 
comph' eating structural abnormalities and functional disturbances which 
aggravate the initial error. 

The secondary infections which, as Czerny believed, may convert the 
relatively innocuous primary manifestations of the diathesis into severe 
forms of disease, may be combated preventively by reducing both the 
predisposition to attack and the opportunity of infection. In the accom- 
plishment of this first aim, dietetic management has proved useful in a 
purely empirical way. Procedures which serve to remove the excess of 
fluid from the tissues, if promptly applied, will have a favorable influence 
upon the hyperplasia of the tonsils, etc., and should take, therefore, a very 
important place in the treatment. 

After the first two years, a largely vegetable dietary is to be recom- 
mended, supplemented with only a small quantity of meat and but one- 
fourth to one-half a litre of milk a day. Eggs, cream, butter and sugar are 
not well borne. During the first two years, the smallest possible quantity of 
milk compatible with gradual gains in weight and general development 
should be given. Human milk is to be preferred, but with any form of 
feeding the number of meals and the length of the individual feeding must 
be curtailed. If, in spite of these measures, a child is inclined to grow too 
fat, carbohydrates, broths and vegetables may be substituted for a part of 
the milk even during the latter half of the first year. At a year and a half 
the child may be put upon the diet of more advanced childhood. 

A poor development of the breast-fed infant with exudative tendencies 
is often improved by a change to mixed feeding, in which such additions as 
buttermilk, gruels or malt soup are desirable. 

An example of a menu for a child of two years, as advised by Czerny, 
follows: 

Breakfast: Milk, diluted with hot water, and toast without butter; 
followed at 10 A. M. by raw fruit. 

Luncheon: A thick soup, preferably of well-cooked legumes; finely 
divided meat; and such fresh vegetables as spinach, carrots, kohl-rabi, 
cauliflower, lettuce or string beans. 

At 4 p. M. Diluted milk with toast or cake. 

Supper: Finely divided meat, with bread, potato or rice, and a very 
little butter. Weak tea, or water with fruit juices, may be added. 



224 TEXT-BOOK OF PEDIATRICS 

The most efficient method of lessening the opportunities of infection to a 
minimum is to keep the child, whether in the country or in the city's 
suburbs, in a place where the air is free from dust and smoke. The summer 
vacation spent in climatically favorable places, avoiding hotels and sanatoria 
should be extended as long as possible. The little patient should be kept 
away from disease carriers, such as adults with catarrhal infections or so- 
called colds. Chilling should be avoided by out-of-door exercise. Attempts 
at hardening or accustoming the child to infective agencies are useless. 

Finally, great emphasis must be put upon the importance of psychic 
treatment in cases which show signs of present or impending nervous dis- 
turbances. This consists in seeking to withdraw the attention of the 
patient from his physical ills by systematized play or occupation, by the 
parental avoidance of anxiety and excessive care and by abstaining from 
medication and sanatorial treatment. The child should be protected from 
association with neurotic or mentally unbalanced persons. In certain cases 
it may be necessary to remove the patient from the home and to change 
his entire mode of living and training. 

The main indications in the treatment of arthritism are similar, for this 
disposition frequently, although not always, arises from the inflammatory 
diathesis and, as a result of harmful psychic influences gradually tends to a 
more and more neuro-psychopathic type. 

In these phases of the condition the largely vegetable dietary recom- 
mended may occasionally exert, a favorable influence upon the viscero- 
somatic symptoms, but will have a less definite or indeterminable effect 
upon the stated neuro-f unction al disturbances. Tonic remedies, whether 
foods or medicines, iron, arsenic, quinine in fact, practically all drugs 
that have been tried, are useless and even harmful, for their use tends to 
fasten the child's attention upon its ailments. For the same reason, all 
highly artificial measures as hydrotherapeutic and other physical treatments 
in sanatoria or elsewhere should be avoided. It is better to place the child 
in natural surroundings, adapted to its physical and mental development, 
which will approach as nearly as may be to "the simple life. " 

Certain symptoms, of course, require special methods of treatment. 
These should be brought into accord, however, as nearly as possible with the 
essential principles of management already laid down. 

As the detail given may suggest, the entire treatment proposed ap- 
proaches at many points, the methods applied in the so-called "nature 
cures." Nevertheless, the aim of this counsel has been to avoid the injuries 
so commonly incurred in these systems; as the sleeping in large wards, the 
entire deprivation of meat, the forced cold water treatment with resulting 
chills, etc. 

In cases of the status lymphaticus, the danger of operative shock and of 
serious nervous excitement, as that attending the use of anesthetics, or the 
Roentgen treatment, or even the administration of hot and cold baths, 
should be emphasized; while the special risks of acute infections diseases, as 
in the severe toxic form of scarlet fever, must always be borne in mind and 
the patient treated with more than ordinary precautions. 



THE BLOOD AND BLOOD-FORMING ORGANS 225 

Formerly, great difficulty was encountered in the differentiation of the 
status lymphaticus from scrofula. The two were repeatedly but mistakenly 
associated and, as a result, progress of pathogenic and clinical research was 
materially impeded. It is true that careful observers, in their bedside 
investigations, had attempted, long ago, to make a definite distinction 
between these conditions; but it was Koch's anaphylactic methods of 
diagnosis and the safe and handy modifications proposed by v. Pirquet and 
Moro which first made their positive separation possible. Hence we have 
come to the acceptance of the view that scrofula is that form of tuberculosis 
in childhood which occurs in cases of lymphatism (Moro, Escherich). 



15 



APPENDIX 

PATHOLOGY OF THE GLANDS OF INTERNAL 
SECRETION 

A. PATHOLOGY OF THE THYROID 

IN the consideration of the pathology of the thyroid body the greatest 
clinical interest attaches to those disease-pictures which are proven to arise 
from functional disturbances of the organ. These disturbances may be 
due, on the one hand, to complete or partial absence of the gland or to 
qualitative changes in its activity, described as athyreosis, hypothyreosis 
and dysthyreosis, and, on the other hand, to a pathologic increase of its 
functional activity, known as hyperthyreosis. For the general pathology of 
these conditions we must refer the reader to text-books of internal medicine. 
However, the point of especial interest to the podiatrist is that during intra- 
uterine life, and probably during early infancy, the lack of the thyroid gland 
in the child may be met by the increased activity of the maternal gland. 
The active principles of the thyroid secretion undoubtedly pass through the 
placenta and, perhaps, through the mammary gland, and thus reach the 
infant organism. Therefore, fatal disease due to absence of the thyroid gland 
is never seen. This is significant since the young and growing organism is 
especially susceptible to injury from disturbances of the functional activity 
of the thyroid. The group injuries due to hypothyreosis are seen only in 
childhood. In these conditions perfect therapeutic results can be obtained 
only when the status is recognized and treated in early life. 

HYPOTHYREOSIS; ATHYREOSIS 

These conditions may be conveniently classified in accordance with 
their anatomic and etiologic causes. 

1. Hypothyroidism may be caused by anomalies of structure, resulting 
in complete absence of true thyroid tissue. The anatomic conception of 
this complete thyroid aplasia, the congenital athyreosis, coincides com- 
pletely with the clinical picture of congenital myxedema. 

Cystic formations are found occupying the place of the lateral thyroid 
germ centres and developing epithelioid tumors at the base of the tongue. 
The epithelial cells persist in this type. The condition is one of actual 
primary aplasia of the gland with an absence of its arteries. 

Short of total aplasia of the gland we may have hypoplasia and 
congenital insufficiency, which lead to partial degrees of congenital 
hypothyroidea. 

2. Hypothyreosis may also result from a more or less extensive degener- 
ation of the gland in extra-uterine life. This may take the form of either a 
primary atrophy or a goitre-like dystrophy; in either of which forms the 
active glandular tissue may entirely disappear. According to Wieland, 

226 



PATHOLOGY OF GLANDS OF INTERNAL SECRETION 227 

this is a condition affecting the germinally weak gland in what may be 
called a " h3 r pothyroidic diathesis." 

In this event, the parathyroid bodies may be included in the degenera- 
tive process. For the sequelae of this involvement the reader is referred to the 
Chapter on Spasmophilia (Tetany). 

Such thyroid degenerations are observed, (a) in certain localities where 
they appear as an endemic cretinism, arising from injuries common to the 
region, of the nature of which but little is known; and (6) as entirely spo- 
radic cases, presenting varying conditions of the thyroid, but resulting in an 
acquired form of infantile myxedema. Either of these types is frequently 
seen in abortive forms. 

3. Finally, hypothyreosis may be caused by the partial or complete 
surgical removal -of the gland which results in an operative myxedema, 
(cachexia thyreopriva). This condition is of great interest from an experi- 
mental standpoint, but may no longer be considered clinically interesting. 

All of these forms of a- or hypothyreosis share the group of symptoms 
which constitue the phenomena of absence, relative or complete, of the 
function of the thyroid gland. Their clinical relationship is therefore a very 
broad one and their differentiation depends primarily upon the demon- 
stration of the etiologic factor in each case. Certain signs, such as the dis- 
turbance of dentition, are, of course, clearly manifest when the functional 
activity of the gland has been wanting from the earliest postnatal 
period ; while others appear only after the condition has existed for years. It 
is quite probable that in cretinism there are injuries to other and possibly 
intracranial organs besides those which have led to the disturbance of 
thyroid function. 

GENERAL SYMPTOMS AND THEIR CAUSES 

1. Affections of the Skeleton. These are among the earliest and most 
constant of symptoms. They arise from a disturbance of both the endo- 
chondral and periostea! growth, with atrophy of the bone and the blood- 
forming marrow. 

The cartilage formation at the epiphyses, the extension of the marrow 
capillaries into the cartilage cells, the resorption and to a degree the appo- 
sition of the bony tissue are all retarded. The process of calcification is 
entirely undisturbed. The result is the development of sclerotic bones of 
normal shape, but of reduced size. It is apparent that the hypothyroideal 
affections of bone are, in some respects, the precise opposite of the rickitic 
forms; so that children with myxedema never give definite signs of rickets. 
The epiphysial centres develop late or are entirely absent, while their 
cartilaginous structure persists. Longitudinal growth is delayed and often 
continues until after puberty. The Roentgen picture usually shows a 
characteristic dark shadow at the diaphyses representing a transverse 
lamella of bone extending toward the epiphysis. (Figures 55 and 56.) 

Clinically, the disturbance is recognized as a fairly proportionate 
dwarfism, which becomes more and more pronounced; by changes of form 
due to anomalies of the soft tissue, to be described later; by a depression of 



228 TEXT-BOOK OF PEDIATRICS 

the bridge of the nose not appearing as an initial dystrophy, but as an inhibi- 
tion of growth at the tribasilar suture; by the permanently open fontanelle 
and cranial sutures, and by anomalies of dentition and of teeth formation. 
These dental anomalies resemble those of rickets. The closure of the flat, 
low, wide cranium may be delayed even longer than it is in rickets, but the 
edges of the bones are hard. Fractures heal very slowly in the hypothyroidic. 

The several characteristics of the cretinoid skull (after Scholz), are: 
orthocephalia, platycephalia, plagiocephalia, platyrrhinia, hypsicephalia, 
and prognathus. 

Recently this disturbance of the bony growth has been repeatedly laid 
to the hypothyroideal injury of the blood-forming marrow (compare rickets, 
scurvy, etc.). The involvement of the blood-forming marrow may be 
regarded as the cause of such marked evidences of anemia as the pallid or 
dull yellow skin, the oligocythemia, oligochromemia and polynucleosis. It 
may be held responsible, also, for the hemorrhagic diathesis and for the 
enlargement of the tonsils and of the lymph nodes which such cases exhibit . 

2. Changes in the Skin and Mucous Membranes. As a result of a 
peculiar redundancy of the elements of the subcutaneous connective tissue, 
the nature of which has not yet been determined, the skin, at certain points, 
becomes loosened from the underlying tissues (cutis laxd), and has a gela- 
tinous, doughy or slippery feeling the myxedema of Ord. True edema, 
however, with complete loss of elasticity does not occur. When the myx- 
edema disappears the skin is left slack and wrinkled. The interference with 
the nutrition of the epidermal layers causes desquamation, cracking of the 
finger-nails, dryness and falling of the hair; the lanugo, however, persisting. 
A suppression of the perspiration also results, in all probability, from the 
dryness and the reduced electro-conductivity of the skin. 

Similar tumefaction and loosening of the mucous membranes of the nose, 
pharynx, middle-ear, Eustachian tubes, and especially of the tongue (mac- 
roglossia), of the larynx, the eyelids and the digestive tract, are held 
responsible although not always convincingly for such functional dis- 
turbances as mouth-breathing, snoring or groaning respiration, hoarseness, 
impairment of hearing, refusal of food and obstipation. The symptoms 
of these three groupings produce very characteristic anomalies in the 
external habitus of the patient. The low, flat brow, covered by wrinkled, 
hairy skin; the flat saddle-shaped nose, the narrowed aperture of the swollen 
eyelids, and the widely gaping mouth, allowing the enlarged tongue to 
protrude between the thick and almost trunk-like lips, are its principal 
features. There is often, also, a double chin; the ears are large and mal- 
formed ; the normal contour of the body, moulded upon the skeletal lines, is 
obscured by the irregularly thickened soft tissues. This certain grotesque- 
ness is increased by spongy skin-pads formed over the clavicles, the scapula 
and the hips and around the nipples. The limbs are cylindrical and pillar- 
like and the fingers and toes seem shortened and stubby. The hand re- 
sembles the paw of a mole. The abdomen is greatly distended nd, in 
younger children, is frequently and further deformed by an umbilical hernia. 



PATHOLOGY OF GLANDS OF INTERNAL SECRETION 229 

3. Psychic Anomalies. The mental development is arrested at a very 
low stage or rather is retrogressive to such a stage. In the more severe 
cases, the intellectual capacity of the patient is less than that of intelligent 
animals (the vegetative man of Kocher). The mental aberration is always 
of the characteristically anergic form. The child is uncleanly and drowsy; 
it lies for days without reacting to sensory impressions, its gaze apatheti- 
cally fixed, its movements automatically responsive when forced. It roars 
when hungry or in pain. Cases of lesser severity are unable to fix their 
attention, to recognize objects or to speak. In mild forms there is observed 




I 





I. __ 

FIG. 55. Hand of a six-year-old girl with congenital FIG. 56. Hand of normal six-year-old 

athyreosis. Height 72 cm. (28.8 fnches.) Thick sclerotic child for comparison. (Children's Hospital, 

bones. All the epiphysial centres of ossification but Zurich, Prof. E. Feer.1 
one small one in the wrist which appeared after treat- 
ment with thyroid extract, are lacking. 

only a certain weakness of the intellect and memory, an inability to concen- 
trate attention and a mental dulness. In such a case the timidity, the cre- 
tinoid demeanor, the gait, the grimaces, the inarticulate sounds, and the 
dull, morose, animal-like physiognomy of the child may lead one upon super- 
ficial acquaintance to under-estimate its actual mental ability. The delayed 
development of child 's static functions, as in the matter of sitting, standing 
or walking, is, in part, due to these psychic disturbances. 

There is still much diversity of opinion as to the organic cause of these 
mental perversions. Severe affections of the auditory apparatus, both of 
peripheral and labyrinthine origin, and to the extent of deaf-mutism, and of 



230 



TEXT-BOOK OF PEDIATRICS 



the tubal and middle ear tissues incident to adenoids are often concerned 
in its etiology. 

4. Changes in Metabolism. These changes consist in a slowing of the 
metabolism, particularly in the field of protein, water and salt interchanges. 
The consumption of oxygen may be reduced to one-half normal. It is 
supposed that the low average body temperature, ranging l-2 C. below 
normal, and the tendency to obesity are connected with this slow metab- 
olism. As a result of the reduction of the katabolic processes there is a tend- 
ency to nitrogen and phosphorus retention. As a further result, the patient 





FIG. 57. Three-year-old child with aplasia of the 
thyroid and congenital myxedema. (University 
Children's Hospital, Munich, Prof. vonPfaundler.) 



FIG. 58. Endemic cretin from 
the Odenwald. 



can maintain weight upon quantities of food which would be altogether 
insufficient for the normal child of the same age. The limit of assimi- 
lation for dextrose is raised. 

5. Affections of the Muscles. The musculature is usually flaccid, pale 
and wanting in power. It is said also, to be microscopically changed. At 
the same time it may be of large bulk and even pseudohypertrophic. Slow 
movements, delayed static functions, a dragging gait with equinus and 
bended kneee, a flattening of the head of the femur, double-jointedness, 
lordosis, abdominal distension, severe obstipation, diastasis of the recti, 
umbilical or inguinal hernia and, probably, cardiac weakness with small 
labile pulse, cold mottled skin and a tendency to cardiac asthma, may all be 



related to this muscular impairment. In some cases one finds on the other 
hand, a large and firm body musculature. 

6. Disturbances of Sexual Development. In the hypothyreoses, 
hypoplasias of the germinal organs and of the external genitalia are found. 
Partial development of sexual functions, a lack of the secondary sexual char- 
acteristics, postponed puberty, genital infantilism and menorrhagia follow. 



1. Congenital myxedema is more common among females. Neither 
hereditary factors nor any other recognizable causes enter into considera- 
tion in the hypothyreoses. The first indications 

of the deficiency, apathy, delayed growth, and 
the changes in the skin and the mucous mem- 
bianes, are usually noticed during the first week 
in artificially-fed infants and after the first 
month in breast-fed babies. The structural 
changes in the skeletal framework originate at 
birth. The entire symptom-complex develops 
rapidly, as a rule, to the point of severity. 
Most of the cases die during their first years 
and only rarely do they pass into the second 
decade. The entire absence of the thyroid 
gland may hardly ever be demonstrated clini- 
cally on account of the changes in the skin and 
in the muscle topography. 

2. (A) Endemic cretinism affects man and 
animals alike in the so-called goitre districts 
of certain mountainous countries of Europe. 
These districts lie particularly in the Swiss Alps 
and the Black Forest but are found in other 
parts of the world. The disease is somewhat 
more common among males. Hereditary and 
familial influences are in part responsible. 
Presumably they consist merely in a peculiar 
congenital lack of resistance of the gland to 
injurious influences. A degree of significance 

appears to attach to the family residence in a dangerous locality. 
Children brought from other and healthy districts into such localities 
are frequently affected at an early age; while children of families af- 
fected with cretinism who leave the infected district in early childhood or 
are born in other parts, often recover or remain healthy. The cretin dis- 
tricts are not confined to mountainous regions but also exist in localities 
marked by the emergence of certain geological strata of the earth 's surface, 
or lie along the lower reaches of rivers which flow through such formations. 
There are many indications that the noxious agent is carried in unboiled 
drinking water. The hypothesis that the mineral substances, taken up by 
the water from these rocky foundations, may exert in young persons a 




FIG. 59. Six-yearK>ld boy, 
sporadic cretinism. 



232 



TEXT-BOOK OF PEDIATRICS 



damaging or degenerative influence upon the thyroid gland (Author, 1907), 
is quite compatible with the known facts. The writer considers the attempts 

that have been made to demonstrate in- 
fectious or contagious influences in the 
causation of the disease as complete failures 
or very unsatisfactory in results. 

Clinically the thyroid is found to be 
enlarged in about sixty per cent, of cretins. 
Structurally, these cases show a variety of 
goitrous degenerations, cystic, parenchy- 
matous, hemorrhagic and, more rarely, 
atrophic in type. Portions of the glandular 
tissue may remain anatomically intact and 
are, perhaps, functionally active. 

The symptoms of endemic cretinism 
appear comparatively late. Usually, the 
disease may be recognized definitely only 
by the fifth or sixth year, or even later: 
The disease-picture becomes very gradually 
definite and hardly ever reaches its extreme 
development during childhood. A constant 
qualitative difference of the entire symp- 



FIG. 60. Twelve-month-old girl 
with myxedema. 

torn-complex from that of other 
hypothyreoses can hardly be said, 
however, to exist. Besides the 
signs of hypothyroidism one finds 
incidentally those of hypogeni- 
talism and hypopituitarism. 

2. (I?) Acquired infantile myx- 
edema is charged to various acute 
diseases of the gland and differs 
from cretinism chiefly in the fact 
of its sporadic occurrence. 

The abortive forms of hypo- 
thyreosis are of special interest 
to the physician. They may de- 
pend initially upon congenital 
causes, such as an actual hypo- 
plasia, an arrested development 
or a functional inadequacy of the 
gland. They may be a manifes- 
tation of hereditary degeneracy, due to alcoholism, lues, or some cachexia 
in the parent. They may depend upon injury acquired in some cretinic 





Fio. 61. Three and one-quarter-year-old girl with 
slight manifestations of myxedema, height SO. 5 cm. 
(32.2 inches), anterior fontanelle patent, 8 incisors, 
cannot stand and kyphosis on sitting. (Children's 
Hospital, Heidelberg, Prof. E. Feer.) 



PATHOLOGY OF GLANDS OF INTERNAL SECRETION 233 



district or at large. Etiologically, in these abortive types, the clinical ex- 
amination of the thyroid is of little value and the findings are variable. 

Usually the psychic symptoms, as, for instance, voice changes, depre- 
ciation of mental ability, etc., are not definite. The somatic picture is 
confined essentially to dwarfism, to disturbances of dentition, to a slightly 
myxedematous, dry and irritable skin, to the cretinoid, care-worn physiog- 
nomy and to the general demeanor. The disease may be characterized, 
also, by such functional disturbances as chills, anhydrosis, awkwardness 
of gait, enuresis, obstipation, monotony of speech, and mental inefficiency. 
The Roentgen picture, showing the delayed ossification and the transverse 
diaphyseal plates, may support a 
diagnosis which will receive even 
greater encouragement from the 
therapeutic results to be reviewed. 

INFANTILISM 

Clinically, these cases, may be 
correctly included in the sympto- 
matic group belonging to the condi- 
tion of so-called infantilism. 1 

Under the term infantilism are 
included conditions of widely vary- 
ing etiology, in which the physical 
and mental development, relative to 
the actual age, present an abnor- 
mally youthful habitus. Some 
authors distinguish two varieties of 
infantilism arising from insufficiency 
of the thyroid function. Of these, the 
Brissand-Hertogh type has true hy po- 
thyroideal manifestations. The type 
of Lorrain, characterized by delayed 
growth in height, with a symmetry 
of proportions, slender bones, grace- 
ful extremities, small narrow head 

and girlish appearance, deviates markedly from the former and its fit plac- 
ing in this class is very questionable. In this type, it would seem, rather, 
that a functional lack in other glands, as the ovaries, the suprarenals, the 
thymus or the pancreas, or that injuries due to improper feeding, early infec- 
tions, intoxications or organic diseases, may enter into the causation (Anton) . 

The abortive infantile hypothyreoses are characteristically benign and 
tend to spontaneous recovery. 

TREATMENT 

The treatment of the hypothyreoses is based upon physiologic substitu- 
tion. The reliability and applicability of this method, in all forms of the 

1 The histologic findings in the osseous system resemble, of course, a senile marasmus 
rather than an infantile dyscrasia (Dieterle). 




FIG. 62. Two-year-old boy with mpngoloid 
idiocy. Characteristic laxity of the joints. 



234 TEXT-BOOK OF PEDIATRICS 

disease in early childhood, is now generally accepted. Doubtless, the 
simplest and most rational procedure would be the implantation of a thyroid 
gland of the same species at any suitable place in the body of the patient, 
provided that such a transplanted organ could maintain its functional 
activity. This has been attempted in a number of instances but, according 
to report, it has seemed impossible to keep the transplanted organ duly 
active. Under the law of biologic specificity, it would not appear possible. 
Fortunately the fairly thermostable active principles of the animal thyroid 
are transferable and may even be absorbed through the digestive tract. It 
is deemed best to feed the thyroid gland of food animals. This is given in 
fresh raw form, finely divided, and prepared with butter, eggs, and spices. 
The glands of sheep are most commonly used, but those of cattle or 
hogs may be employed. Care should be taken to see that the animal from 
which the gland is taken is healthy and that such other organs as the 
thymus, salivary glands, lymph nodes, or pancreas are not substituted. 
One or two pairs of sheep glands are given two or three times a week. 

As a similar substitute, the more easily obtained pharmaceutical prep- 
arations of the dried, or desiccated or extracted thyroid gland are recom- 
mended. Thyroxin, the active principal of the gland may be used. Other 
methods of administration, as by subcutaneous injection or enemata, have 
been discarded. 

The results of this treatment are usually very marked. It affects all the 
somatic and psychic manifestations of hypothyreosis at once. Improve- 
ment may be noted within a few days and may lead to the complete disap- 
pearance of the symptoms. Discontinuance of the remedy quite naturally 
causes a remission. Especially favorable results are seen in the treatment of 
congenital and acquired myxedema, but benefit is had even in endemic 
cretinism among young patients. The average of results of the treatment 
gathered from large numbers of cases would probably be even better than it 
is, if occasional complicating Diseases, unrelated to the hypothyreopis, could 
be excluded. In the cretin, the treatment does not affect the disturbances 
of hearing as markedly as it does other symptoms and the unrelieved deaf- 
ness may hinder mental development. 

The treatment with the thyroid gland must be begun very carefully and, 
at first, the patient must be scrupulously watched. Injuries resulting from 
excessive doses may be of hyperthyroideal nature, such as restlessness, 
palpitation of the heart, cardiac weakness, flashes of heat, perspiration and 
vomiting, or they maybe of a toxic character, resembling those of botulism 
or meat poisoning. The latter accident occurs only when suspicious pharma- 
ceutical preparations are used. 

GOITRE 

Congenital and acquired hyperplasias, or rather hypertrophies, and 
strumous degenerations of the thyroid gland are seen quite frequently in 
certain families in which the disease prevails; but are otherwise quite rare. 
Congenital goitre frequently appears to be caused, in large part, by a 
vascular congestion of the organ; and with suitable treatment, or even 



PATHOLOGY OF GLANDS OF INTERNAL SECRETION 235 



without treatment, often disappears rapidly. In other cases, parenchy- 
matous overgrowth and the formation of nodes and cysts are observed. 
In the former event, a scleral degeneration with hypothyreosis, and in the 
latter the very opposite condition may constitute the permanent injury. 
A congenital struma may spread very gradually until it extends to the lower 
jaw and may occupy the entire neck. This may result in symptoms of com- 
pression of the esophagus, with reflex vomiting; of the cervical vessels, lead- 
ing to cyanosis and edema; and particularly of the soft trachea, causing 
dyspnoea, stridor, pulmonary atelectases and broncho-pneumonia. Fibrous 
goitres surrounding the trachea and extending downward beneath the ster- 
num are especially dangerous, but are for- 
tunately quite uncommon. 

At puberty the frequency of goitre is 
again marked and especially in girls. In 
these cases, we may also find general dis- 
turbances, due to an excessive secretion 
of the gland. They may go on to the 
development of Basedow's disease. Glands 
enlarged by degenerative changes may fail 
to give symptoms of hyperthyreosis (q. v.), 
even though there is a huge goitre present. 

Treatment. The greater number of 
strumata in children react favorably to 
iodine treatment in the form of potassium 
iodide given internally, 0.1-0.5 gms. (2-8 
grs.), a day; or to the external application 
of potassium iodide ointment with the 
addition of a small amount of iodine. 
Preparations of the thyroid gland cannot be recommended and are, in fact, 
contraindicated. The vascular strumata of the new-born should be treated 
with applications of ice alone. 

BASEDOW'S DISEASE 

This disease is rare in childhood and is met with, but little more fre- 
quently toward puberty. It is a hyperthyreosis of unknown etiology, 
characterized by a rapid and demonstrable increase in the size of the gland. 
Its manifestations and treatment in the child are the same as in the adult. 

INFANTILE BASEDOWOID DISEASE 

Recently this term has been applied to a condition found by Hochsinger 
in one case. It is said to be characterized by mild ocular symptoms, resem- 
bling those of Bascdow 's disease by tremor, palpitation, and hyperhydrosis. 
This condition coexisted with true epilepsy and yielded to treatment with 
the thyroid gland. 

B. PATHOLOGY OF THE GERMINAL ORGANS 
Hypogenitalism, eunuchoidism, dystrophia, adiposo-genitalis, are terms 
applied to a condition resulting from perverted interstitial development of 




FIG. 63. Facial expression of a ten-year- 
old boy with cretinoid degeneration. 



236 TEXT-BOOK OF PEDIATRICS 

the reproductive glands. It resembles the status which follows castration. 
Eunuchoid individuals are tall and long-limbed and inclined to adipose 
deposits over the lower abdomen, thighs and eyelids, or sometimes to general 
obesity. The development of the secondary sexual characteristics is re- 
tarded and poorly achieved. The epiphysial grooves remain open for a 
long time and the genitals are small. Abdominal or inguinal crypt orchidism 
is common. Eunuchoid boys (for in females the condition is, to say the least 
rare), are remarkably quiet, unassuming and dependent. The condition is 
most frequently recognized at puberty. In the course of years spontaneous 
recovery may occur. Thyroid treatment is useless. 

C. PATHOLOGY OF THE HYPOPHYSIS 

Hypopituitarism, or the reduction of the function of the glandular 
portion of the hypophysis, may obtain in later childhood as a result of 
pathologic changes in the organ itself, or in the neighboring structures. 
Such a disturbance is associated with a dystrophy of the genitals (hypophys- 
ial form) since it causes a retardation of the development of the inter- 
stitial and generative portions of these organs. Aside from the obesity or 
abnormal distribution of the fat which becomes especially marked about the 
thighs, breast and hips, the small genitals and the failure of the secondary 
sexual characteristics with reduced metabolism and increased carbohydrate 
tolerance; we have here also the growth anomalies of the eunuchoid type. 
This is characterized by the great height, due to the continued growth 01 the 
long bones after the normal period for the attachment of the epiphj r ses 
which, in turn, is delayed because the generative organs do not stimulate 
the growth. In many cases, however, a disturbance of ossification of true 
pituitary origin counteracts this continued growth. The pituitary action 
here is to delay the growth of the centres of ossification resulting in a small 
child-like body. The two forms of genital dystrophy with obesity can 
further be distinguished by the appearance of focal brain symptoms or by 
the appearance of the cella turcica in the radiogram. 

The treatment with pituitary extract by mouth is apparently of some 
benefit, surgical interference and Roentgen treatment of doubtful value. 

D. DISTURBANCES OF GROWTH 

GENERAL PHYSICAL ANOMALIES OCCURRING WITHOUT RECOGNIZED 

RELATION TO THE HEMIC GLANDS 

Chrondrodystrophia (Kaufmann, 1892), achondroplasia (Parrot 1878), 
or micromelia chrondromalacia, is a disease of the fetal cartilaginous skele- 
ton. It occurs chiefly in females. The proliferation of the cartilage at the 
junction of the epiphysis and the diaphyses, which represents the method of 
longitudinal growth of the bones performed in cartilage, is inadequate. 
On the contrary the calcification and ossification of the shorter cartilaginous 
shafts, as well as the periosteal ossification, are not affected or proceed even 
more rapidly than usual. The end result is seen in abnormally short and 
thick bones and in premature synosteoses. An abnormal strand of con- 
nective tissue passing from the periosteum into the epiphysial-diaphyseal 



PATHOLOGY OF GLANDS OF INTERNAL SECRETION 237 



boundary the characteristic periosteal lamella causes an irregular one- 
sided growth and results in the decurvation of the bone. The width of the 
cartilaginous epiphyses varies. Occasionally it is diminished; again it may 
be enlarged to a mushroom-like thickening, represent ing both the hypoplastic 
and the hyperplastic forms. 

The clinical picture presents a micromelia, determined by the shortness 
of the limbs and accompanied by the true saddle-form nose caused by 
synosteosis of the tribasilaris. The 
excess of fatty, but not gelatinous 
skin hangs upon the short limbs in 
folds and wrinkles like trousers or 
sleeves that are too large. These 
appearances are often mistaken for 
the myxedematous cutis laxa and 
for the true cretinoid physiognomy. 
For the cranium is large, the neck 
heavy, and the three stub-pointed 
middle fingers, on account of the 
union of their basal phalanges and 
the spreading of their distal pha- 
langes, form the characteristic 
trident hand. Other malformations 
and strumata are common in these 
cases. The children who survive 
attract attention because of their 
muscular weakness, double-jointed- 
ness, the delay in the acquirement 
of their static functions and in 
the closure of the fontanelles, the 
rotatory spasm and the profuse 
sweating. The condition is some- 
times mistaken for rickets. When 
the patient learns to walk with a 
characteristic waddling gate, the 
preexisting lumbar kyphosis becomes a lordosis with a markedly protrud- 
ing abdomen. 

His intellectual development is not retarded and is often surprisingly 
good. It is said that court jesters and clowns have been recruited from 
this class. 

Treatment with thyroid preparations is generally useless. 

OSTEOGENESIS IMPERFECTA (VROLIK) 

OSTEOPSATHYROSIS 

This is a condition of deficient endosteal and periosteal ossification with 
normal formation of cartilage. It is a disturbance of osteoblastic function. 
The bones grow long, but are thin and very porotic. On this account, 
numerous so-called spontaneous fractures occur in all parts of the skeleton. 




FIG. 64. Eleven-year-old 



ith Basedow's 



disease. Improvement after ligature of the arteries. 



238 



TEXT-BOOK OF PEDIATRICS 



both in fetal and postnatal life. These fractures, and there may be many, 
lead to malformations and to a shortening of the extremities (micromelia). 

The development of numerous calluses may 
produce a conditon which resembles an 
abnormal thickening of the bones. In the 
cranial bones, preformed in membrane, large 
membranous openings may persist. (See 
Rickets.) During life, the Roentgen picture 
shows this condition very plainly (Fig. 66). 
Therapeutically, phosphorus and cod-liver oil 
to prevent rickets has been found valuable. 
Adrenalin has been suggested. No doubt, 
fresh air, sun-baths and diet must all be 
looked after. All cases in which the diagnosis 
was definitely established died during the 
first year. The so-called late form appear- 
ing in older children appears to be a differ- 
ent disease. 

Mongolism-mongoloid Idiocy. (La ng- 
don Downs 1866.) This is a complex 
congenital abnormality which suggests a 




FIG. 65. Month-old child with chon- 
drodystrophy, habitus and form of face, 
unusual laxity of the skin. 

"reversion to the ape-man type." Its struc- 
tural peculiarities are associated with serious 
impairment of mental functions. It produces 
characteristic changes of habitus and fre- 
quently implicates to a great extent the 
functional systems of the affected individual. 
According to Jodiche, the serum of a mongo- 
loid patient, studied by Abderhalden's sero- 
diagnostic method, showed the degeneration 
of a number of organs and especially, of the 
reproductive glands. Little positive knowledge 
of its etiology has been acquired. Varying 
indications of senility in the mother during 
pregnancy seem to play their part. The dis- 
ease only occurs sporadically, but appears in 
all strata of society and in all countries. It has seemingly increased in 
frequency of late years. The sexes are affected equally. 




FIG. 66, Upper extremity of a new- 
born infant with osteopsathyrosis, 
multiple fractures, and callous for- 
mation. 



PATHOLOGY OF GLANDS OF INTERNAL SECRETION 239 

The habitus, faintly resembling that of the Mongolian, is the most 
reliable criterion of recognition. It is marked by brachycephaly, a small 
saddle-shaped nose, slanting eyes, the inner canthus being lower than the 
outer, with narrow lid apertures, epicanthus (the sickle-shaped, vertical 
fold of skin over the inner canthus), habitual conjunctivitis and blepharitis, 
and frequently divergence of the rather prominent eyeballs. The mouth 
gapes and is constantly salivated. The cheeks and chin show a distinctly 
circumscribed red color, suggestive of a clown's mask. The external ear 
is atavistically malformed. The abdomen is distended and a diastasis of the 
recti muscles is observed. A double-jointedness, resulting from a muscular 




Fio. 67. Mongoloid. (Children's Hospital, Breslau, Prof. Tobler.) 

flaccidity or aplasia is common. Finally the shortened and incurvated small 
finger, incident to hypoplasia of the distal phalange, is in evidence. 

The demeanor of the imbecile or idiotic child is very characteristic. 
While it is, at first, apathetic, by the end of the second year, or even later, 
it becomes restless, active and aggressive, with a tendency to imitation, to 
make grimaces, and to gesticulate in an ape-like fashion. It employs itself 
energetically with all sorts of mischief, in the way of tipping over objects, 
pulling things apart, and especially in climbing. It likes to talk, but fool- 
ishly; it gives the more or less definite impression of a happy and lively dis- 
position, adaptive to its surroundings. 

This mental change, which is hailed with joy by the layman, as evidence 
of decided progress in the psychic development of the child hardly ever leads 
to the attainment of useful coordinated acts and purposeful mental capac- 
ity. The Mongolian child hardly ever learns to speak correctly, to com- 



240 



TEXT-BOOK OF PEDIATRICS 



prehend any great number of words, to recognize its surroundings, to keep 
itself clean and the like. It is scarcely ever capable of school training but 
remains upon its mentally low plane or falls back into a mental torpor. Its 




FIG 68. Twenty-one-month-old child with mongoloid idiocy. Brachycephaly, 
typical form of face and attitude, strabismus. 

special love of music is often noticeable. Milder cases generally acquire ab- 
normal habits. 

The skeleton is affected by a group of facultative qualities, such as 
retarded growth, delayed development of the epiphysial centres of ossifica- 
tion, delayed dentition, tardy closure of the fontanelles. Chicken-breast is 
of common occurrence. In the reproductive system there is a lack of de- 
velopment- of the sexual characteristics 
and functions. Mongolism in its later 
course is not infrequently found in asso- 
ciation with true hypothyreosis, with its 
characteristic physiogonomy, myxedema, 
microglqssia, faulty breathing and sub- 
normal temperatures. It is also compli- 
cated, sometimes, with rickets or with 
adenoid vegetations and their sequela. 
The general defect may be coincident, 
too, with a number of congenital mal- 
formities, e. g., heart lesions, cleft palate, 
polydactylia, etc. 

Atypical cerebral convolutions sug- 
gest a more or less constant structural 
substratum of the psychic syndrome 
of mongolism. 

The skeletal symptoms are based 
upon fatty and interstitial changes in 
the bone-marrow, with the formation of 
transverse bands of bone at the epi- 
physeo-diaphyseal junction. This anatomic basis of the hypothyreosis 
and of such sexual symptoms as the delay in the development of the repro- 
ductive glands is to be found in a hypoplasia of the thyroid gland with pro- 
liferation of its interstitial tissue. 

The semigenesis of the mongoloid habitus itself is still rather obscure. 
It may be readily imagined that an unknown constitutional injury affecting 




FIG. 69. Eighteen-month-old girl with 
indistinct but recognizably mongoloid fea- 
tures. Later developed into a typical mon- 
goloid idiot. 



PATHOLOGY OF GLANDS OF INTERNAL SECRETION 241 

the cerebral cortex may also affect the bone-marrow and the several glands 
of internal secretion, either directly or indirectly, without producing any 
characteristic or constant structural change. 

The first somatic indication of mongoloid degeneracy, in the physiog- 
nomonic appearance, may probably be noticeable at, or soon after birth. The 
psychic manifestations attract attention during the first year. The laity 
and physicians who have not learned to recognize Mongolism often miss any 
clear picture of the disease. This is surprising enough to the man of experi- 
ence. But very rarely does a general disappearance of all symptoms and a 
more or less complete recovery from the disease occur in the course of the 
child 's development. The morbidity and the mortality of the Mongoloid 
type is surely very great. 

Therapy. Hypothyreosis, coincident with Mongolism, can be overcome 
with thyroid treatment. But, in spite of the fact of its popularity among 
mothers, this treatment has no distinct affect upon the Mongolism itself. 
It may be readily understood that any stimulation of the metabolic func- 
tions by the active principles of the thyroid gland may have a favorable, 
but non-specific influence upon the somatic and psychic processes, particu- 
larly in the apathetic stage. This effect, however, never suffices to make 
the patient anything but refractory to pedagogic training. He remains 
therefore, socially impossible. Furthermore, the thyroid treatment has its 
elements of danger (heart failure, nephritis, stomatitis, etc). 



m. 

DISEASES OF THE DIGESTIVE SYSTEM 

BY 

H. FINKELSTEIN and L. F. MEYER, 

Berlin. 

REVISED AND EDITED BY 

Dr. JOSEPH BRENNEMANN, 

Attending Pediatrician, Children's Memorial Hospital, Chicago, 111. 

DISEASES OF THE MOUTH 

STOMATITIS 

INJURIES of many kinds, thermal, chemical and bacterial, may cause a 
primary inflammation of the mucous membrane of the mouth. They may 
also become secondarily involved when, in the course of general diseases, 
a weakening of the local and general resistance causes a predisposition to the 
growth of pathogenic organisms, as, for instance, in all kinds of fever, 
gastro-intestinal disturbances, etc. Finally, changes of the mucous mem- 
brane may be symptoms of many general infections (measles, scarlet 
fever, etc.). 

Catarrhal stomatitis is the most common and important of the primary 
forms. A diffuse, dark, reddening appears upon the swollen, readily bleed- 
ing, mucous membrane of the gums, cheeks and fissured lips, while the 
tongue, usually covered with a heavy white coat, appears roughened 
because of the swelling of its papillae. In children with teeth, we may have 
salivation which irritates the skin surrounding the mouth; fetor exists, and, 
in severe grades, restlessness. The feeding is interfered with because of 
pain. Slight rises of temperature and, occasionally, slight regional adenitis 
occur. In new-born and very young children catarrhal stomatitis presents 
several peculiarities. It is usually accompanied by thrush and Bednar's 
aphthae, traumatic palatal ulcers, pterygoid ulcers, (Fig. 70), i. e., gray 
exudations on the mucous membrane of the palate which may change into 
superficial eroded sores which are typical in their location upon both sides 
on the pterygoid procese and on the median raphe. On the process, they 
are usually round and on the raphe elongated. Of the various attempts at 
explanation of these ulcerations, but one is correct; they are nothing more 
than mechanical erosions caused by attempts at cleansing the mouth. 
Bednar's aphthae always point to ignorance in the treatment of mouth 
conditions. At the time of the first dentition a special predisposition to 
catarrhal conditions of the mouth exists. The so-called "epithelial pearls," 
yellowish white masses, the size of a pinhead, are frequently seen on the 
median line of the hard palate. They are supposed to be inclusions of nests 
of epithelium formed by the closure of the structure. 
242 



243 



The prognosis of the disease is good. With proper treatment and care of 
the all-important general disease, healing may be expected in a few days. On 
the other hand, there is the possibility of complications, especially of a 
septic nature. 

The most important and successful prophylactic measure in infants is 
the omission of the customary mouth cleansing. Epstein has shown that 
washing the mouth causes traumatic aphthae and that the omission of this 
routine scrubbing avoids catarrhal conditions. So long as a child is not 
given anything to chew and nothing becomes lodged between the teeth to 
decompose, the mouth should be left severely alone. This is also the best 
therapeutic measure in successful treatment. With older children, the 
condition of the teeth must be looked 
after. Under certain circumstances, 
measures used for the aphthous forms 
of stomatitis apply to this type. 

Septic Stomatitis. Veryfrequently 
in infants, less frequently in older 
children, we find septic catarrhal con- 
ditions of the mouth. These are 
characterized by severe purulent in- 
flammation and often by circum- 
scribed or flattened fibrinous plaques 
with a tendency to ulcer formation. 
Accompanying these severe general 
symptoms, high fever and, not uncom- 
monly, the picture of general septic 
poisoning appears. Locally, spreading 
necroses and gangrenous disintegra- 
tion are occasionally seen. In other 
cases, the dental germs may become 
inflamed and form abscesses. Com- 
plications, in the way of lymphaden- 
itis, inflammation of the salivary 
glands, phlegmon, erysipelas and 
septic metastases, are not uncommon. 

An especially appalling condition is seen in the pseudodiphtheria of the 
new-born (Epstein). In feeble children during the first few weeks of life, 
and usually arising from aphthae, tough, flat, necrosing deposits, following 
confluent fibrinous exudates, appear which frequently attack the underlying 
soft parts and bones. They spread rapidly to the pharynx, nose, larynx and 
esophagus. At autopsy, this disease may be mistaken for lesions caused by 
the ingestion of caustics. 

The cause of septic stomatitis is to be found in virulent pyogenic organ- 
isms, most commonly streptococci. Diphtheria may, at times, be the cause. 
The lowering of resistance due to an existing or intercurrent disturbance of 
nutrition may be the fundamental cause and gives an especially bad prog- 
nosis. The necrosed and gangrenous forms are doubtless found only in 




FIG. 70. Catarrhal stomatitis, thrush and 
Bednar's aphthae in an infant. (Berlin Chil- 
dren's Asylum.) 



244 TEXT-BOOK OF PEDIATRICS 

generally run down children. A suitable feeding therapy often gives the 
first and most surprising results, when all other measures have had only a 
palliative effect. 

Aphthous stomatitis (canker sore mouth), is characterized by the appear- 
ance of white or yellowish, round, lenticular plaques slightly raised upon an 
hyperemic base, found especially on the anterior portion of the mouth and 
tongue, while the posterior portions, the soft palate and the tonsils are much 
less frequently attacked. These "aphthse" may become confluent here and 
there and form large patches or areas. They are the result of the effusion 
of a fibrinous exudate into the upper layers of the epithelium. 

The eruption occurs with local symptoms, pain, consequent difficulty 
of feeding, salivation, fetor, and fever. The duration of the disease is usu- 
ally from one to two weeks. In most cases recovery then takes place. With 
feeble children, however, a disturbance of nutrition or a pneumonia may be 
added to this, or a severe local disease of long duration may be ushered in 
by the aphthse. With high and continuous fever, disseminated membran- 
ous exudations, ulcerations, extreme swelling and fissuring of the lips and 
irritation of the surrounding skin may occur. Septic complications are not 
uncommon. These are probably the result of a septic stomatitis implanted 
upon the soil of the aphthse. In the diagnosis, one must consider true 
diphtheria; and, aside from the bacterial examination, the appearance of 
typical lentil shaped plaques is diagnostic. 

Herpetic stomatitis, which is not uncommon in children, gives a similar 
exudation when the small vesicles have broken. The mode of onset, the 
group formation of the efflorescence and the absence of infective organisms 
make the differentiation possible. The cause is unknown. Some observers 
connect the disorder with the foot and mouth disease of cattle. It is un- 
doubtedly transmissible and the companions of the child should be pro- 
tected against infection by special measures (isolation, separate utensils, 
etc.). In the treatment, energetic local measures should be avoided. Rins- 
ing or irrigating with warm infusions or with antiseptic solutions, as potas- 
sium permanganate, hydrogen peroxide, or boric acid solution may be 
employed. With tractable children, the disease spots may be touched with 
a 2 per cent, solution of silver nitrate or phenol. For the pain, penciling 
before eating with anesthetizing solutions (novocaine, 1 per cent, or 3 per 
cent, eucain lactate) or dusting with sterilized bolus alba, to which one of the 
above anesthetics has been added, is useful. The anesthesin candies may 
also give relief at times. The nourishment must be liquid; highly seasoned 
soups are to be avoided because of the pain they cause. 

Ulcerative Stomatitis. Ulcerative inflammation of the buccal mucous 
membrane is found only when teeth are present and most commonly in 
children after the sixth year. It begins as a purulent gingivitis at a molar 
tooth, recognizable by a yellow line, and soon identifies itself by a discolored 
necrotic sloughing. By the destruction of the gums, the roots of the teeth 
are bared and the teeth themselves loosened. In milder forms the inflam- 
mation does not spread ; in the more severe, it may cover the whole alveolus 
and be carried to neighboring parts of the mouth and tongue, and at times 



DISEASES OF THE DIGESTIVE SYSTEM 



245 



even to the palate (see ulcerative angina). The intense fetor is character- 
istic. External adjoining tissues, as well as the regional lymph nodes, be- 
come swollen. Fever and other general symptoms usually occur with these 
lesions and with the pain and the far-reaching influence upon feeding, a 
severe disease-picture is produced. 

In spite of this, the prognosis is usually not bad. Normally, the process 
ends in one to two weeks and scar formation begins. But in weak children, 
deep necroses, similar to noma, and local and general septic comph' cations 
may set in and cause death. 

The occurrence of ulcerative stomatitis only when teeth are present and 
especially when these are uncared for or carious, gives direct indication of 
the cause. In fact, we find in smears from the ulcers, fusiform bacilli and 




Fia. 71. Fusiform bacilli and spirilla in ulcerative stomatitis. (Berlin Orphan Asylum.) 

spirochsetes (Fig. 71) associated, as they are in carious teeth, and 
their etiologic significance can hardly be doubted. Of course, they may not 
be looked upon as primary disease producers, and that their pathogenicity 
demands a previous lowering of the general health is shown by the fact 
that ulcerative stomatitis occurs most frequently in cachectic children or 
those weakened by other infections. The microscopic identification of the 
bacteria is important for diagnosis. For differentiation, mercurial stomati- 
tis and scorbutic stomatitis must be considered. 

The treatment is that of all stomatites. The feeding, especially, is of 
extreme importance. For local treatment, cauterization, once or twice 
daily, with a 5 per cent, solution of chloride of zinc, or penciling with tinc- 
ture of iodine or with 95 per cent, phenol by glass rod, is recommended. 
Dusting with antiseptic powders, xeroform, iodoform, bismuth-iodo- 
gallate, in small quantities to prevent poisoning, is also useful. Ulce rations 
in the recesses of the mouth are favorably influenced by applications of 



246 TEXT- BOOK OF PEDIATRICS 

iodoform gauze saturated in a solution of aluminum acetate. Recently 
intravenous injections of salvarsan and local applications of a 10 per cent, 
solution of the same in water, glycerin or oil, have been used in adults with 
surprising success and this treatment should also receive consideration in 
extreme cases in children. 

Hemorrhagic stomatitis in infancy and early childhood is usually a 
symptom of scurvy. Other infectious hemorrhagic stomatites, also of a 
serious nature, occur but rarely at this age. 

In older children we occasionally see a condition resembling scurvy, 
without its usual history, which may end in death by uncontrollable 
bleeding. 

Noma. Gangrenous stomatitis, also called noma or water cancer, 
occurs, with few exceptions, only in children who are initially feeble and 
have been affected by other diseases (chiefly measles, typhoid, diphtheria, 
disturbances of nutrition, etc.). It usually begins opposite one of the pre- 
molars with a small discolored infiltration on the mucous membrane of the 
cheek, which soon pierces the cheek and is then seen externally as a small 
brownish spot. This Spot rapidly takes on the black color of necrotic tissue ; 
it enlarges and while the central portion disintegrates, the peripheral lines 
spread with startling rapidity, so that a large part of the cheek or even the 
whole side of the face may be affected in a few days. After the sloughing of 
the foul, putrid mass the interior of the mouth is exposed. The process is 
not terminal and continues to necrosis of the bones. At the borders, toward 
the normal tissue, we find edematous swelling with little or no inflammatory 
reaction. The general well-being is soon affected; fever, cachexia, and diar- 
rhoea consume the strength of the patient and usually cause death. Most 
cases last but a short time ; only a few extend over several weeks. Spontane- 
ous healing does occur, but very rarely. Scar formation in the lesions 
naturally takes a long time. 

In the etiology of noma, cachectic conditions are of the same importance 
as in ulcerative stomatitis. The agent which acts with such fatality upon 
susceptible soil is not yet definitely known. In many cases, a massed 
grouping of a cladothrix-like micro-organism, growing, in threads at the 
border between the diseased and normal tissue, has been found and there 
are many indications that this may be of etiologic importance. An occa- 
sional case, perhaps may be caused by diphtheria. 

Treatment. But little is to be expected from internal medication. The 
antiseptics (H2O2), as well as the caustics (40 per cent, chloride of zinc paste), 
are useless ; nor is the actual cautery any better. The best results have been 
reported from energetic surgical interference, the excision of all diseased 
tissue, bony structures as well as soft parts, followed by the cautery. 
Plastic operations are necessary after healing. 

Thrush. Thrush is peculiar to infancy. In older children it occurs 
rarely and only accompanies extreme cachexia, as in adults. In the infant, 
however, it may occur upon very slight disturbance, the severe forms only 
appearing with more marked cachexia. 

The disease appears first in the form of pinhead, or larger, white, and 



DISEASES OF THE DIGESTIVE SYSTEM 247 

slightly raised patches (see Fig. 70), which later become confluent into thick 
flat deposits which may occupy the whole mouth and take on a yellowish 
or reddish discolorization from blood-stain. They are quite adherent and 
consist, as is shown by smears under the microscope, of thread-like mycelia 
and round shining gonidii of a fungus which, according to Plaut, is closely 
related to the monilia Candida, which anchors itself by the growth of its 
mycelia between the epithelial cells. 

It was formerly supposed that thrush demanded severe general disease 
for its development. Today, however, it is known that it is due to a com- 
paratively harmless nosoparasite and that diarrhoeas and other severe or 
fatal general diseases, in connection with which it is found, are not its results, 
but rather create a predisposition which permits its growth as an intercur- 
rent malady. However, even children with such diseases may remain 
almost or entirely free from thrush, so long as the abuse of mouth-washing 
does not produce lesions of the buccal epithelium and a traumatic stoma- 
titis which appears to be absolutely necessary for the growth of the fungus. 
The consensus of experience of all institutional physicians has taught us 
that with the prohibition of mouth-washing, thrush, which formerly could 
not be exterminated, disappears from the wards. 

Thrush itself is not dangerous. With a very rare involvement of the 
larynx, however, a stenosis may occur, or when the pharynx is affected there 
may be difficulty in swallowing. There is reason to believe that the fungus 
may get into the general circulation, causing embolic abscesses or even 
severe general disturbances (Heubner). 

The most certain prophylactic against thrush is the omission of mouth- 
cleansing; and, added to this, the increase of the resistance of the child by 
proper nutrition. The normal mucous membrane of the mouth is not a 
favorable soil for the fungus. Thrush will heal if the mouth is left alone and 
the general health is improved. All penciling or rubbing hinders healing, 
or at least delays it. An aid to healing may be secured from the sucking of 
pacifiers consisting of gauze-covered cotton tampons saturated or powdered 
with fungus killing substances [boric acid powder and benzosulphinide 
(saccharin) or 20 per cent, boroglyceride]. 

ANOMALIES OF THE TEETH AND TEETHING 

The presence of teeth at birth is not uncommon. Frequently the central 
incisors are present, although the bicuspids or canines have also been 
observed. They are probably caused by a misplacement of the dental germ 
and in this event are without roots and being loose in the gum should be 
removed. Or they may be developed from the alveolus as a result of an 
eaily germ centre or an accelerated growth. In the latter variety, inflam- 
mation of the peridental membrane is frequent. This may cause necrosis 
of the alveolus if the tooth is not extracted. 

Early appearance of the teeth is noted occasionally as a family peculi- 
arity. It may occur in connection with general and sexual precocity. The 
chief cause of retarded and irregular dentition is rickets. Of course, other 



248 TEXT-BOOK OF PEDIATRICS 

facts (severe disturbance of nutrition, myxedema, mongolism, etc.) may 
enter into its causation. 

In most cases, dentition occurs without symptoms. The old doctrine of 
difficult dentition, which taught that fever, convulsions, mental symptoms, 
cough, dysenteries, eczemas and the like may be caused by the appearance 
of the teeth, is today accepted, if at all, in but a very limited and circum- 
scribed sense. Restlessness, disturbance of sleep, local pruritus, slight stoma- 
titis may possibly be caused by dentition. It is possible that variations of 
temperature and crops of "tooth rash" may be directly connected with it, 
especially in neurotic children. This also applies to the occurrence of 
convulsions, which must be considered as manifestations of spasmophilia. 
All other "teething symptoms" are more than questionable. According 
to Heubner, the phenomena of growth in the jaw during dentition are 
of sufficient importance to cause a higher demand upon the total energy 
of the body and may thus make the child more prone to exhibitions 
of spasmophilia. 

Disturbances of the dental follicles also occur with the development of 
the permanent teeth and appear in early years in the form of erosions, 
cracks, notching, softening and tendency to early caries. Rickets plays a 
major part in their causation as, also, does congenital syphilis which pro- 
duces the so-called Hutchinson's teeth. A circular green deposit at the 
base of the temporary teeth or, more commonly, circular caries is especially 
frequent, but not pathognomonic, in scrofulo-tuberculous children (H. 
Neuman). It justifies, to a certain extent, a suspicion of this condition. 
The temporary dentition should receive the same care as the permanent set. 
Brushing with a soft brush with a non-gritty dentifrice is an easily acquired 
habit. The early loss of teeth from the jaw delays its proper growth and 
also affects the permanent teeth. Anomalies of position favor the occur- 
rence of caries and its complications and early orthodontia is advisable. 

DISEASES OF THE SALIVARY GLANDS 

Of the acute diseases of the salivary glands (chiefly the parotid) other 
than mumps, it is necessary to discuss only those that are secondary to 
purulent inflammations of the mouth. The most frequent of chronic con- 
ditions is ranula, the congenital or acquired retention cysfof the sublingual 
gland. As rarities, many others may be mentioned, especially in the pa- 
rotid; new growths, swellings of intermittent character, ptyalolithiasis, 
tuberculosis and a chronic inflammation belonging to the symptom-com- 
plex of Mikulicz. 

DISEASES OF THE TONSILS, THE PHARYNX AND 
THE ESOPHAGUS 

ANGINA 

Angina is the name generally applied to inflammatory diseases of the 
pharynx and nasopharynx which occur in the child, as well as in the 
adult, with extreme swelling of the adenoid tissue involving the "lymphatic 
ring" (Waldeyer), which surrounds the fauces and the nasopharynx, 



DISEASES OF THE DIGESTIVE SYSTEM 249 

resulting in the hypertrophy of the tonsils and adenoids to tumor-like 
masses. This region is usually involved in its entirety; so that the custom- 
ary differentiation of palatal angina (tonsillitis) from retronasal angina 
is not always justified, even though the different parts are affected in vary- 
ing degree. In the first year of life, the affection of the faucial tonsil is much 
less frequently encountered than in later years, while the retronasal form is 
more common. 

CATARRHAL ANGINA AND EXUDATIVE ANGINA 

The cause of angina?, if we except those which are symptoms of general 
infectious diseases (scarlet fever, influenza, cerebrospinal meningitis, etc.), 
are the usual pyogenic organisms (such as streptococci, pneumococci, 
micrococcus-catarrhalis, etc). In many cases it is an auto-infection in 
which an accidental cause (exposure to cold, vocal strain, or other diseases), 
lowers the resistance of the body and gives the pathogenic organisms 
inhabiting the mouth opportunity to grow. On the other hand, the disease 
may be earned from person to person, so that true epidemics occur. Occa- 
sionally, the possibility of scarlatina sine eruptione must be considered. 
Aside from this, an individual predisposition seems to exist because of 
which some children are especially prone to angina?. More important even 
than predisposition in the local sense (hypertrophy, the tonsillar crypts 
acting as reservoirs of infective material), is the general predisposition, 
dependent upon lessened immunity, which is probably connected with 
lymphatic conditions. 

The general symptoms are those of an infection; acute onset, with chills, 
fever, headache, malaise, convulsions in the spasmophilic and, frequently, 
initial vomiting and diarrhoea. Older children, usually but not invariably, 
complain of pain in swallowing. The submaxillary and cervical glands swell 
and become painful. A foul breath is noticeable and, with severe grades 
of swelling, muffled speech and probably stridor. Upon inspection, the cause 
of these symptoms is found to be one of the various forms of angina. 

Catarrhal angina is an inflammation characterized by hyperemia, mu- 
cous secretion and enlargement of the lymph nodes. The epithelium has a 
lack-lustre appearance; small hemorrhages occur, but no membrane 
appears. This form includes the larger number of mild attacks, but may be 
accompanied by severe symptoms. Its duration is usually only from two to 
three days, but it may last longer. 

Follicular angina is to be differentiated from the catarrhal form by a 
marked swelling of the lymph follicles of the tonsils which show gray and, 
later, yellowish, round, flat or raised lesions. These are equally distributed 
over the tonsil and may drop out or cause superficial ulcerations. 

Lacunar angina differs from the above form in the appearance of a gray 
or grayish-yellow mucopurulent exudate which, at first, may cover the 
whole tonsil, but later is rubbed off from the exposed parts so that the 
exudate is found in the crypts only, and therefore gives a lacunar appear- 
ance. The general and local symptoms are usually more severe than in the 



250 TEXT-BOOK OF PEDIATRICS 

former types. When there is a recurrence, or the spread of infection from 
one side to the other, the disease may be of long duration. 

Circumscribed, multiple, fibrinous exudations upon the tonsils, the 
palate, etc., are not uncommon in grippal angina. Widespread infiltration 
may occur in septic forms. 

The inflammation of the pharyngeal tonsil (retronasal angina, adenoid- 
itis, pharyngeal angina, pharyngitis superior) is of great importance. The 
severe interference with nasal breathing, the rather nasal than palatal 
voice sounds, the involvement of the ear (sharp lancinating pains, slight 
deafness), the purulent discharge from the nose, are diagnostic of this con- 
dition. Upon inspection, the nasopharynx may be seen to be covered with 
mucous and pus. Digital or rhinoscopic examination shows the tonsil 
inflamed and greatly enlarged. The cervical glands are swollen. The 
course and duration resemble that of lacunar angina, but in this condition 
long continued fever is common. 

Variations of the usual course are frequent. In some cases, excessive 
gastro-intestinal symptoms may simulate typhoid, and in patients of 
excessive nervous irritability meningismus may arise. In retronasal an- 
gina especially, we have fever of long duration and at times with very 
slight local manifestations. Fevers of one, two or more weeks duration, of a 
remittent or intermittent type, which lead one to suspect the presence of 
pus, but usually end benignly, are also of importance. Further, we may 
have chronic recurring angina3, the attacks of which follow one another so 
closely as to cause serious disturbance. 

The number of complications is very large indeed; tonsillar abscess, 
otitis media, exanthemata, diseases of the respiratory organs, lymphadenitis 
with pus formation, in particular, and others. 

Glandular fever (Filatow and E. Pfeiffer) is the term applied to a disease 
which is recognized by a reddening of the pharynx, acute swelling of the 
cervical glands and frequently by involvement of other lymph node groups, 
even the mediastinal and mesenteric, and which, in spite of severe symp- 
toms, usually goes on to recovery, without abscess formation, after a dura- 
tion of weeks. In this disorder, we probably have to deal, not with an 
entirely separate disease but with a retronasal angina with very slight local 
symptoms. Glandular fever frequently occurs in epidemics and probably 
stands in close relation to la grippe. 

When we consider that angina represents a local septic infection, it may 
be readily understood that its sequelae present many conditions which appear 
as symptoms of rheumatic or general septic infection. To this class belong 
erythema nodosum and exudativum, purpura, nephritis of hemorrhagic 
type, serous and purulent inflammation of the joints, the heart and body 
cavities, osteomyelitis, etc. 

The diagnosis of angina is made by inspection. This should be done, 
even when no subjective symptoms call attention to the throat. The con- 
sideration of an inflammation of the regional lymph nodes is important. 
The differentiation from scarlet fever may cause great difficulty in cases 
with erythematous eruption. In these instances, the indefinite demarcation 



DISEASES OF THE DIGESTIVE SYSTEM 251 

of the reddening of the throat and the absence of the rasberry tongue is of 
importance. In diphtheria the exudate is in patches and is not lacunar, 
although we may have a real lacunar angina with diphtheritic cause, 
which may be distinguished by bacteriologic examination or by the sequelar 
paralysis alone. 

Treatment. Because of the undeniable infectiousness of many anginse, 
isolation is advisable. Treatment consists of rest in bed, careful feeding, 
cold applications to the neck, even of ice packs ; gargling with salt water and 
glycerin, lemon water, weak solutions of aluminum acetate, lime water, etc. 
Internal remedies, e. g., potassium chlorate 2 per cent., 1-2000 cyanate of 
mercury, are better avoided. 

Sweat-producing measures are often useful. For the swollen lymph 
nodes, hot applications, causing local hyperemia, give good results both in 
reducing the swelling and aiding abscess formation. To prevent recur- 
rence, a change of constitutional conditions should be brought about by 
diatetic and hygienic prophylaxis. 

Membrano-ulcerative Angina (Vincent's angina, Plaut's diphtheroid 
angina, angina a' bacille fusiform.) In membranous angina, we find tough, 
spreading membranes which are due to an extension of the necrotic exudate. 
into the mucosa. After the sloughing of these necrotic membranes, distinctly 
circumbscribed ulcers of varying depths are seen. The entire pharynx is 
swollen and there is a tendency to hemorrhage from the mucous membrane. 
A strong fetor, resembling that of ulcerative stomatitis, is characteristic. 

Distinction is to be made between the milder diphtheroid form, with 
more superficial membrane formation and smaller ulcers, and the membrano- 
ulcerative form with deeper and more widespread lesions. 

In many cases, the fever and general symptoms, as well as the objective 
signs, are extremely mild, so that only the routine examination of the throat 
brings out the cause of the illness. The contrast between the mild gen- 
eral symptoms and the severe local changes is, in fact, quite characteristic 
of the disease, although cases are seen with high fever and typical angi- 
nal symptoms. 

The course of the diphtheroid form resembles the ordinary anginse. 
Transitional forms exist. In these, the long duration, the slowness of the 
sloughing process and the tendency to recurrence are quite characteristic. 
The disease usually ends in recovery; only exceptionally, and probably in 
cachectic children, have extended necroses, with a fatal result, been reported. 
Complications are hardly to be feared. 

The same fusiform bacillus and spirochseta that cause ulcerative stoma- 
titis, may be assigned as probably etiologic factors. A certain infectivity 
undoubtedly exists in grouped cases observed in families, houses or barracks; 
but the transmissibility is evidently not very great. 

Together with the throat findings and the characteristic fetor, the 
demonstration of the fusiform bacillus and spirochseta in a smear stained 
with fuchsin, is diagnostic (Fig. 71). In the differential diagnosis, diph- 
theria and syphilis must be considered. This form of angina often resembles 
the latter disease so much that French authors have applied the term 



252 TEXT-BOOK OF PEDIATRICS 

" chancrif orm " to its lesions. The absence of other signs of syphilis, the 
negative results of cultures for diphtheria bacilli and, finally, its course 
are diagnostic. 

The treatment is that usual for anginse. The cleansing of the ulcers may 
be attempted by touching with hydrogen peroxide and by the application of 
antiseptic powders. Of late, good results have been obtained, as in ulcer- 
ative stomatitis, with salvarsan. 

Rare forms of gangrenous angina, of unknown origin and of doubtful 
prognosis, with extremely foul-smelling, progressive disintegration of the 
entire throat and a tendency to hemorrhage are seen. The very fatal serous 
or seropurulent pharyngeal phlegmon and pharyngeal erysipelas may 
also oc'jur in the child. 

HYPERPLASIA OF THE TONSIL 

Tonsillar hyperplasia, leading to a globular or longitudinal tumor, 
frequently extending far downward into the pharynx or developing into a 
ragged polyp-like growth, is closely related in its etiology and course to 
adenoid growths (q. v.). Treatment should not be too energetic. It is 
generally well to await a gradual physiologic recession. Tousillectomy is to 
be advised only in case of large protruding tumors. The hope of curing a 
frequently recurring angina by snipping off the tonsil is very slight. A 
harmless diphtheroid membrane is always formed upon the wound after the 
operation. It must not be forgotten, however, that true diphtheria may 
occur there. 

Tumors of the pharynx are usually congenital or are formed upon a 
congenital base; and among them we must consider dermoids, lipomata, 
fibromata and fibrosarcomata (so-called nasopharyngeal polypi). The 
most serious is the lymphosarcoma of the tonsil, which must be considered 
in cases of rapidly growing unilateral swelling of the tonsil. 

RETROPHARYNGEAL LYMPHADENITIS AND RETRO- 
PHARYNGEAL ABSCESS 

The lymph channels of the nasopharynx pass, in part, on their way to 
the cervical nodes, through lateral pharyngeal groups which lie at the level 
of the atlas behind the tonsils. These in turn communicate with the deep 
cervical nodes. They may also be connected with small, inconstant nodes 
which become obliterated during childhood and which lie in the median line, 
at the level of the odontoid axis, imbedded in the fascia. In the event of 
inflammatory conditions in the territory drained by these glands, they may 
enlarge, become inflamed and finally suppurate. This is the ca.use of the 
occurrence of retropharyngeal lymphadenitis or retropharyngeal abscess. 

The primary process is usually a coryza or a retronasal angina. The 
condition may also be connected with lues, measles, or scarlet fever. Fur- 
ther, wound infection from rhagades and ulcers must be considered. 
Idiopathic lymphadenitis, of which older physicians speak, does not exist. 
Streptococci, and less frequently influenza bacilli or other micro-organisms 
are etiologic factors. 



DISEASES OF THE DIGESTIVE SYSTEM 253 

The disease occurs especially in the first two years of life. Later on it is " 
less common, probably because of the obliteration of the nodes involved. 
A simple swelling of the lymph nodes is quite frequent ; the severer forms, 
on the contrary, are comparatively rare. 

The first stage of the disease causes no symptoms aside from fever 
and only by digital examination can the movable swelling, which may be of 
the size of a bean or hazel-nut, be discovered. More severe symptoms 
appear when the swelling becomes larger and the infiltration of the sur- 
rounding connective tissue more extensive. Among these may be mentioned 
dysphagia, rattling and gurgling in the throat due to the collection of mucus 
above the obstruction, a muffled voice, and pharyngeal stridor. The rigid 
pose of the head, at tunes resembling torticollis, taken to guard the painful 
swelling from pressure, is notable. The superficial glands are frequently 
involved. The condition may cause attacks of suffocation or, extending far 
down, may produce edema of the larynx. The swelling of the throat may then 
be noted upon inspection; but better information is given by palpation, 
which shows whether there is still a hard infiltration or a fluctuating abscess. 

Course. Many simple swellings and tissue infiltrations recover spon- 
taneously; only a few go on to abscess formation. In the latter cases, 
recovery may set in after evacuation. Frequently, the neighboring nodes 
are affected and, becoming suppurative and confluent with the retropharyn- 
geal group, form a large abscess. Extension into the mediastina and later, 
pyemia may occur. Spontaneous rupture may cause death by inspiration 
of the pus. 

With early recognition and treatment the prognosis is favorable. 

The diagnosis, frequently missed by beginners, is made upon the signs 
of stenosis and the discovery of swelling by palpation. Differentiation from 
laryngeal diphtheria, without recourse to digital examination, should be 
possible by the pharyngeal tone of the stridor, the rattle of the mucous and 
the rigid position of the head. 

The treatment of the non-suppurative stage is that of angina in general. 
Abscess demands immediate incision, either with an ordinary scalpel 
wrapped with adhesive plaster to the point, or with a special knife (Schmitz 
or Carstens). Perhaps it is still more satisfactory to use a slender, curved, 
sharp, rat-toothed forcep. The incision is made with the guidance of the 
finger, the child being held in an upright position. As soon as pus appears, 
the body should be bent forward to prevent aspiration and the opening 
should be gradual!} 71 increased. This does not insure absolutely against an 
attack of asphyxia. The wound usually heals rapidly and only exception- 
ally will it be found necessary to reopen it. In case of large confluent ab- 
scesses pointing outward, the opening should be made from without. 

Occasionally a chronic tuberculous, retropharyngeal glandular swelling, 
glandular abscess or mediastinal abscess, due to gravitation, may occur. 
Their treatment is that of tuberculosis in general. Incisions are to be 
avoided. In cases with symptoms of obstruction, aspiration with a syringe 
is recommended. Retropharyngeal abscess due to acute osteomyelitis of the 
bodies of the vertebrae is very rare. 



254 TEXT-BOOK OF PEDIATRICS 

CONGENITAL ANOMALIES OF THE ESOPHAGUS 

The congenital anomalies of the esophagus are chiefly stenoses or atre- 
sias. Congenital atresia, which may occur in many different forms, as 
entire absence of the organ, absence of the upper or lower portion, a cul-de- 
sac, a circular closed channel, communication with the trachea or bronchii, 
is recognized immediately at birth by the fact that even the smallest 
quantity of nourishment is vomited at once in an unchanged condition. 
This vomiting may occur with attacks of suffocation which lead to the 
conclusion of a connection between the esophagus and the respiratory pas- 
sages. The esophageal bougie brings up against an impassible barrier at 
very short distance. The unsuccessful attempt to aid such infants by 
gastrostomy has always proved fatal. The rare congenital stenoses, to be 
differentiated from acquired forms by the fact that the narrowed portions 
show a normal structure of the connective tissue, may exist for months and 
years, and even be latent until old agp. Only the severe forms cause symp- 
toms of difficulty in swallowing, gurgling of mucous, rumination, and 
temporary occlusion. The bougie shows the presence of an obstruction. 
Congenital diverticula have occasionally been reported. 

ACQUIRED DISEASES OF THE ESOPHAGUS 

Corrosive Esophagitis. Numerous cases of burning of the esophagus 
with strong acids or caustic alkalies (lye and soap powders) which children 
have swallowed or which have been accidentally administered by adults, 
still occur. The action of the caustic, in milder forms, is shown by a croup- 
ous necrosis of the epithelium which may heal without scar formation. 
With more severe lesions, the entire thickness of the mucous membrane is 
eroded, deep sloughing occurs, followed by circumscribed ulcers which may 
perforate. Healing, with stricture-forming cicatrices, results. 

The symptoms of corrosive esophagitis are local pain, vomiting of bloody 
masses and pieces of the mucous membrane even to the extent of the entire 
esophagus. Added to these, is a tendency to collapse. Many cases end 
fatally, while in others convalescence sets in. But in convalescence a new 
danger threatens at the end of several days, in the erosion of, and hemor- 
rhage from neighboring blood-vessels, perforation with mediastinitis, and 
pyopneumothorax. If these later symptoms do not occur, those of stenosis 
may appear subsequently. Of those poisoned with sulphuric acid, over 
one-half die; of those with caustic alkali, one-fourth. The survivors have 
strictures, more than one-half of which are severe. 

The stricture is usually located in the upper third, less frequently in the 
middle or lower third of the esophagus. Above the obstruction, the esoph- 
agus is widened and hypertrophic, the mucous membrane being fre- 
quently inflamed and covered with ulcerations. The nature and severity 
of the condition depends upon the grade of the burning. The symptoms 
of the stricture appear two or three weeks after the poisoning and are 
those of obstruction to the passage of the swallowed food. 

The diagnosis is made from the history and the condition of the cicatrix is 



DISEASES OF THE DIGESTIVE SYSTEM 255 

established by examination with the sound or the esophagoscope. The 
prognosis is better than in adults. With proper treatment, recoveries are 
reported in from fifty-six to sixty per cent, of the cases. 

The treatment of the poisoning consist in efforts to neutralize the caustic. 
Organic acids, chalk, calcined magnesia are employed; carbonates, because 
of the formation of CO2 gas, should not be used. The pain may be controlled 
by morphin hypodermically or by the application of local anesthetics 
(10 per cent, anesthesin in oil, novocaine, or alypin, 2 per cent, solution 
5-10 drops). Liquid nourishment should be given. The treatment of the 
sequelae may usually begin by the third week and consists in gradual 
dilatation with the bougie and of injections of thiosinamin. 

Corrosive esophagitis with its sequelae is the most common lesion of the 
organ in childhood. All other conditions are great rarities. Cases of nervous 
cardiospasm, with symptoms of regurgitation and rumination, as well as 
stenosis following syphilitic ulcers, are known. 

NUTRITIONAL DISTURBANCES OF INFANTS 

Introduction. The understanding of the disease conditions discussed in 
the following paragraphs has undergone enormous change within the last 
three decades. Formerly physicians recognized in them nothing more than 
diseases of the stomach and intestine which could be considered analogous 
to the fermentative dyspepsia, fermentative catarrh, gastro-enteritis and 
diarrhoea with vomiting, in the adult; the physiologically slight resistance 
of the infant predisposing it to a severe course. Example of this is seen in 
the teaching of the Vienna school, which was able to obtain general recog- 
nition through the classical presentations of Widerhofer. From the study of 
anatomical findings, this school distinguished severally, the purely func- 
tional, the catarrhal, and the inflammatory ulcerative lesions of the intes- 
tine ; each of which could be recognized clinically by the varying consistence 
" of the stools and the degree of constitutional disturbance. This conception 
further enabled these authorities to recognize (1) acute and chronic dys- 
pepsia, as subdivisions of the purely functional disturbances; (2) histologi- 
cally and clinically severe entero-catarrh ; (3) follicular enteritis chiefly of 
the large intestine, belonging to the inflammatory type and (4), the extreme 
form of entero-catarrh, formerly known as cholera infantum, as final sub- 
division of this group. 

Useful as this system was in its time and excellent as the observations 
were upon which it was based, further advance of knowledge has made its 
abandonment necessary. With great difficulty could cases in actual prac- 
tice be classified under these sharply differentiated forms of disease, in 
view of the frequent occurrence of intermediate and transitional forms. In 
infancy, inflammatory conditions occurred which resembled the intestinal 
affections of the adult; but these, again, were greatly exceeded, alike in 
frequency and importance, by disturbances which had to be considered 
purely functional. Identical and entirely normal findings in the bowel were 
shown in cases presenting the most variable clinical symptoms in which, 
according to previously accepted teachings, severe anatomical lesions were 



256 TEXT-BOOK OF PEDIATRICS 

to be expected. It has become clear that in infancy, as in later life, func- 
tional alterations of the gastro-intestinal system underlie pathological 
conditions, but these, in the infant organism, give rise to so many and such 
important changes in the general health that we may no longer speak of them 
as merely organic, but rather as general diseases; and, further, as general 
diseases so exceedingly grave that frequently the entire symptom-complex 
is characteristic of, and the prognosis dependent upon the constitutional 
status rather than upon the intestinal lesion. Again, it has been found 
that the bacteriolcgic etiology of these diseases does not play the essential 
role formerly attached to it. Both acute and chronic disorders, either of the 
mildest or the most severe form, may be of purely alimentary origin, and 
numerous diagnostic symptoms, formerly supposed to be caused by bacterial 
toxins, may be the results of a direct food poisoning. In a word, disturb- 
ances created by intestinal lesions are commonly seen to induce so complete 
and so severe derangement of the entire metabolic process that the term 
gastro-intestinal disease has become too narrow. In its place has appeared 
the phrase "disturbance of nutrition." 1 

In view of this conception the necessity of distinguishing the nutri- 
tional disturbances of the breast-fed infant from those of the artificially-fed 
at once becomes obvious. The very feeding of a food other than that in- 
tended for the infant by nature is a pathologic condition. Such feeding 
lowers the resistance and may very readily be the cause of disease. Only 
rarely does the bottle-fed infant thrive anywhere near as well as the breast- 
fed. The tendency to rickets, spasmophilia and anemia is very great. The 
immunity against infection is reduced and the tendency to the conditions, 
to be discussed i. e., the disturbances of nutrition, is exceptionally great. 

DISTURBANCES OF NUTRITION OF THE ARTIFICIALLY- 
FED INFANT . 

GENERAL ETIOLOGY AND PATHOGENESIS 

1. Milk. The increased tendency to disease, and the actual causation of 
disease in infants fed upon milk other than that intended for them in the 
natural process of nutrition, i, e., mother's milk, is not dependent to any 
great extent upon such accidental factors as the bacterial contamination of 
the milk or the improper combination of the food elements, etc. It may be 
accepted as proved, rather, that this tendency to and actual increase in the 
morbidity of bottle babies is due primarily to the milk itself, simply because 
it is not suitable for the human young, falling short in many essential 
requirements. The morbidity is exceedingly great even in those artificially- 
fed infants in whose feeding no criticism can be brought against the technic 
or the food mixture. For an explanation we must accept the theory that the 
specific peculiarities of cow's milk are directly or indirectly the causative 
factor. And this brings us to the outstanding problem of all artificial 
feeding, i. e., what is there in cow's milk which, though it be modified to 
resemble mother's milk in every respect, still leaves it so inadequate a food 
for the human young? 

1 Ernaehrung Stoerung, Czerny. 



DISEASES OF THE DIGESTIVE SYSTEM 257 

The first attempts at explanation were made by Biedert when he put 
forth the proposition of the indigestibility of the casein of cow 's milk. He 
claimed that the absorption of the products of protein digestion was very 
poor in the bowel and this formed the basis for the injury. At present, this 
explanation seems to be successfully controverted by the consistent findings 
of more careful chemical examination of the stools, the digestive processes in 
the intestine, metabolism experiments and clinical observation. Similarly 
the theory of Hamburger that the injury is due to toxicity of the foreign 
protein is not born out clinically. Indeed, no definite proof has been 
brought forward to show that the protein is the prime factor in the 
etiology. There is no doubt, however, that fat and sugar have a harm- 
ful action. But even these substances are not primarily the cause of 
the nutritional disturbance except when fed in improper dosage. This fact 
is demonstrated by the more recent researches, which show that by chang- 
ing certain other constituents of the food, as for instance; increasing the 
percentage of protein, reducing the amount of whey or replacing the carbo- 
hydrate by one less fermentible, immediately relieves the disturbance. 
Others have attempted to show that the injurious factor lay in certain 
chemically undemonstrable substances in the whey. According to Schloss, 
it is hardly probable that the whey has a distinctly injurious action on the 
intestinal function. According to the theories of Marian, Concetti, Escherich, 
Pfaundler and others, the great advantage of breast-milk is due to cer- 
tain specific ferment-like substances which act as a stimulant to growth 
and development. The absence of such substances in cow's milk or rather, 
the fact that these substances in the milk of various species are not inter- 
changeable is the cause of the failure of artificial feeding. If these substances 
are contained in the whey, the deleterious action of whey is easily explained. 
Even without bringing to our aid the theory of such hypothetical ferments, 
it can be conceived readily that the physical and biochemical structure 
of the whey of cow's milk is such as to make it a fluid in which the digestive 
function of the intestinal mucosa is much more difficult than in the medium 
of breast-milk, which also has a certain catalytic action (Finkelstein and 
Meyer). Strong, lusty infants can call up the reserve strength necessary to 
overcome this hampered action of the digestive apparatus, while weak 
infants succumb. 

Some authors do not believe in the theory which blames the injury to the 
specific action of any one foreign substance in the milk, but lay the difficulty 
to the varying relation of organic and inorganic components. 

2. Tolerance. In infants with strong metabolic powers, overfeeding 
will cause merely an excess of fat (Fig. 72) which can hardly be rated as a 
disease. Very commonly the symptom of excessive fat is combined with 
manifestations of rickets, spasmophilia or exudative diathesis. Very few 
infants, however, have a digestive system which will withstand overfeeding 
for any length of time; signs of dystrophy or dyspepsia supervene and, if the 
excess of food be continued, even more serious conditions result. In some 
cases, indeed, the actual excess of food does not have to be so very great, 
for there are infants that become ill when the amount of food does not sur- 
17 



258 



TEXT-BOOK OF PEDIATRICS 



pass or is below the physiologic requirement. Such infants may be said to 
have a low tolerance. This injurious excess may be due to too great volume 
of a properly modified food as is seen in the " overfeeding dyspepsia" of the 
breast-fed infant or it may be due to too much of one ingredient in the 
mixture. The injuries of high sugar or high flour feeding serve as examples 
of the latter. 

3. Composition of the Food. Closely related to the above category of 
causes of nutritional disturbances is that group in which an improper rela- 




FIG. 72. Adiposity in an overfed eight-month-old child, 
weight 9.4 kilos (21 pounds). (Gisela Children's Hospital, 
Munich, Prof. Ibrahim.) 

tive balance of the individual food components forms an essential factor; 
" nutritional disturbance ex correlatione. " The correlation of the ingredients 
of cow 's milk are, in themselves, not adapted to the infant. In addition to this 
the infant is rarely fed with natural cow 's milk but with cow 's milk to which 
innumerable other things, such as water, flour, fat and various carbohy- 
drates, have been added. As a result, the correlation of the elements of the 
food becomes even more abnormal and resultingly more liable to produce 
disturbances. Such an etiology is probable, for example, in those cases in 
which a persisting dyspepsia is relieved by the addition of a small amount of 
casein to the formula without other change. Or in the reverse, infants that 
have not thrived may be made to develop normally by reducing the milk 



DISEASES OF THE DIGESTIVE SYSTEM 259 

and increasing the carbohydrate. Very slight changes in the correlation 
may cause marked changes in the nutritional status of the infant either for 
better or for worse. 

According to our present conception, the transition from the tendency 
to disease, to disease itself, results from a disproportion of the demand upon, 
and the ability of, the metabolic functions leading to irregularities of the 
digestive and resorptive powers which in turn results in pathologic bacterial 
growth and putrefactive or fermentative processes. This adds a new fac- 
tor to the complex for harm in the shape of changed endogenous fermenta- 
tion. According to Moro, Tobler and Bes-sau the ascent of this fermentative 
process into the normally almost sterile small intestine is of greater impor- 
tance than the increase of this process in the large bowel. For here, at the 
very seat of the digestive function, slight changes in the chemical process 
are greatly magnified in their importance to the organism. The form of the 
decomposition depends largely upon the composition and correlation of the 
food. Usually the disturbance affects the digestion of the fat and carbo- 
hydrate. This results in the formation of acids of fermentation which are 
usually looked upon as pathogenetic of these conditions. Recently several 
authors have added to this " fermentation injury," the conception of a 
"putrefaction injury" which is caused by an excessive decomposition of 
protein on the basis of the acid formation (fat and sugar). This condition is 
supposed to cause diarrhoea and other symptoms of bowel irritation in its 
acute form. In its chronic form it is characterized by far reaching general 
manifestations and putrefactive stools. 

4. Inanition. Underfeeding also plays an important role in the causa- 
tion of nutritional disturbances. New-born infants are often greatly under- 
fed because of the fear that a cow 's milk mixture might be harmful, and for 
the same reason children with intestinal disturbances are often underfed 
for a long time. Aside from simple underfeeding, that is the feeding of a 
perfectly satisfactory food in too small amount, we must also consider 
qualitative underfeeding. This condition obtains when the caloric require- 
ment is fully covered, but one or more essential elements of the diet are 
below requirement. Normal development can occur only when the require- 
ment of every food element including the inorganic substances is fulfilled. 
Frequently quantitative and qualitative inanition may be combined as in 
the continued feeding of thin gruels. 

The usual results of moderate inanition are failure to gain in weight or 
slight gradual losses. Persisting inanition leads to subnormal temperature 
and slowing of the pulse. The condition may be quickly relieved in the early 
stages by the addition of liberal amounts of suitable food. In the cases of 
long standing, however, the tolerance is markedly lowered and any sudden 
increase of food may bring on extreme diarrhoea and toxic manifestation 
and death. In new-born and young infants, inanition may cause vomiting 
and frequent loose bowel movements, a hunger dyspepsia. 

5. Infection. In contrast to the etiologic factors of disturbances of 
nutrition of purely alimentary origin and without other provocative influ- 
ences, we have another category of nutritional disturbances which must be 



200 TEXT-BOOK OF PEDIATRICS 

considered as secondary to other forms of injury to the general infantile 
organism and affecting the gastro-intestinal function especially. The 
digestion is so definitely injured that food which was well accepted can no 
longer be borne. This form of reduction of the tolerance as a result of exo- 
genous weakening may be, to a certain extent, contrasted directly with the 
reduction of tolerance by excess feeding. The most characteristic member 
of this group is the disturbance of nutrition resulting from acute or chronic 
infection. The bacterial poisons injure the entire cell structure of the body 
and, of course, this also affects the organs of digestion. As a result their 
functional capacity is reduced, and, unless the food is promptly changed to 
meet the altered tolerance, a complicating alimentary disturbance is added 
to the infectious process. The complication may become grave enough to 
govern the entire clinical picture and obscure the original infection. Recov- 
ery from the nutritional disturbance may take place before the infectious 
process disappears or the two may be relieved coincidently or, finally, the 
digestive trouble may persist and become chronic as an independent disease. 

6. Milk Infection and Milk Toxins. The etiology of a nutritional dis- 
turbance caused by the bacterial content of milk or by milk toxins is identi- 
cal with that of the condition above. Formerly the bacterial content of 
cow's milk or the chemical products of their activity before ingestionwas 
held to be the chief etiologic factor in the digestive disturbances of artifi- 
cially-fed infants. At present, however, but slight stre?s is laid upon this 
phase. The majority of milk bacteria are harmless saprophytes, which may 
be ingested in large quantities without harm. It must be admitted that 
pathogenic organisms are sometimes found in dirty milk. Furthermore, in 
weak infants fermentation processes occur more readily if huge numbers of 
fermentation producing organisms are added to intestinal flora, than when 
the food is sterile. It is also possible that injury may come from substances 
occurring in the milk as a result of improper feeding of the animals, or from 
the products of decomposition of the milk such as acids, peptones, etc. This 
possibility is limited, however, by the fact that if these substances occur in 
any appreciable amount, the taste, odor and even appearance of the milk 
are such that the mother will not use it or the child itself will refuse it. 

Until recently, two important points of argument Avere urged in favor of 
the etiologic relation of the contaminated milk, viz., (1) the increase of 
gastro-intestinal disease and of the death-rate from this cause in the hot 
months of the year (the summer apex of infant mortality) ; and (2) the fact 
that these prevalent conditions affect principally artificially-fed infants while 
breast-fed babies remain almost wholly immune. The parallel between the 
statistical evidence and the increase in the contamination of milk during the 
summer months appeared to be undeniable evidence of the serious patho- 
genicity of spoiled food. At present, however, even this conclusion is denied 
and there is an inclination to accept a belief in the harmful influence of heat 
upon the child, although the exact nature of this influence has not yet been 
determined. In some cases the summer heat may cause overheating 
(hyperthermia) producing disease and death which may be considered 



DISEASES OF THE DIGESTIVE SYSTEM 261 

closely related to the phenomena of heat stroke. Such disease begins sud- 
denly and runs an acute or subacute course, characterized symptomati- 
cally by convulsions and hyperpyretic coma. The conditions may be 
prevented or cured by the prompt application of fever-reducing measures. 
La other cases, the gradual effect of the summer heat is to reduce the limit 
of tolerance, so that alimentary disorders occur very readily and tend to 
run an especially severe course. Moreover, bacterial infection, entering 
through the =kin eroded by excessive perspiration, appears to play an impor- 
tant role during the hot weather and death may frequently occur through 
such an intercurrent invasion of pathogenic bacteria. Not until we have 
eliminated all these causes may we entertain the etiologic relations to sum- 
mer diseases of contaminated milk. 

A plausible explanation of the immunity of breast-fed infants from heat 
injury is also suggested. It appears that an infant with impaired nutri- 
tion is much less resistant of heat influences than the normal babe. Since 
most breast-fed infants are well and veiy many artificially-fed babies have 
some slight disturbance of nutrition, the difference in the effects of heat is 
possibly explained. 

In considering the relationship between high temperature and infant 
mortality, the prevailing custom of burdening young children too heavily 
with clothing may add to the injuries caused by the heat of summer. How 
and to what extent these several factors of diminished tolerance produce 
secondary disturbances of nutrition, is again a question of relation between 
the degree of resistance and the strength of the attacking forces. In feeble 
children or in children weakened in any way, especially in those with im- 
paired nutrition, a slight overheating, a coryza, a small phlegmon, or a 
vaccination, may give rise to serious symptoms. A healthy, normal child, 
on the contrary, may resist even severe infection, without the appearance 
of any gastro-intestinal disorder. 

7. Constitutional Anomalies. There are infants that will thrive on any 
form of artificial food and apparently never have a nutritional disorder 
even though subjected to severe infections. Others require the most exact- 
ing study of the feeding formula, are extremely prone to intestinal and nutri- 
tional disturbances, their nutritional function suffering severe upsets as a 
result of the mildest infection. Every podiatrist sees children that are 
extremely hard to raise because they respond to the slightest irregularities 
of the food or to every mild infection with the most stormy general symp- 
toms. These differences in the nature of the individual can be explained 
only on the basis of a congenital, constitutional tendency that acts in the 
form of a greater or lesser tolerance. We have no definite knowledge of the 
basic etiology of such a constitutional difference and no great advance in the 
understanding is made by looking upon it as a manifestation of '"neuro- 
pathy" or "hypersensibility" or as a part of the "exudative diathesis." 
It seems more satisfactory to consider the one group as "trophostabile" 
and the other as "tropholabile" and leave further discussion for a time 
when more study has given a clear understanding. 



262 TEXT-BOOK OF PEDIATRICS 

GENERAL SYMPTOMATOLOGY 

It has been shown in the introduction to the Chapter on the Disturbances 
of Nutrition that symptoms of these conditions may be much more varied 
than has been hitherto supposed. To appreciate the> complexity of, this 
symptomatology, we must recall the several phases of the process of nutri- 
tion. It Includes not only the digestion and the absorption of food from the 
bowel, its assimilation, the repair of the waste of tissue incident to func- 
tional activity, and the process of growth, but also the maintenance of the 
normal concentration of the tissue-cells, the function of internal secretion 
and the regulation both of heat production and of heat loss. Accordingly 
the symptoms of nutritional disturbance are not confined to pathologic 
alterations in the gastro-intestinal tract, to loss of body-weight, or to an 
arrest of growth. It is to be expected that variations of body-temper- 
ature and perversions of function in many different organs will be met 
with. The relationship of such symptoms to disturbances of nutrition is 
shown in the fact that they are often favorably influenced by changes in the 
form of feeding. There is a type of alimentary fever which disappears 
almost immediately when feeding is discontinued; an albuminuria of 
similar origin, and even cerebral and spinal symptoms, with anomalies of 
cardiac and pulmonary function, which may be relieved at once by changes 
in diet. 

Recognition of the symptoms of disturbances of nutrition presupposes a 
knowledge of the " normal conditions of nutrition and of the normal meta- 
bolic processes." 

As superficial evidences of normal health may be noted : the proper devel- 
opment of the musculature and the fat layers of the body, the turgor of the 
skin and the skeletal tissues, and the normal color of the skin and visible 
mucous membranes. Broadly speaking, health means the normal func- 
tioning of all organs, and particularly of the kidneys, lungs, heart and ner- 
vous system; a general development proportional to age; and a due degree of 
agility and of static and dynamic power. 

As indications of especial bearing upon nutritional integrity, the normal 
activity of the gastro-intestinal tract, the proper adjustment of body- 
temperature, a progressive increase in weight and the maintenance of 
natural immunity may be cited. 

With a fairly equable atmospheric temperature, the curve of body-tem- 
perature of the infant is remarkable for its slight variations (monothermia). 
The weight-curve shows the same continuity. So small variations are seen 
with daily weighings that the curve shows an almost evenly rising line. 
The active formation of antibodies is to be recognized by the infrequency 
of infections and their ordinarily mild course. 

As a final and a most important indication of normal nutrition, we note 
the standard of tolerance for food; meaning thereby the exercise of a wide 
range of tolerance toward the food-stuffs ingested. This tolerance is 
exhibited in two ways; in the quick adaptation of the unimpaired digestive 



DISEASES OF THE DIGESTIVE SYSTEM 263 

functions to increased quantities of food without consequent harm, a 
quantitative normal tolerance; and in the successful response to food in the 
most varied mixtures, whether of mother's milk or cow's milk, whether in 
preparations rich in fat and poor in carbohydrates or vice versa, in so far 
as they are adapted to continuous feeding. This response may be denned 
as the normal reaction to food. 

Equally, the healthy child exhibits a normal reaction to and endurance 
of those external influences which tend to reduce tolerance; e. g., in the large 
measure of resistance it shows to infectious disease or to abnormal tempera- 
ture changes, to which it does not succumb unless the attack from without 
is more than ordinarily severe. 

On the other hand, symptoms of disturbance, in the direction of lowered 
nutrition, are seen in loss of weight, emaciation, increased or diminished 
tonus, abnormal dryness or increased fluidity of the tissues, and pallor or 
injection of the sldn and mucous membranes. Numerous signs of functional 
insufficiency are shown in the form of muscular weakness, decreased or 
increased nervous irritability, the disordered functional activity of various 
important organs, and especially of the nervous system. Important indi- 
cations of pathologic changes in the gastro-intestinal tract are to be found in 
an abnormal curve, characterized by slow rises and frequent drops, in 
abnormal temperature changes, and in the lowering of the power of resis- 
tance to bacterial infections. 

It should be observed that either subnormal temperature or fever may 
be caused by dietetic disturbances. Fever is frequently associated with 
other symptoms characteristic of fevers due to infections such as cardiac 
weakness, albuminuria, leucocytosis, etc. " Alimentary fever" or "dietary 
toxemia" can be distinguished from the results of infection only by their 
etiology and by their quick response to changes in diet. 

Different combinations of the symptoms briefly described above, and 
variations in their course give us clinical pictures, and sometimes symptom- 
complexes of contrasting significance. The form which any individual case 
may take, whether indicated by arrest of development and loss of weight or 
by symptoms resembling acute toxemia, depends largely upon the kind and 
amount of food given. Infants with a primarily high tropholability and 
infants severely injured by alimentary or infectious 'processes react more 
definitely to the influences which cause only mild disturbances in children 
less liable, influences which in strong infants may even be favorable. This 
peculiar irritability in response to food and other stimuli is known as the 
paradoxical reaction. 

The reduction of the tolerance is not only shown by the variation in the 
metabolism but is reflected in an unusual susceptibility to external influ- 
ences. In such patients, infection occurs more readily and tends to serious 
results, or minor ailments now readily lead to secondary disturbances of 
nutrition. Summer heat or excessive artificial temperature produces vari- 
ations in body-temperature or other disease symptoms which may as- 
sume a severe type. 



264 TEXT-BOOK OF PEDIATRICS 

CLASSIFICATION 

The classification of disturbances of nutrition, into acute and chronic 
dyspepsia (the latter also called atrophy), entero-catarrh, cholera infantum 
and enteritis, until recently accepted, is no longer tenable. Since it has 
become apparent that in these several conditions we have but variant forms 
and degrees of general alimentary disorder, and since it is known that one 
form may be transformed into another form by changes in diet, it is no 
longer fitting to use terms which bring the intestinal symptoms into the fore- 
ground and, at the same time, encourage the view that each is to be looked 
upon as a distinct disease. 

The classification of Czerny and Keller gives the alimentary element in 
the disturbance its proper place. It distinguishes (a) disturbances of 
nutrition due to food (6) disturbances due to infection, and (c) those due to 
congenital constitutional defects. Under the first class, we have as sub- 
classes, the various "food injuries," such as those caused by an excess of 
milk or of flour. Under the second, disorders due to contaminated milk and 
diseases due to enteral and parenteral infection, such as dyspepsia or chol- 
era infantum under the older classification. Under the third, the diatheses 
associated with the nutritional problem. 

The authors are convinced that an etiologic classification is not only 
unessential but impossible. In the group as a whole, and even more so in the 
individual case, the causation is not clearly recognizable nor devisible into its 
separate factors. Take, for instance, the child that does not thrive on a 
cow's milk mixture, with the result that the immunity is decidedly reduced. 
To this primary nutritional abnormality add an infection which will bring 
on manifestations of dyspepsia. In this case it is obviously impossible to 
lay the cause to any one definite etiologic factor. In chronic cases leading 
gradually to atrophy, all sorts of etiologic factors have come into play, 
either together or in sequence, so that, again, a systematic classification is 
impossible. These difficulties are avoided if we accept a simple clinical 
grouping such as the following. 

A. Nutritional disturbances without toxic manifestations. 

I. Dystrophy. 1 Disturbance of qualitative and quantitative growth. 

(a) Without diarrhoea, or slight diarrhoea. 

1. Dystrophy as a result of excessive milk feeding (the milk- 
feeding injury of Czerny and Keller). 

2. Dystrophy as a result of excessive flour feeding (the flour- 
feeding injury of Czerny and Keller). 

3. Dystrophy as a result of inanition. 

(b) With diarrhoea. 

4. Dystrophy with dyspepsia (chronic dyspepsia). 

ir The authors have replaced the older term "Disturbance of balance" by that of 
"Dystrophy" which seems to bring out the changes noted in the clinical picture and 
especially, the delayed development more clearly. Langstein suggests the term "hypo- 
trophy" but this is almost synonymous with the term "hypoplasia" which refers rather 
to a failure of the germ cell. 



DISEASES OF THE DIGESTIVE SYSTEM 265 

II. Decomposition, loss of body-weight as a result of imbalance of 
the metabolic processes with the loss of essential body elements, 
especially water, because of the advanced degree of alimentary 
and dyspeptic injury. 
B. Nutritional disturbances with toxic manifestations. 

I. Acute dyspepsia; acute gastro-intestinal disturbance resulting 
from abnormal endogenous decomposition of the food, character- 
ized by free purgation and leading to intoxication. 

II. Intoxication, severe general disturbance of a toxic nature with 
terrific losses of weight, probably the result of poisoning by 
intermediate products of metabolism in combination with se- 
vere dehydration. 

It is hardly necessary to say that the individual headings in each group 
do not represent definitely separable disease entity in each case. They 
should be considered rather as various stages which may at any time progress 
from the milder to the more severe. Such transition may take place if the 
food is changed or if the patient be subjected to an external injury which 
reduces his resistance. 

A. NUTRITIONAL DISTURBANCES WITHOUT Toxic MANIFESTATIONS. 

I. Dystrophy, 
(a) Without diarrhoea. 

1. Dystrophy as a result of excessive milk feeding. (Milk-feeding 
injury of Czerny and Keller. Mild form of atrophy.) 

Symptoms. This condition is characterized chiefly by delayed develop- 
ment both in a qualitative and quantitative way without other distinct 
indications of illness. 

Even at the outset, daily weighings show great variations, both upward 
and downward, so that the curve becomes very irregular. Later, periods of 
variable duration occur in which there is no change of weight or a continuous 
loss, again equalized by a rise (Fig. 73). On the whole, the weight falls 
gradually below the normal average and, although not actually emaciated, 
the child gives the impression of great debility. Retardation of growth is 
noticeable, so that the infant is generally smaller than a healthy child of the 
same age. 

The evidences of reduction in the qualitative conditions of nutrition are 
to be especially noted. The tone of the tissues is reduced, the muscles are 
relaxed, the abdomen is distended, the skin dry, the color pale, dynamic and 
static power are below the standard to be looked for at the given age. 
Disposition and sleep are affected. The reduction of immunity is seen in 
the tendency to secondary infections, chiefly of the skin, which donot usually 
extend beyond their local limits. 

The stools may be normal or, again, dryer and lighter than usual, or 
even white in color. Rarely do we see the fat-soap stools, the so-called 
"gray obstipation." The temperature is more variable than in health. 
With the exception of the meteorism and occasional vomiting, other evi- 
dences of disease of the gastro-intestinal tract are absent. 



266 



TEXT-BOOK OF PEDIATRICS 



Etiology. The origin of the condition described lies solely and 
primarily in an excess of milk in the diet with an insufficiency or absence 
of carbohydrate. In many cases the milk was given in too large amounts; 
in others, the error in the diet appears after a short time even though the 
food was apparently quantitatively correct. In these latter, it may be sup- 
posed that a constitutional peculiarity of the digestive function of the infant 
plays a part, for innumerable infants thrive on unaltered whole milk for a 
long time. This inherent peculiarity of the infant is further demonstrated 
by the fact that the symptom group is often encountered in infants that are 
receiving as high as five per cent, of carbohydrate and that such children 



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Fio. 73. Weight curves showing the increase of a healthy infant as compared with one 
suffering with dystrophy. 

often develop satisfactorily if the starch is increased to as high as ten per 
cent., and even higher. 

Pathogenesis. The explanation of the failure of development in spite 
of food of sufficient caloric value is usually sought in a disturbance of the 
metabolism of some one constituent of the milk. Most commonly, the 
blame has been laid upon the fat metabolism. Recently the suggestion 
has been made that increased putrefaction in the intestine might possibly 
be the cause. It seems more probable, however, that the disturbance of 
the fat metabolism as well as the intestinal putrefaction is secondary to the 
low carbohydrate. In this case, the condition would be explained as a 
carbohydrate requirement. Such a condition is characteristic of rickitic 
infants, of those with spasmophilia and the exudative child. 



DISEASES OF THE DIGESTIVE SYSTEM 267 

Metabolism. The metabolism is apparently not greatly altered so far 
as the absorption of organic substances is concerned, although there may 
be some slight reduction in the absorption of the fats. In consequence of 
altered intestinal conditions, an increased secretion of alkalies into the bowel 
occurs, partly in combination with the abnormal quantities of higher and 
lower fatty acids and partly by increased secretory activity. The balance of 
the earthy alkalies may even become negative. This, however, is not so 
important in the matter of gain in weight as the coincident reduction of the 
sodium and potassium retention. The reduction of the available quantity 
of these mineral substances, so important for growth, is probably the cause 
of the decreased development. The irregularities of absorption and reten- 
tion, due to the variation of alkali and water content, are the basis of the 
variation in weight. The beneficial action of increased carbohydrate is ex- 
plained by the marked affect upon the alkali reserve and the water retention. 

The fat-soap stools are distinguished from the normal by the difference 
in the partition of the fecal fat. They contain much more of the earthy- 
alkali soaps and much less of the free fatty acids. Their light color is 
caused by an extensive reduction of the bilirubin into colorless urobilinogen. 
A strong alkalin reaction in the large intestine is necessary for the formation 
of such stools. 

Soap stools were at first looked upon as pathologic, i.e., as evidence 
of the abnormally great excretion of bases into the bowel. It is certain now 
that these materials occur regularly in the feces under perfectly normal 
digestion if the alkalin reaction is sufficiently strong; so that the diagnosis 
of nutritional disturbance cannot be made from the soap stools alone. Some 
feeding cases are seen which fail to thrive because their caloric requirement 
of about 100 calories per kilo is largely supplied by milk. The history and 
a careful examination reveals no definite pathology and there is no diar- 
rhoea. Such cases may be included under the group of dystrophy due to 
excessive milk feeding. In the differential diagnosis the group of dystro- 
phies due to inanition and also the failure of growth due to constitutional 
anomalies must be considered. The latter is, of course, still a purely hypo- 
thetical condition and its action in delaying growth is far from being under- 
stood. Such an endogenous disturbance of growth resists all therapeutic 
intervention. Delayed development also occurs in cases where there is 
sufficient carbohydrate in the mixture. This is probably an early stage of 
dyspepsia in which the characteristic changes in the stool have not 
taken place. 

Prognosis. The prognosis is favorably influenced by proper regulation 
of the food mixture. 

Treatment. The treatment consists in a rational regulation of the 
quantity of food and the number of meals, in a reduction of milk and the 
addition of suitable carbohydrates to the diet. In disturbances of recent 
origin, the addition of gruel or flour, with a slight reduction in the quantity 
of milk, frequently produces immediate benefit. The following list of carbo- 
hydrate foods is suggested in order of value. Dextrin-maltose preparations, 
(malt soup, etc.); prepared or dextrinized flours; toasted breads, simple 



268 TEXT-BOOK OF PEDIATRICS 

flours. Sugar of milk is to be excluded and cane-sugar should be used only 
in combination with gruel or flour. The quantity of the carbohydrate 
should be five per cent, of the total amount of food given, although fre- 
quently one needs more. The sum total of the nourishment should, at first, 
be small; when the tolerance of the child has been ascertained, it may be in- 
creased until finally the child itself determines the quantity which will it take. 
Few and, at most, not over five feedings in twenty-four hours are to be given. 

If the carbohydrate used does not give satisfactory results, one of higher 
value is to be substituted. In cases of long standing, it is well to give the 
most efficacious form from the beginning. Liebig 's malt soup may be used, 
according to the formula of A. Keller, or buttermilk mixture. 

Malt soup, with its nutritive value of about 700 calories per litre, is 
sufficient for children to the weight of 5 kilos, or 11 pounds, and to the age of 
seven or eight months. In older and heavier children, it should be mixed with 
more milk, less water and less flour; otherwise the mixture becomes too thick. 
Children under three months of age should be given only two-thirds of the 
original solution of carbohydrate. 

Malt soup is prepared as follows : Stir 50 grams (2 ounces) , of white flour 
into one-third of a litre (11 ounces) of milk, warming it gradually. In 
another dish dissolve 100 grams (3}/ ounces) of malt soup extract (malt 
extract neutralized with potassium carbonate), in two-thirds of a litre (22 
ounces) of water. Mix this with the milk and flour; boil and strain through 
a fine sieve. 

Malt soup produces somewhat thin and frequent stools and is therefore 
to be recommended when constipation follows the use of other food. 

Buttermilk intended for use in infant feeding should be produced in as 
cleanly a manner as possible. Its acidity should be about 7 c.c. normal 
NaOH solution. 

Heat one quart of buttermilk. Mix five grams (^ ounce), or two level 
tablespoonfuls of flour to a smooth paste with a few tablespoonfuls of the 
buttermilk. Stir the paste into the remainder of the hot buttermilk. Con- 
tinue stirring until it boils, withdraw from the fire a moment, and then 
reboil without stirring. Add 50 to 70 grams (l%-2% ounces) of granu- 
lated sugar, dissolving it thoroughly and bring the mixture to a boil the 
third time. 

Changes in the relative quantities may be made to meet the tendency to 
either constipation or diarrhoea. The dextrin-maltose mixture may be 
substituted. Benzosulphinidum (saccharin), may be used if the sugar 
given does not make the mixture sweet enough. Beginning with two to 
three per cent., the quantity may be increased gradually. 

When the child is given this therapeutic diet, an increase in weight 
should immediately follow and continue progressively; a noticeable 
improvement in the general well-being should be observed (Fig. 74); and 
the stools should be of good quality. If improvement is not seen and 
marked diarrhoea does not suggest the transition to the type of dyspepsia, 
it is necessary to make greater changes in the carbohydrate components 
of the food (see next division). Malt soup or buttermilk having been given 



DISEASES OF THE DIGESTIVE SYSTEM 



269 



for six or eight weeks, an attempt should be made to return to an ordinary 
diet and to ascertain thereby whether a longer period of the therapeutic 
diet is necessary. The recovery may be considered complete when con- 
tinued development is reestablished upon ordinary milk mixtures. 

The therapeutic dietaries above are better adapted to older infants. 
In new-born infants and those of four to six weeks, great care must be exer- 
cised in making changes. Gradually increasing amounts of gruels and sugars, 
preferably dextrin and maltose mixtures and granulated sugar up to seven 
per cent., or small amounts of buttermilk mixture with five per cent, sugar, 
may be cautiously employed. If immediate improvement is not noted, 



'height. 




Milk and Sugar. 



FIG. 74. Typical curve of successful treatment of dystrophy with diet poor in fat 
and high in carbohydrate (MS. =Malt Soup). 

there is danger of transition to dyspepsia and the treatment for this con- 
dition is advisable from the onset. 

2. Dystrophy as a result of excessive flour feeding. . (Flour-feeding* 
injury of Czerny and Keller.) 

Pap or flour paste feeding, with or without small additions of milkor other 
food material, is a method of infant feeding still encountered occasionally. 
Flour-feeding injuries may also be caused when a flour diet, ordered by the 
physician or selected by the mother herself to cure a diarrhoea, is continued 
for too long a time. The younger the child, the more rapidly does injury 
occur when flour is the chief constituent of the diet. 

Symptoms. In not a few cases, disease symptoms fail to appear for 
some time in spite of the improper diet. A normal development may be 



270 



TEXT- BOOK OF PEDIATRICS 



simulated for a time for the great water-retaining power of the carbohydrate 
causes marked increase in weight. The general appearance of the child is 
good and the fat deposits abundant. But even at this time, certain abnor- 
malities may be observed. The musculature may be slightly hypertonic, 
the complexion poor; a nervous irritability (latent tetany) may be dem- 
onstrated upon close examination. 
Later, the development of extreme 
symptoms is threatened. A severe 
flour-feeding injury develops which 
may take on varyingly graded forms, 
according to the exclusive or non-ex- 
clusive use of this article of diet. 

The atrophic type appears when 
the feeding has consisted of flour 
alone, without the addition of salt. 
It can hardly be differentiated from 
simple severe starvation. The only 
distinctive features are the hyperto- 
nicity of the muscles and the drying 
out of the tissues, which are partic- 
ularly noticeable. A brownish-red 
coloring of the skin should attract es- 
pecial attention. 

In the hydremic form, which oc- 
curs in flour feeding with large addi- 
tions of salt, the weight is increased 
markedly, in consequence of the re- 
tention of large quantities of water in 
the tissues. This may be recognized 
clinically by a pale, bloated appear- 
ance of the face, the spongy consist- 
ency of the skin and, finally, by the 
appearance of edema without evi- 
dences of injury to the kidneys 
(Fig. 75). 

A hypertonic form is also described 
in which the chief symptom is the 
rigidity of the musculature. This 
hypertonicity may at times take so 
severe a form that not only the limbs 

but the entire body becomes stiff. This condition, however, is not confined 
to flour-feeding injuries alone, but may occur in other disturbances 
of nutrition. 

Stools are formed or soft, are of brown or yellow color, alkalin or acid, 
according to the flour used and to the tendency to constipation or diarrhoea. 
If the digestion of the flour is impaired, they become pasty, slimy and 
foamy, due to the formation of gas, have a foul, acid odor, and contain 




FIG. 75. Alimentary edema. (University Chil- 
dren's Hospital, Breslau, Prof. Tobler.) 



271 

many undigested particles which will stain with iodin. Irritation of the 
large intestines, with symptoms of colitis, may result from the fermentation 
of the flour. 

A characteristic peculiarity of flour-feeding injury is the great and 
sudden variation of the weight-curve which occurs spontaneously, or when 
the child is attacked by an additional nutritive disturbance, or by an infec- 
tion. Then a fall of several hundred grams, or even a kilogram, may occur 
within a few days, accompanied by correspondingly severe general symp- 
toms. Such events are the more frequent, because such children show a 
definite reduction of immunity which affords an especially responsive soil 
for infective organisms which produce bacterial injuries of the most variable 
sort ; such as, pyodermia, inflammatory lung affections, and pyelitis. Of the 
non-bacterial complications, cornea! and conjunctival xerosis may be men- 
tioned, while manifest tetany (spasmophilia) is not uncommon. 

Metabolism and Pathogenesis. The disturbance of the organism 
occurring in exclusive flour feeding is to be considered a qualitative inani- 
tion, produced by the absence of one or more of the necessary tissue-building 
foods (fat, and in part, also, protein and salts); on account of which the 
formation of normal body tissue, if not the development in general, is impos- 
sible. Usually the caloric value of the food is insufficient, so that quanti- 
tative inanition also plays some part. The enormous quantity of water 
retained, because of the large salt content of flour food, stands in direct 
relation to the variations of weight. The reduction of immunity may be due 
rather to the scant formation of antibodies, as a consequence of inanition, 
than to the high water content of the body. 

Prognosis. The prognosis depends upon the age of the child and the 
duration of the period of incorrect feeding. The younger the child and the 
longer the continuance of flour feeding, the less hopeful is the final result. 
The great mortality is caused rather by unavoidable intercurrent infections, 
than by the feeding injury itself. The tetany and the spasmophilic convul- 
sions resulting from it are very dangerous manifestations. 

Prophylaxis. The incidence of a primary flour-feeding injury is 
avoided by an appropriate diet. It is important to consider, the possibility 
of the occurrence of such an injury when flour feeding is resorted to for 
therapeutic purposes, whether for the purpose of alleviating symptoms of 
spasmophilia or for the treatment of dyspeptic diarrhoea. The danger may 
be avoided in the first instance by the addition of casein preparations, fat 
and small amounts of salts, and in the second case by continuing the pure 
flour diet for only a very few days; and overcoming the difficulties of a return 
to a milk diet by the methods to be described below. 

Treatment. In young infants, and especially in the severer class of 
cases, the most rapid recovery is to be expected from breast-milk feeding. 
Remembering that inanition may have caused a lowering of the limits of 
tolerance, it is well to begin, as in decomposition, with small quantities 
200-300 c.c. (7-10 ounces per diem) ; and then to increase the amount as 
carefully but as rapidly as possible. Whole milk, slightly diluted, or milk 
with moderate carbohydrate additions (3-5 per cent.), are the artificial 



272 TEXT-BOOK OF PEDIATRICS 

mixtures to be recommended. With these infants it is well to begin as 
though decomposition were present. Protein-milk has given very good and 
certain results. 

In all these cases in so far as we do not have to deal with the purely 
atrophic type, a decided loss of weight is to be expected as a result of the 
feeding of mixtures poor in carbohydrates, because of the rapid loss of the 
water which has been retained during the flour feeding. Occasionally this 
may produce a serious condition and it is advantageous therefore to retard 
the loss by the addition of small amounts of flour or of dextrin and maltose 
preparations to the milk mixture. 

If the change from flour to milk mixtures is made gradually by adding 
small quantities of milk to the gruel, as is customary when the period of 
flour-soup feeding for the relief of diarrhrea is to be ended, the diarrhrea 
often recurs; which leads to the further discontinuance of milk in the mix- 
ture, and to the conclusion that milk is not well borne by the child. Fre- 
quently this trouble is due to the fact that flour ferments more readily in 
the presence of milk; as, for example, with sugar, a strong solution of which 
may be taken care of in dyspepsia, while the same amount, added to milk, 
produces symptoms of severe intestinal irritation. In these cases, the 
desired results are often obtained if the change is made suddenly and the 
flour omitted at once. In this event, again, the best results are obtained by 
feeding protein-milk. 

3. Dystrophy as a result of inanition. 

In addition to the forms of dystrophy considered above, must be added 
the innumerable cases in which the failure of proper development is due 
solely to quantitative insufficiency of food. A common cause of this is a 
food of too great dilution, the caloric value is so reduced that the child 
cannot take enough to supply its requirement. Frequent vomiting and 
regurgitation is a cause. Inanition also plays an important role in those 
older children who have been much delayed in weight but are still being fed 
on the caloric requirement of that weight instead of the requirement of a 
normal child of that age. They have a much greater requirement than 
younger infants of the same age and will not thrive on 100 to 150 calories 
per kilo. At times, children are seen who, because of anorexia, do not take 
sufficient food of their o\vn accord to cover their needs. 

Diagnosis. The diagnosis is made by an investigation of the actual 
amounts of food taken and the determination of the caloric value of the same, 
in relation to the age and weight. 

Treatment. In the milder cases, gain in weight and improvement in 
the general development may readily be obtained by changing to a more 
concentrated food or, if necessary, by giving seven or more feedings instead 
of the customary five. If the child is markedly underweight and does not 
take its food well, highly concentrated food must be given. In such a case, 
whole milk with twelve to seventen per cent, of carbohydrate, which nearly 
doubles its food value ; concentrated protein-milk with fifteen to twenty per 
cent, carbohydrate; Sauer's farina mixture; and other thick gruels are 
valuable. Fat may be added to the food in the form of butter or cream. 



DISEASES OF THE DIGESTIVE SYSTEM 273 

These are the cases in which the "butter-flour mixture" of Czerny and 
Kleinschmidt is especially indicated (see feeding of normal infants in 
General Part). 

B. NUTRITIONAL DISTURBANCES WITHOUT Toxic MANIFESTATIONS 

WITH DIARRHOEA. 

4. Dystrophy with dyspepsia (chronic dyspepsia). 

Etiology. In many cases, the cause of the failure of development, the 
dystrophic condition, is found in abnormal digestive processes. This may 
occur without producing extreme gastro-intestinal symptoms, both in pri- 
marily healthy children and in conjunction with acute dyspepsia or with 
flour or milk-feeding dystrophy. The condition is encountered when there 
is a distinct intestinal digestive insufficiency for the food offered. It may 
be the result of absolute or relative inanition; or of primary reduction 
of the tolerance, especially by infection. This insufficiency may become 
so great that pathological fermentation takes place and brings on the 
symptom-complex to be described. The products of fermentation cause in- 
creased peristalsis and resulting diarrhoea. 

Symptoms. The symptoms of disturbed gastro-intestinal function are 
the chief indication of the dyspeptic condition. The appetite may be 
diminished; regurgitation and vomiting may occur. The motor power of 
the stomach is reduced. The analysis of the stomach content usually shows 
the absence of free HC1. But the free and volatile fatty acids are increased, 
as can be recognized from the characteristic odor. Frequently the abdomen 
is distended. Increased peristalsis may be visible or may be determined by 
auscultation. There is a tendency to flatulence and colic, with a resultant 
restlessness of the child. The stools are more numerous and definitely 
abnormal. They become thinner, watery or lumpy and contain mucus. 
Their odor is abnormal, indicating either putrefaction or fermentation. 
Their chemical reaction is variable, usually acid. Their color is often green, 
in consequence of the oxidation of bilirubin to biliverdin. 

The increased peristalsis interferes more or less with the absorption of 
the products of digestion, a fact which may be determined not only by 
metabolism experiments, but also by macroscopic, microscopic and chemical 
examination of the feces. 

The stools contain fat soaps, seen as small white or yellowish lumps 
("milk curds"), from which fatty acid crystals may be obtained by heating 
with strong mineral acids. Neutral fats in the form of fine granules or 
coarser globules, and fatty acids in the form of needles, clusters or droplets 
are also present. Usually present in small amounts only, both occur 
occasionally in enormous quantities. Microscopically, fatty stools are 
soapy or shiny in appearance, semisolid or fluid in form, yellow or green in 
color, and of markedly acid reaction. In the stained preparation, a large 
number of Gram positive bacilli are noticeable, resembling in this respect, 
the stools of the breast-fed infant. 

A good conception of the distribution of the fats may be obtained by 
staining a smear with dilute carbol-fuchsin. Neutral fat remains unstained, 
soap-fat appears bright pink and fatty acid bright red. The fat globules in 
18 



274 TEXT-BOOK OF PEDIATRICS 

the stools vary in the shade of red, so that we may conclude that the neu- 
tral fat is always mixed with fatty acids (Fig. 76). 

Flour stools are pasty or foamy. With iodin, the undigested starches 
stain blue and the erythrodextrins red. Frequently, large numbers of 
idiophilic bacteria may be found. 

For a long tune, the question whether undigested casein appears in the 
stools has been of interest. The whitish-yellow flakes, or so-called "milk 
curds, " have been erroneously considered as particles of casein which had 
escaped absorption because of their indigestibility. It is now an estab- 
lished fact that these alleged casein flakes consist, almost entirely of the 
salts of fatty acids and of bacteria. Only under raw-milk feeding do large, 

tough, rubber-like casein curds pass 
undigested through the intestine. 
Their appearance does not permit 
us any conclusion as to their path- 
ogenetic importance. 

The general symptoms when 
sharply differentiated from other 
severe forms of disturbance of nutri- 
tion, e. g., intoxication, decompo- 
sition, with acute incidence are 
not of great variety. The patient 
is pale and restless, his sleep light 
and his disposition altered. The 
tone of the tissues is reduced. While 
the body-weight may increase in 

^^ the milder cases, there is usually 

. Y * no increase or a slight loss of weight. 

* *_/ The body-temperature is impor- 

tant; the daily curve varying be- 
tween a slightly subnormal point 
and slight fever, (see alimen- 

FIG. 76. Microscopic preparation of stool in case *Ty iGVGT). 
of fat diarrhoea. Stained with carbol-fuchsin. Fatty T>a timer An acic fQoa o1c./~> mvnamT 

acids red, soap fats pink. .rainogenesis. ^Qee aiso general 

pathogenesis.) The local symptoms 

of dyspepsia are usually caused by the increased formation of the acids of 
fermentation. 2 In all probability, the pathologic decomposition of the 
carbohydrates (sugar, flour), must be considered the primary cause of the 
fermentation; while the decomposition of the fat, when given in ordinarily 
small amounts, is secondary to it. No satisfactory proofs of injury to the 
intestinal tract by the decomposed digestive products of casein, of which so 
muchhasbeenwritten,havebeenbroughtforward. Rather,has it been shown 
that the harmful decomposition of carbohydrates may be combated by large 

2 Cases are occasionally seen in which there is a poor gain in weight with increased 
slimy stools, and which are easily cured by the addition of a more readily assimilated 
carbohydrate. Evidently, there is an actual carbohydrate hunger in this condition. 
The chemistry is not understood. 





DISEASES OF THE DIGESTIVE SYSTEM 275 

quantities of casein which acts beneficially as a therapeutic agent. It is 
true that when large amounts of casein are fed, there is a possibility of 
the protein entering into the circulation with severe general symptoms, as 
frequently happens in premature and very weak infants. The main sup- 
port of the view that the primary cause of dyspepsia is the carbohydrate, lies 
in the fact that it is nearly always possible to reduce the abnormal fermenta- 
tion and the excessive peristalsis by sharp reduction of the sugars, eliminat- 
ing, in certain cases, even the lactose of the milk itself. The different sugars 
show important differences in their susceptibility to fermentation. Sugar of 
milk is most readily fermented; cane-sugar less readily; while the dextrin 
and maltose preparations of commerce, dextri-maltose, etc., are the least 
liable to fermentation. 

The results of clinical experiment indicate that the intestinal tolerance 
for carbohydrate and the greater or less tendency to pathologic fermentation 
are not constant, but are dependent, as is the tolerance for fat, upon the 
liquid in which the carbohydrate, in solution or suspension, is given. A 
given quantity of sugar in undiluted whey gives rise to symptoms of dys- 
pepsia more readily than when added to water or diluted whey. Thus an 
increase of the protein content may counteract the tendency to fermen- 
tation, while an increase of the whey with reduced protein favors it. 

The pathogenesis of the general symptoms of dyspepsia is akin to that of 
the symptoms common to the several grades of disturbance of nutrition. 

A reduction of absorptive power, which may be demonstrated clinically, 
has been proved by metabolism experiments. Not only the organic, but the 
inorganic food-stuffs are involved in this reduction. However, in dyspepsia, 
in contrast to decomposition, a lessening of the mineral bases of the body is 
rare, because increased retention of the inorganic salts compensates for the 
diminished intake. So rapid a deterioration and so greatly reduced tone of 
the tissues is not seen, therefore, in dyspepsia. 

Variations in the Course. It is essential in every case to attempt to 
arrive at some conclusion as to the etiologic characteristics. This is espe- 
cially true in those cases in which the dyspepsia is more or less directly the 
result of infection. In young infants, enteral and parenteral infections are 
very commonly seen in combination with secondary disturbance of nutri- 
tion and conversely a nutritional disturbance may often have a secondary 
infection added to it. There can be no doubt of the presence of an infective 
process when rises in temperature persist in spite of the correction of the food 
as required for the dyspepsia. Further infection must be suspected when, in 
spite of a diet practically free from sugar and definitely non-fermentation 
producing, the frequent stools still contain large amounts of mucous. Such 
a condition is due to a mild secondary enterocolitis. The pedantic differ- 
entiation between infection and dyspepsia is in itself of minor importance, 
provided that the treatment is not influenced to the extent of deviating 
from that to be indicated for dyspepsia in the following. There is danger, 
however, that the persisting intestinal irritation kept up by the local or 
hematogenous infection be interpreted as a continuance of the fermentative 
process that initiated the disorder. In a similar manner, the dyspeptic 



276 TEXT-BOOK OF PEDIATRICS 

symptoms that appear with hunger and inanition may lead the treatment 
astray. For this reason, the possibility of hunger dyspepsia should con- 
stantly be kept in mind. This especially in the new-born. 

Diagnosis. Diagnostically it is important to determine whether the 
diarrhosa is merely a manifestation added to simple failure of development 
(dystrophy), or whether it is a far-reaching nutritional disturbance with 
actual loss of body substance (decomposition). These two conditions 
differ not only in their prognosis, but require entirely different treatment. 
The differentiation is made from the clinical examination and from the 
history. Emaciation, sudden losses of weight and subnormal temperature 
indicate decomposition. A history of repeated diarrhoea with periods of 
loss of weight, and recurring injuries reducing the tolerance also indi- 
cates a reduction of the functional ability of the organism in the sense of 
a decomposition. 

Prognosis. The outcome of a persisting dyspepsia may still be favor- 
able, as long as there is no loss of weight and the general condition of the 
child is not markedly affected. In recurring dyspepsia, the prognosis must 
be more guarded because of the great reduction of the tolerance. This is 
also true in cases of diarrhoea in infants during the first few days of 
life. On account of the very low tolerance at this age and the readiness 
with which the condition may go on to decomposition the prognosis is al- 
ways grave. 

Dietetic Treatment. The safest food for cases of the dyspeptic form of 
dystrophy is breast-milk. Especially during the first few weeks of life, every 
effort must be made to give the infant the natural food, for at so early an 
age the results of artificial food are always doubtful. The full caloric re- 
quirement may be supplied in breast-milk but even with this food it is well 
to underfeed slightly at first. 

In using artificial food in the treatment of dyspepsia, the cure must be 
affected by changes in the composition of the mixture and not by reducing 
the quantity. The diarrhoea may be stopped temporarily by cutting down 
the diet that caused it, to a starvation ration, but the intestinal fermenta- 
tion flares up again as soon as the food is brought up to the requirement. 
The course to be chosen, therefore, is rather to change to a mixture contain- 
ing less fermentable carbohydrate. The reduction of the abnormal fermen- 
tation is most rapidly accomplished (1) by the reduction of a possible excess 
of carbohydrate; (2) by replacing the more easily fermented sugar of milk or 
cane-sugar with the readily assimilated dextrinized flours or maltose and 
dextrin mixtures; (3) by the addition of calcium caseinate (protolac, 
larosan) up to two per cent. 

In the milder cases, these additions may be made to mixtures of gruels 
and lean milk (Fig. 77). When the symptoms have persisted for a time, it 
is well to eliminate even the lactose of the milk by substituting buttermilk. 
Some authors ascribe a beneficial effect to the acid of the buttermilk. 

The results of the treatment are evidenced by the reduction of the 
number of the stools and the improvement of their consistency. With the 
slowing up of the peristalsis, the weight as a rule begins to increase. The 



DISEASES OF THE DIGESTIVE SYSTEM 



277 



temperature, which during the illness is extremely variable, returns to the 
typical monothermia. Nevertheless, it usually takes weeks before the gen- 
eral condition of the infant returns to the normal well-being. 

With quite a few children, however, this method fails. While the loss 
of weight may be favorably in- 
fluenced, the stools do not de- 
crease in number or improve in 
consistency; or the loss of weight 
is continued and the diarrhoea 
persists. In these cases, we have 
probably to deal with a secon- 
dary infection or with a severe 
nutritional disturbance of a type 
transitional to decomposition. 
Nothing can be more mistaken 
or more disastrous than to con- 
tinue underfeeding with the idea 
that the intestine will yet re- 
cuperate with continued rest. 
Children are killed in this way. 
Only a quick recourse to the 
treatment indicated in infective 
nutritional disturbances and in 
decomposition will avail. There- 
fore we would urge that while 
the schematic rules for the treat- 
ment of dyspepsia be first fol- 
lowed, under no circumstances 
should the underfeeding be con- 
tinued in case of failure, but 
that the directions given for the 
treatment of decomposition be 
instituted at once. 

One of the most successful 
methods of treating dyspepsia, 
in artificially-fed children, has 
been the use of protein-milk. 
While this is not necessary in 
many cases, the mixture protects 
those patients who do not re- 
spond to the ordinary therapy 
from the delay of improvement and the consequent serious loss of strength. 

In the treatment of chronic forms of dyspepsia, there is no indication for 
underfeeding. Since we do not have to deal with a temporary injury, but 
with a chronic reduction of the limits of tolerance, the added trauma of 
hunger can only do harm. The feeding should be rational; the carbo- 
hydrates should be reduced to the absolute minimum (from 2-3 per cent.) 





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Fia. 77. Dystrophy with dyspepsia in a young infant. 
Recovery after the addition of casein to the food. 



278 TEXT-BOOK OF PEDIATRICS 

at once, and those forms more difficult of assimilation should be replaced by 
the more readily assimilated dextrin and maltose preparations. If this 
does not suffice to improve the condition of the stools, better results may 
be obtained with breast-milk or protein-milk. If these cannot be obtained, 
nothing remains but to continue the use of carefully measured quantities of 
the above food in order to keep the child alive in the hope that increasing 
age will produce an increase of tolerance and resultant recovery. 

Medication is usually unnecessary. Astringents (tannigen, tannalbin, 
tannocol, etc., 5 to 10 grains four to five times daily; or bismuth salicylate, 
five grains four times daily) , may be of use in long continued irritative cases 
with mucoid diarrhoea. 

II. DECOMPOSITION 3 
(PEDATROPHY) 

The various degrees of nutritional disturbances discussed above, while 
serious do not have actual injurious effect upon the body structure. In the 
next grade, decomposition, however, there is such an effect with a true loss 
of body constituents. As a result of an extensive lesion of the intestine, 
there is a gradually increasing disturbance of the metabolism. This leads to 
destruction of body substance with grave pathologic loss of body fluids and 
body substance. 

Symptoms. Dystrophy is in the stage of transition into decomposition 
when marked losses of weight occur. These losses are, at first, gradual but 
later, and in severe cases, are sudden and large. As the case progresses, we 
may have extreme emaciation which causes the "old man" appearance 
and later the skeleton like body of the "atrophic infant" (Figs. 78 and 79). 
The abdomen is usually distended, even tense; the musculature flabby or 
hypertonic. The patient may be pale at first, but later has a characteristic 
pasty gray color, while the mucous membranes of the seemingly huge mouth 
are a deep red. 

The urine is free from protein and sugar. The stools are usually dys- 
peptic, frequently diarrhceic; liquid and solid evacuations may alternate. 
At times, during periods of remission of the fundamental disease process, 
only formed stools are passed. In a peculiar condition known as fatty 
diarrhoea, the discharges are characterized by excess of fat. Often the 
stools are tarry or reddish black, due to bleeding from peptic duodenal 
ulcers (Fig. 80). 

At first, the patients are irritable, cry a great deal and eat ravenously. 
Later, they become dull and lethargic. There is a noticeable tendency to 
slowing and irregularities of the pulse. The temperature may be subnormal 

3 " Decomponere " means to "separate into its constituents" as well as to "change 
the composition," (in an unfavorable sense). Both definitions apply to the condition in 
question. Not only do the tissues of the body break down, while their separate cell con- 
stituents are excreted in various ways, but the remaining cell contents are changed in 
composition, as shown in their seriously disordered functions. Although the term 
decomposition, and particularly alimentary decomposition, since it is traceable to the 
influence of feeding, has been criticised, the nature of the condition is better so described 
than by the ambiguous word "atrophy. " 



DISEASES OF THE DIGESTIVE SYSTEM 279 

and is liable to great variation in distinction to the normal monothermia. 
Edema and cyanosis are common symptoms. 

Aside from the emaciation and its accompanying phenomena, decompo- 
sition is characterized, symptomatically, by the sensitiveness of the patient, 
or rather by the sensitivity and severity of his paradoxical reactions to 
nutritive, infective, and other influences. A slight alteration in the quantity 
and quality of the nourishment may immediately cause a very threatening 
aggravation: a minor bacterial infection, a coryza, a bronchitis, etc., may 
lead to serious decline. A little overheating may produce high fever and 
collapse. By this very sensitiveness the diagnosis of the condition may be 
rnade when the child is in a remission, or is beginning to recover and even 
when the symptoms of the body loss are not apparent. The reduced im- 
munity predisposes to infective complications (furunculosis and other pyo- 




\ 

FIG. 78. Facies in moderate decomposition. (Berlin Children's Asylum, Dr. Dessauer.) 

dermatites, pyelitis, septic diseases, bronchitis, pneumonia, etc.), which 
occur frequently and run an exceptionally severe course. 

A peculiar form of interruption of the course is often seen in decompo- 
sition and also at times in dyspepsia. To this the name of "Reversion" 
has been applied. The patient seems to be doing especially well for several 
days. There is a constant gain in weight up to several hundred grams and 
the attendant is greatly encouraged. This is not a true manifestation of 
growth, but is largely due to a retention of water. The slightest error in the 
treatment or the mildest external injury throws the patient back and the 
gain is lost in a few days. The patient has not gained anything by the period 
of improvement but has actually been weakened. 

Pathogenesis and Metabolism. Formerly it was believed that inani- 
tion was the cause of severe "atrophy" and was due to interference with 
food absorption in consequence of a chronic inflammation and destruction 
of the secretory mechanism. The foundations of this teaching are today, 
however, overthrown; for the concurrent reports of all observers show that 
the intestine of the atrophic child is anatomically normal. It is clearly a 



280 



TEXT-BOOK OF PEDIATRICS 



question of a functional disturbance, leading to a reversive metabolism, 
recognized by Parrot many decades ago. In fact, clinical observations 
prove that we have to deal with a paradoxical reaction of the food material; 
the more food we give the more the patient loses, while in the milder cases 
an arrest of the disease may be secured by reducing the allowance of food. 
In severe cases, of course, even this measure will not stop the wasting. 
From the rapid loss of weight, it will be seen that the pathologic loss of 

water and salts is primary, because this 
alone can produce such sudden changes 
in weight, while other tissue losses must 
be more gradual. 

The experiments in metabolism 
have cast some light upon this problem. 
It may be readily understood that the 
continual enteral fermentation grad- 
ually , produces so high a degree of 
alteration in the processes of digestion 
that severe damage is done to the 
agencies of interchange between the 
intestinal content and the tissues. A 
radical alteration in the water and salt 
retaining function of the cells probably 
ensues. This results in the increased 
secretion of water and alkali into the 
intestine, which is not balanced by a 
compensatory reduction of the renal 
output as it is in the healthy or the 
only slightly-ill child, in whom a nega- 
tive balance often exists. Doubtless 
abnormally increased quantities of 
water are given off by the lungs. As 
a result of the loss of salts by the 
bowel, a greatly increased excretion of 
ammonia in the urine follows, a con- 
dition of relative acidosis. The alkalies 
are lost, in part by increased secretion, 
and are, in part, consumed in the 
necessary neutralization of the great quantity of acids formed by fermen- 
tation. To cover these losses, the storage depots of the body are drawn 
upon. When these are exhausted, those stored in the constant constituents 
of the organism must provide the necessary quantity of water and salts 
by the decomposition of the cell substances. In addition to this, an actual 
inanition also ensues. The carbohydrates and fats are fermented in large 
quantities; the acids of fermentation prevent the normal splitting of the 
sugar preparatory to absorption; and as a result of the violent peristalsis 
large quantities of food material pass through the intestine entirely un- 
changed. To this is often added the semi-starvation of underfeeding 




FIG. 79. Extreme form of decomposition. 



DISEASES OF THE DIGESTIVE SYSTEM 281 

usually adopted for therapeutic purposes. The "decomposition" of the 
more important organs finally leads to so great an alteration of their cell 
conditions and, in consequence, of their functional activities, that not only 
because of the continued diarrhoea, but even after this has disappeared, 
the normal internal metabolism can no longer be maintained and an auto- 
intoxication results which produces the terminal symptoms of the disease. 

Cases of decomposition of purely alimentary origin are probably found 
in new-born and very young infants only. In older children the infectious 
influence takes a very prominent place in the etiology. To this must be 
added the frequent starvation periods employed in 'the attempt to stop the 
diarrhoea, which undermine the strength of the patient more and more. 
Such starvation cause recurrences even in cases on the road to recovery and 
are often to be blamed for the fatal termination. In fact, numerous factors 
are combined in the pathogenesis of decomposition. 

Course. In young infants the course is often uninterrupted, the fatal 
outcome occurring in a few days or weeks, at the most. In older children, 








FIG. 80. Duodenal ulcer in decomoosition. Fatal hemorrhage occurred from this lesion 
(Berlin Children's Asylum). 

periods of improvement and periods of decline alternate. Serious catas- 
trophies may occur anywhere along the course. In this manner, we may 
have an illness of weeks' duration, with exacerbations and ameliorations. 
The intestinal processes determine the occurrence of such remissions. As 
long as the stools are infrequent and formed, the weight remains stationary 
or there may even be slight gains. As soon as diarrhoea again appears, 
there is actual loss of body substance. A sudden change in the disease- 
picture is often brought about by hemorrhage from the peptic duodenal 
ulcers, which are generally fatal. The etiology of these ulcers is not known. 
The termination of unfavorable cases is attended by a variety of symp- 
toms. In many children, a narcosis develops with an absence of reflexes, 
general torpidity 'and subnormal temperature continuing for a number of 
days. Others die with the appearance of symptoms which, with or without 
fever, resemble those of alimentary intoxication. Sudden death in collapse, 
in consequence of some exciting influence or after several hours of hunger, may 
occur. Complicating infections tend materially to increase the death-rate. 



282 TEXT-BOOK OF PEDIATRICS 

The prognosis depends to a very great extent upon the dietetic treatment. 
If errors are avoided and the treatment is instituted early enough, even the 
extreme cases may be saved. If, however, the loss of weight exceeds one- 
third of the original body- weight (the so-called, Quest 's quotient) , recovery 
is apparently impossible. 

Diagnosis. The diagnosis of severe cases is clearly given by the 
clinical picture. The mistake of confusing the symptomatic emaciation of 
tuberculosis and other diseases leading to cachexia, or the weight-loss of 
severe starvation, must be avoided by careful examination and a study of 
the history. In milder forms, the differentiation from dystrophy and simple 
dyspepsia, without destructive losses, is of so much greater importance since 
the treatment indicated for these conditions, viz; a diet rich in carbohydrates 
and a period of starvation, may cause serious injury in children suffering 
with decomposition. In such cases, the history is of the greatest impor- 
tance. Repeated diarrhoea, loss of weight, in contrast to the stationary 
weight incident to non-development in dystrophy, or in infective fever of 
varying degree, are suggestive evidences of decomposition. A final con- 
clusion must be reached by the reaction of the patient to the prescribed diet. 
If with a fairly plentiful diet, the paradoxical reaction (diarrhoea, loss of 
weight, occasional fever, etc.), occurs definitely and severely, the diagnosis 
of decomposition is certain. 

Treatment. -For the cure of decomposition, it is necessary that the 
fermentation which causes a continuance of the destructive phenomena be 
abated, so that the organism may again retain water and salts, and the 
digestion may again take care of the organic food-stuffs, in a normal manner. 
Therefore, the same problem is present as in dyspepsia and one might be 
inclined to inaugurate the same treatment as it demands; that is, a period 
of starvation, followed by a gradually increasing use of suitable food mix- 
tures. In fact, this procedure is frequently adopted. One must realize, how- 
ever, that success cannot rightly be expected, save in a certain number, 
only, of older infants; and among these only in cases where the debility 
has not advanced too far. For the methods recommended in dys- 
trophy are absolutely contraindicated by the principles of treatment in 
any severe form of decomposition. These principles are (1) that the child 
with decomposition must not be starved; (2) that the child should be put to 
the breast, for it is to be feared that artificial feeding, under prevailing 
methods, will rapidly and progressively aggravate the disease. 

In children with severe disturbances of nutrition, the'dangers of a star- 
vation period are very much greater than in well infants or those with 
slight disturbances. Hunger causes much more rapid loss of weight, marked 
slowing of the pulse, subnormal temperature and collapse and occasionally 
death. Repeated starvation periods at short intervals are especially 
dangerous. The second or third such period is usually fatal (Fig. 81). The 
special emphasis laid upon this point is necessary because starvation treat- 
ment is still very much in vogue and is recommended in text-books. Aside 
from the above, it is further true that subjecting the patient suffering from 



DISEASES OF THE DIGESTIVE SYSTEM 



283 



decomposition to hunger periods can only result in a further loss of strength. 
Persistent underfeeding makes the prognosis very grave even in cases in 

Weight. Week. 



3600 



3300 



3100 
0000 



Stool 



2600 



m 



WO 
300 



100 




19. 



u 



20. 



%M. 



21. 



\i\ 







ut: 




I I I I+++ it + +4i. 



FIG. 81 . Showing the injury caused by repeated starvation periods in cases of disturbance of nutrition. 
After the first starvation period the weight is stationary for a time but there is no improvement of the 
intestinal condition. Soon the temperature rises again and further losses of weight occur. Death resulted 
on the third day of the second starvation period. 

which there was some hope of recovery. It is essential that the calorie 
requirement be supplied from the very beginning of the treatment. In the 
large majority of the cases, this is not possible with the customary artificial 



284 TEXT-BOOK OF PEDIATRICS 

foods and, for this reason, breast-milk is to be preferred to all other forms 
of food. 

In the use of breast-milk, certain points must be taken into consideration; 
and first, the matter of dosage. The curative influence of breast-milk, 
apparently due to the constituents of the whey, is not at first so active as to 
preclude the injurious effect due to the fermentation of its large amounts of 
sugar and fat. This danger is increased as more food is taken; yet if too 
little is given, the danger of renewed injury from inanition again confronts 
us. The best plan is to give a daily total of 200-300 c.c. (7-10 ounces) without 
any preceding starvation period. It is better to give the breast-milk from a 
bottle so as to relieve the weakened child of the labor of sucking. In addi- 
tion to the food, large quantities of water sweetened with benzosulphinidum 
(saccharin) should be given. Eight to ten feedings may be offered in 
twenty-four hours, for experience has shown that the same quantity in small 
doses is less liable to cause injury than in large ones. In the shortest 
possible time, about every other day, the quantity should be increased 
until by the seventh to the tenth day 100 calories (130-150 c.c.), per kilo of 
body-weight are being given and in less frequent feedings. By this time, the 
child may be put directly to the breast. 

It is further to be remembered that even with breast-milk the severer 
type of cases will, at first, show an aggravation of symptoms; the patient 
becomes more pale and more dull; a subnormal temperature and a slow 
pulse may appear; while the loss of weight continues. Only after several 
days, or even during the second week, does the weight-curve become station- 
ary and the other symptoms begin to disappear (Fig. 82). 

The danger of breast-milk feeding is greatly reduced and favorable 
outcome enhanced by adding 200 to 300 c.c. of buttermilk or fat-free milk 
without carbohydrate addition to the daily allowance of mother's milk at 
the outset. This prevents the continued loss of weight since the high whey 
content favors water retention. As the amount of breast-milk can be 
increased, the additional fat-free milk can be gradually reduced. It is 
better, however, not to stop it entirely for slight losses of weight may result. 

Now follows a period of varying duration, sometimes continued for 
several weeks, during which the weight remains stationary, while the im- 
provement in the general condition co.ntinues. The inexperienced advisor 
concludes, therefore, that the milk of the wet-nurse is not good and recom- 
mends a change. This is a mistake. We have to deal with a period of repair 
during which the body is rebuilding without being able to attain any 
appreciable increase, partly because of still inadequate absorptive power 
and partly because breast-milk, poor in protein and salts, affords so little 
material for cell-growth. Only after this period does an increase of weight 
occur. The period of repair may be shortened by giving suitable addi- 
tional food; the best, probably, being buttermilk to which carefully regu- 
lated proportions of dextrin and maltose preparations or malt soup are 
added. This supplemental food should not be given before the fourth 
week and then at only one meal a day. The addition of powdered casein 
is often beneficial. 



DISEASES OF THE DIGESTIVE SYSTEM 



285 



Complete recovery cannot be expected in less than two to three, months. 
Not until this period of time has passed should a return to artificial food be 
considered. It is advisable to precede the discontinuance of breast-milk 
with small artificial feedings, for there may be an idiosyncrasy for cow's 
milk. If it is impossible to obtain breast-milk for the patient suffering from 
decomposition, the treatment to be followed should be that recommended 
for dyspepsia. Buttermilk, or milk poor in fat, diluted with gruels should 
receive first consideration. But while with breast-milk the intestine soon 
recovers to such an extent that it is possible to give adequate quantities of 



Weight. 



Week. 







i 




J 










7 






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r 


6 






* ! 


T 




1 ff/l/O il 












































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17/7/7 

















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won 












































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t , 


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tuUV^ 

yuvi . 


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Milk 


JW 








































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i/t/t _ 








































Milk. 




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FIQ. 82. Recovery of a case of decomposition treated with breast-milk. Aggravation when breast- 
milk was first given shown by subnormal temperature and disturbances of weight. Then for two weeks 
no change in weight. Increase occurred after addition of buttermilk (Bm). + = pathologic stool; 

I = normal stools. 

food, the slightest increase in artificial feeding may produce a recurrence of 
the diarrhoea or an entire arrest of improvement. No gain is to be hoped for 
from the continuation of the infant's former food, or from the feeding of 
gruel soups, which are hazardous because of the danger of inanition. 
The prospect of good results under artificial feeding especially with younger 
children, is slight. Recent experience, however, has shown that the pos- 
sibility of recovery is considerably enhanced by the use of protein-milk or 
like preparations. 

The object of protein-milk (Eiweiss Milch), is to avoid as fully as pos- 
sible the occurrence of injurious acid fermentation. This is accomplished 
by the reduction of the milk-sugar content of the milk by a dilution of 
whey, which, in itself, improves the tolerance of the intestine for sugar, and 



286 TEXT-BOOK OF PEDIATRICS 

by the subsequent addition of large quantities of protein which tend to 
counteract the acid fermentation by the development of an alkalin reaction. 

This preparation is made in the following manner: One litre (1 quart) 
of milk is warmed over a water-bath to 98 F. and curdled with one table- 
spoonful essence of pepsin. The whey, containing the sugar, is separated 
from the curd by straining through cheese cloth (one-half hour). The curd, 
mixed with one-half litre (1 pint), of water, is then rubbed through a fine 
wire milk strainer two or three times without excessive pressure; and to it 
one-half litre (1 pint), of good buttermilk is added. Finally the required 
amount of a malto-dextrin preparation (dextri-maltose), is added and the 
mixture is brought to the boiling point stirring constantly. The curd should 
not form lumps, the mixture resembling a very thin porridge when shaken. 

The preparation is sterilized by boiling with constant energetic stirring, 
which is best done with a " Dover" egg-beater. If insufficiently stirred, the 
protein becomes tough and the mixture is useless. 

Separate feedings must be warmed gradually and high temperatures 
should be avoided. 4 Benzosulphinidum (saccharin), may be added to 
sweeten. 

Protein-milk contains 3 per cent, casein; 2.5 per cent, fat; 1.4 per cent, 
sugar of milk; and about 0.5 per cent. ash. Its food value is four hundred 
and fifty calories per litre. 

A number of food mixtures based upon the principle of protein-milk have 
been devised. It has been our experience that some of these have the cer- 
tain effect of the original protein-milk. Among others may be mentioned : 
larosan and protolac, casein calcium preparations. Twenty grams (2-3 
ounces), of this are added to one litre (1 quart), of equal parts whole milk 
and water. Feer's protein-cream-milk is prepared by adding 50 grams of 
20 per cent, cream, 10-50 grams dextri-maltose, and 15 grams calcium 
caseinate to 500 c.c. (1 pint), of whole milk and 600 c.c. (18 ounces) of 
water. The protein-milk itself may be most easily prepared according to 
the directions of Engel or those of Mueller-Kran. Engel accomplishes the 
fine division of casein which is so important, by using a special rennet 
tablet to curdle the milk after it has been boiled. Unfortunately, the 
coagulation is not always complete with these tablets; Mueller and Kran, 
therefore, recommend the following process: Mix one litre, (1 quart), of 
buttermilk with an equal quantity of water, boil and make up to two litres 
(2 quarts), with water. Let the mixture stand for thirty minutes until the 
casein settles to the bottom. Remove 1125 c.c. (36 ounces), of the fluid 
from the top by means of a dipper. To the remainder add 125 c.c. (3^6 
ounces) of 20 per cent, cream and make up to a litre again with water. 

The advantage of protein-milk feeding lies in the fact that a return to the 
full amount of nourishment required may be made more rapidly than with 

4 Difficulty is frequently experienced in the preparation of protein-milk. In a poor 
preparation, the curative action is often lost, the child refuses it. or quite frequently 
vomiting results. For this reason, it has been prepared commercially and may be 
obtained in the powdered form. 



DISEASES OF THE DIGESTIVE SYSTEM 



287 



any other food, without causing a recurrence of the fermentation processes. 
The danger of inanition is thus excluded and repair is hastened. 

In early decomposition and in dyspepsia it is customary to begin, after 
twelve hours of starvation, by giving 300 c.c. (10 ounces), of food, with at 
least 3 per cent, or even 5 per cent, dextri-maltose, in five or six feedings. 
Milk-sugar is not advisable, nor is the cane-sugar likely to produce good 
results. The additional fluid required is given in the form of weak tea. 

The quantity of protein-milk is increased in the succeeding days without 
regard to the condition of the stools, giving an additional 100 c.c. every 
second day, or even more frequently if the stools are formed, until a daily 
total of 180-200 c.c. per kilo is reached. The total feeding should not exceed 



Week 



? s 9 10 it n a. u. it w. r? is is zo ?i 22 zj 




Y 2 Milk. 



\ Milk 
and 

5% 
Malt. 



Stool 

FIG. S3. Typical recovery of case of decomposition on protein milk (black). Rapid disappearance 
of the diarrhoea (+) with the appearance of soap stools (D) while the weight remains stationary. 
Later undisturbed growth on ordinary milk mixture. . 

1000 c.c. In typical cases, the dry-soap stool is formed on the first or second 
day; the weight soon remains stationary, and the child is moving on to 
uninterrupted recovery (Fig. 83). 

When the quantity of food has been brought up to the required amount, 
without regard to whether the stools are infrequent or still numerous, the 
addition of carbohydrates should be made and increased gradually to 
five per cent. If possible, the carbohydrate addition is increased up to five 
per cent, in the course of ten day?. If the weight remains stationary and the 
stools are homogeneous, even though they are not formed, the sugar may 
be increased to even more than 6-10 per cent, and 1 per cent, to 2 per cent, 
carbohydrates in the form of flour may be added. 

In advanced cases of decomposition, the intestine must be emptied as 
rapidly as possible. In spite of the danger of starvation, a hunger period 



288 TEXT-BOOK OF PEDIATRICS 

of from six to twelve hours cannot be avoided. After this 200-300 
c.c. of protein-milk is to be given in frequent feedings (eight to ten in num- 
ber), during the first twenty-four hours with a rapid increase in the quantity 
of food and a decrease in the number of feedings; to which, \\ithinaweek, 
carbohydrates, in quickly increased amounts, should be added. If the loss 
of weight does not cease within the first three or four days and there is a 
tendency to subnormal temperature and exhaustion, even though the stools 
are frequent, the carbohydrates should be further increased, in the effort 
to stop the condition. 

Treated in this manner, the number of unsatisfactory cases is happily 
a small one. It is, of course, impossible to save children in whom the ter- 
minal comatose symptoms have developed. Experience has shown that 
several common mistakes are made in the treatment with protein-milk, 
which are responsible for seeming failures. They all arise from further 
injury to the patient through inanition or carbohydrate starvation. Among 
these errors may be mentioned: (1) the too gradual increase of quantity, 
thereby lengthening unduly the period of underfeeding and aggravating the 
condition; (2) the tardy addition of the carbohydrates and their use in 
insufficient quantity; (3) an arrest of the increase of food quantity and 
especially of the carbohydrates when the stools do not immediately improve; 
(4) a decrease of the amount of food and particularly of the carbohydrate 
when diarrhoea reappears, or when temperature rises, or a loss of weight 
occurs. All these errors are to be avoided. Only when a sudden decline 
in weight occurs and severe diarrhoea sets in, should the volume of the food 
be slightlyreduced and the carbohydrate lowered to three per cent., ju'st as is 
often necessary in dyspepsia or intoxication. After the disappearance of 
these symptoms, the return to full feeding should be made as rapidly as 
possible. In feeding the protein-milk the food-stuffs are less frequently 
responsible for such remissions than are the accidental infections. 

During the first part of the period of treatment with protein-milk, 
tendencies to temporary aggravation, similar to those which occur when the 
infant is fed upon breast-milk, occur; but this should not hinder us from 
increasing the quantity of food. Rapid improvement usually follows, pro- 
vided enough carbohydrate is supplied. 

Protein-milk feeding may be continued for six to eight weeks in young 
infants; in older children from four to six weeks. After these periods, the 
repair of the disease condition will have progressed so far that milk mix- 
tures, suited to the age of the child, will be taken care of. It is best to dis- 
continue the protein-milk at once, replacing all the feedings with milk 
mixtures. If a relapse occurs, it may be necessary to return to the protein- 
milk treatment. 

In a child who has suffered a disturbance of nutrition we may be assured 
of a complete recovery only when through a sustained period of feeding 
with ordinary milk-mixtures, within a normal range of quantity, the devel- 
opment continues its uninterrupted course (Fig. 83). 

In the child with decomposition, medication is necessary only when a 
tendency to collapse occurs. Stimulants may be used, e. g., citrated caffein; 



DISEASES OF THE DIGESTIVE SYSTEM 289 

caff em with sodium benzoate, in 0.5 to 1 per cent, solution, teaspoonful 
doses, four to five times daily; camphor, a 10 per cent, solution in oil, five 
to ten minims subcutaneously, every two hours ; brandy, ten drops, several 
times a day. During the early period of the illness, artificial heat, by means 
of hot water bottles or warm ba+hs, 36-40 C.. (96-104 F.) should be 
applied ; or, if possible, the child may be kept in an incubator. Care should 
be taken to avoid overheating, for the child with decomposition is especially 
prone to heat injury. The attempt to replace losses of water by means of 
normal salt solution is not efficacious in this condition, because the salt 
does not cause water retention, and because, in decomposition, it may 
produce edema. 

For hemorrhage from duodenal ulcers, the treatment recommended for 
bleeding of the new-born in that section, is effective. 

B. NUTRITIONAL DISTURBANCES WITH Toxic MANIFESTATIONS 
I. Acute Dyspepsia 

Symptoms. Acute dyspepsia is distinguished from the dyspeptic form 
of dystrophy by its sudden onset and severe clinical manifestations. An 
infant that has been doing very well and apparently is developing normally, 
suddenly develops severe gastro-intestinal symptoms. Nausea and vomit- 
ing may precede the more marked signs, but very soon the bowels become 
extremely loose. The stools are \vatery with much gas and frequent. The 
intensity of the diarrhoea is usually greater than in the chronic dyspepsia. 
In other respects, the difference between the two conditions is rather one of 
degree only. All the symptoms of chronic dyspepsia are also seen in the 
acute, but are more severe. This is especially true of the alimentary fever 
which may be very high in the acute. Because of the greater severity of the 
symptoms of this form of dyspepsia, it may be considered as a forerunner of 
intoxication and treated as such. Improper treatment very frequently com- 
pletes the transition. 

The remaining symptomatology, metabolism and pathogenesis is iden- 
tical with that of dystrophy with dyspepsia. 

Etiology. In most cases, a parenteral infection is probably responsible 
for the sudden disturbance. When no infectious process can be demon- 
strated the cause may lie in an excess of carbohydrate in the mixture or may 
be found in a sudden overfeeding. 

Diagnosis. The question whether the sudden serious condition arises 
in a previously normal infant or whether it is an exacerbation of an old dis- 
turbance of the nutritional function, or whether the patient is one of the not 
uncommon constitutionally " tropho-labile " infants, must be carefully an- 
swered, for the treatment depends entirely upon this. 

Prognosis. The result of proper dietetic treatment in a child that has 
been well up to the time of the acute attack is good. In very young infants, 
the danger of transition into decomposition is constantly present. In older 
children, the possibility of transition into chronic dyspeptic dystrophy must 
be kept in mind. 
10 



290 TEXT-BOOK OF PEDIATRICS 

Treatment. In the acute form of dyspepsia in previously healthy chil- 
dren the treatment may be based upon the fact that the patient has an 
uninjured tolerance and that the cause of the sudden diarrhosa is due to an 
acute discrepancy between the food ingested and the metabolic capacity. 
In such a case, rapid recovery may be expected after a short period of free 
purgation. Accordingly, the following procedure is recommended for the 
typical case. (1) A starvation period of not more than six to twelve hours. 
During this time liberal amounts of water sweetened with benzosulphinidum 
(saccharin) are given. The emptying of the gastro-intestinal tract may be 
made more complete by the use of gastric lavage and high enemata. If the 
diarrhoea is moderate, castor oil, one tablespoonful may be indicated. (2) 
After this, the food is again given but in greatly reduced amounts. Usually 
only about one-third of the caloric requirement is supplied. Large amounts 
of fluids are essential and the quantity may be made up by diluting the food 
or by giving water flavored with tea and sweetened. (3) Rapid increase of 
the food quantity should follow, so that the full requirement is again given 
by the second or third day. The underfeeding period must be limited to the 
shortest possible time. 

As to the food, it must remembered that the diarrhoea will disappear no 
matter what food is used, if the quantity is small enough. This is true even 
though the food that caused the disturbance is continued. As in chronic 
dyspepsia, however, those mixtures containing the less fermentable carbo- 
hydrates give more certain results. But the carbohydrate additions cannot 
be omitted entirely except for a very short period of time. Mixtures high 
in fats are contraindicated because of the unfavorable action of fatty acids 
on the intestine already injured by the fermentation. Accordingly, in 
mild cases the feeding is best begun with a simple gruel, to which may be 
added small amounts of partially skimmed milk with the addition of a less 
fermentable carbohydrate using flour, dextrinized flour, maltose and dex- 
trin preparation but no milk-sugar. Skimmed lactic-acid milk or butter- 
milk is useful, and calcium caseinate may be of benefit. Protein-milk is 
especially good. In fact the foods used in the chronic form of dyspepsia are 
also indicated in the acute stage. 

Gruels or flour soups may be used in infants older than three months. 
Several objections can be raised against this treatment, however. In the 
first place, there is distinct danger of qualitative inanition (flour-feeding 
injury) due to the lack of protein and fat, and the danger that the food will 
be continued longer than was intended. In the second place, the change to 
a mixture containing milk is often very difficult because of the recurrence of 
diarrhoea when even small amounts of milk are added. If the gruel treat- 
ment is used, it is well to add a small amount of calcium caseinate and a few 
spoonfuls of meat broth for the mineral salts, and even then the mixture 
must not be continued for more than three or four days. 

Cases treated according to the above method of procedure recover 
rapidly (Fig. 84). After a sharp decline of the weight-curve, as a result 
of the starvation period, the line gradually becomes less steep and after a 
day or so remains stationary. At the same time, the temperature also 



DISEASES OF THE DIGESTIVE SYSTEM 



291 



becomes normal and the stools, less frequent, are more formed. As soon as 
the caloric requirement is completely covered, the weight increases. At 
times it may be necessary to add more carbohydrate to produce an increase, 
and this may be done even though the stools are not entirely formed and 
still more frequent than normal. If improvement is delayed, or there is still 
some loss of weight, no further time can be lost before instituting the treat- 
ment for the severe forms of dystrophy with dyspepsia, or for decomposition. 
No greater harm can befall these patients than persisting in underfeeding. 
In those forms of acute dyspepsia arising from parenteral infection, such 
as coryza or grippe, strenuous interference is contraindicated and the case 
should be treated expectantly. As long as the infection does not produce 
marked loss of weight, it will hardly be found necessary to change the food. 

Weight 



Stool 



3900 
3800 
3700 



3500& 
34WJ. 
700J6 
600 
WO 
WO 
300 
ZOO 
100 




ullr jr y 




Sugar. 



Milk. 



Fia. 84. Dyspepsia 
lypical course 



with alimentary fever after feeding with sweetened buttermilk. 
of recovery. += pathologic stool; I = normal stool. 



After the infection has disappeared, the digestive function frequently returns 
to normal without therapeutic alterations of the diet. Only when there are 
severe losses of weight, or when the diarrhrea persists after the infection 
has been overcome, will it be necessary to institute the procedure described. 

II. Intoxication 

(ALIMENTARY TOXICOSIS, ENTERO-CATARRH, CHOLERA INFANTUM, ETC.) 
Intoxication may arise gradually from the acute form of dyspepsia, or it 
may at any time appear as an acute catastrophy in the chronic course of a 
disturbance of the type of dystrophy or decomposition. Furthermore, it 
may occasionally develop repeatedly in the same infant. In the previously 
comparatively normal child, the development of intoxication requires a 
rather severe injury, but in infants with decomposition, a very slight irreg- 
ularity of the diet or a mild added infection brings on the dire symptoms 
very quickly. 



292 



TEXT-BOOK OF PEDIATRICS 



Symptoms. The first sign of the toxic action of food is the fever. In its 
mildest forms there is a slight rise above the daily maximum of tempera- 
ture; at other times, subfebrile temperatures are seen; or even high fever 
may occur. 

Alimentary fever, with dyspeptic stools continuing for a long period, 
may be the only symptom of the toxic nature of the disturbance. This 
condition does not necessarily preclude increase of weight. In most cases, 
however, additional indications are seen, such as loss of weight, weakness, 
and symptoms of disorder of the kidney. From these prodromes, complete 
intoxication may develop more or less rapidly and even acutely. 

Typical and fully developed alimentary intoxication may be recognized 
by the following symptoms: Fever, collapse, severe diarrhoea, disturbances 

of the sensorium, sighing respira- 
tion, albuminuria, casts, glyco- 
suria, leucocytosis, and abrupt 
loss of weight. Disturbance of 
the sensorium is seen early, in the 
form of abnormal lassitude and 
drowsiness. The patient is un- 
usually quiet and lies very still 
or relapses rapidly into lethargy 
after being aroused. When he 
opens his eyes, the look seems 
vacant and can be engaged only 
with extreme difficulty. The us- 
ually lively expression is covered 
by a mask-like stare. Slight shad- 
ows lie about the eyes. In place 
of the ordinarily rapid movements 
of the healthy child, infrequent, 
slow, listless, apathetic and in- 
direct gestures are observed. The 
normal pose of the limbs is replaced by unusual attitudes continued for a 
long time and due to a cataleptic condition. The so-called "boxer's posi- 
tion" is very frequent among these peculiar poses (Fig. 85). 

In severe cases true coma may follow this stage. From this the child 
awakens with severe jactitation and loud shrieks. As the condition pro- 
gresses, these become less frequent and the child lies moaning in a deep 
stupor. Convulsions, other symptoms of meningeal and cerebral irritation 
and paralyses frequently occur. 

Pyrexia or even hyperpyrexia is common; normal or subnormal temper- 
atures occurring only in children with decomposition and intoxication. 

The respiration is of that peculiar type frequently designated as "toxic 
breathing." The rhythm is long, deep, without pause and of increased 
rapidity, at times resembling that of the 1 "hunted beast." 

During the prodromal period, the stools resemble those of dyspepsia or 
decomposition. At the height of the illness they become very numerous, 




FIG. 85. Facial expression of child with intoxication. 
Indication of "boxer's position" (Dr. Dessauer^ . 



DISEASES OF THE DIGESTIVE SYSTEM 



293 



watery, of a greenish-yellow color, wanting in substance and containing 
flakes of mucus. The reaction, strongly acid in the beginning, may change 
to an alkalin one on account of the excessive intestinal secretion. 

Vomiting is frequent and, in definitely established cases, very violent. 
It may take so important a place in the symptom-complex that the desig- 
nation of diarrhoea with vomiting is probably justified. In the severest 
forms, the vomited matter consists of 
dark, "coffee-grounds" masses which 
indicate gastric hemorrhage. 

Sharp decline in the weight-curve is 
caused by the excessive loss of water. 
Five hundred to one thousand grams 
(1-2 pounds) or more, may be lost in a 
few days. The skin becomes dry and 
plastic, so that if pinched the impress 
remains (Fig 86) ; the features are sharp 
and the fontanelle sunken. There may 
be muscular hypertonicity and painful 
cramps or contractures, especially of the 
leg muscles. 

The drying out of the tissues is prob- 
ably the cause of collapse, which is 
accompanied by a small pulse, dull and 
faint heart sounds, and cold and cyanotic 
extremities. The polycythaemia pro- 
duced by the extraction of fluid from 
the blood is probably the cause of the 
characteristic pale bluish-yellow color of 
the skin. The urine contains albumin 
and usually much sediment with hyalin 
and granular casts. The occurrence of 
glycosuiia 5 is purely dietetic; that is, it 
disappears upon the withdrawal of food. 
The sugar in the urine is of the form 
ingested. When the infant is fed mix- 
tures containing sugar of milk, lactose 
and galactose are found in the urine; with othe,r foods, other sugars 
are present. 

There is always a leucocytosis, the maximum count being as high as 
thirty thousand. 

In severe cases, fat sclerema, that peculiar hardening of the skin and sub- 
cutaneous tissues, beginning on the legs and buttocks and finally extending 

5 The demonstration of sugar in the infant's urine is not a simple matter. In doubt- 
ful cases, the osazone test should be used, in addition to the Trommer's and Nylander's 
tests. In the Trommer's test the urine should be boiled for quite a long time, since the 
cuprous oxide is not precipitated, in the presence of much ammonia, by simply heating. 
The exact identification of the sugar can be made only by microscopic study of the pre- 
cipitated osazone. 




FIG. 86. Severe dehydration, showing the 
loss of elasticity of skin. Cholera infantum. 
Two-year-old child. 



294 TEXT-BOOK OF PEDIATRICS 

over the whole body, may develop. The nature of this change has not been 
determined. The explanation, formerly given, of a solidification of the 
infantile fat of high melting point by the subnormal temperatures, is con- 
tradicted by clinical observations. 

The large number of symptoms suggests the complexity of the disease. 
The clinical picture is varied by the prominence of one or another indication 
in the symptom-complex. Soporific, choreiform arid cerebral types may be 
differentiated; the latter probably corresponds to the hydrocephaloid type 
of the older authorities. 

Pathologic Anatomy. The structural changes are not great and do not 
aid in the understanding of the severe clinical findings. A serous or sero- 
hemorrhagic catarrhal condition is found in the stomach and intestine. 
The gastric mucous membrane is covered with tough bloody mucus. The 
intestinal walls are injected, of a deep red color, and edematous. In the 
jejunum, there is a disseminated macular hyperaemia, with punctate or 
streaked hemorrhages. Peyer's patches are swollen and surrounded by a 
slight hyperaemia. Microscopically, the intestine may appear practically 
normal. More frequently, however, we see, besides a round cell infiltration, 
mucoid degeneration of the goblet cells. In severe cases there is destruction 
and marked loss of epithelium. In other organs, mild parenchymatous 
changes occur. In the liver, a capillary hyperaemia is a common occurrence 
and degeneration of the endothelial and liver cells is noted. Hyperacidity 
of the liver tissues and of the muscular tissues may be demonstrated by 
special staining methods. 

Etiology. The great resemblance of these symptoms to those of real 
cholera and cholera nostras in the adult, described in the older terminology, 
was the reason for the acceptance of an infectious etiology in the intoxica- 
tion of the infant. Even though toxic symptoms may raise secondarily in 
enteral and parenteral infections of the young child, this explanation is 
hardly tenable. Not only has it been impossible to demonstrate specific 
organisms, but the most careful clinical observations show that we have to 
deal with a condition of alimentary poisoning in which the question of 
specific pathogenic germs is not to be considered; but in which fermentation 
products of the food or constituent parts of the food itself are the etiologic 
factors. The importance of preformed poisons in the food (exogenous milk 
decomposition), must also be excluded, since intoxication may arise with 
absolutely aseptic food. 

Cases are seen in which the symptom-complex is of purely alimentary 
origin. In other and probably more frequent cases, there may be a mild 
infective process causing dyspeptic manifestations from which the intoxica- 
tion develops as a secondary alimentary complication. After the infection 
has been relieved, the intoxication persists and forms the essential part of 
the picture. A third large group shows no relation to the feeding and must 
therefore be considered purely infectious. 

The etiologic role played by the food is convincingly shown by the results 
of the withdrawal of food and the inauguration of the water-diet for thera- 
peutic purposes. In all pure cases, uncomplicated by infection, we observe 



DISEASES OF THE DIGESTIVE SYSTEM 



295 



a critical drop in temperature upon the cessation of feeding. In almost all 
such cases, which are not in extremis a critical detoxication also occurs 
If the food quantit}' be increased too rapidly after the hunger period, 
a relapse follows. Thorough investigations have shown that the causation 
of the diarrhoea and the fever is to be found in the action of the carbohy- 
drates of the food, combined with the whey constituents (Fig. 87). If these 
are given in sufficiently large quantity, their pyrogenic action may be aug- 
mented by the toxic effect. Large additions of fat alone may exhibit a 
toxic action; but a primary fat poisoning is possible only when the metabolic 
functions have been previously damaged by a severe sugar injury, or by an 
existing decomposition, or by severe infection. 

THE NATURE OF THE Toxic CONDITION; ITS PATHOGENESIS AND ME- 
TABOLISM. So far as the results of investigation of the metabolism go, at 
present they show that intoxication is due to an insumciencyof all of the inter- 




6% Without. + Sugar. Without + Sugar. 

Sugar. Sugar. Sugar. 

Flo. 87. Alimentary fever during buttermilk feeding, produced by the addition of sugar 
(shaded days) and relieved by the omission of the sugar. 

mediate metabolic processes, in which the evidences of acidosis are especially 
prominent. The present knowledge of the metabolism of these severe general 
disturbances permits the following statements as to theetiology. Thereis, no 
doubt, a far reaching injury to the intestine which permits abnormally free 
osmosis of the products of the perverted digestion from without inward and 
also, unquestionably, acts in the opposite direction. This condition is 
caused by the extreme decomposition of the ingested food, the products of 
which affect the mucosa. According to the older theory this abnormal per- 
meability of the intestinal lining permits the absorption of bacterial poisons, 
the cause of the fever and the toxic manifestations. More recently, however 
the blame has been laid on the sodium salts, sugar and protein, for clinical 
observation on the pyretogenic and toxic action of these substances make 
it apparent that the physicochemical disturbance must be taken into con- 
sideration. It is possible that the portal blood carried to the liver is in a con- 
dition of osmotic imbalance, this injures the liver cells resulting in catabolic 
products which are causative factors of free purgation. Some experimental 
foundation for this theory has been brought out. If the diarrhoea becomes 



296 TEXT-BOOK OF PEDIATRICS 

very severe, there is a great dehydration and ultimately a lack of water in 
the tissues. In such a condition of dehydration, the oxidation processes 
would naturally be impaired. Very probably poisonous derivatives of food 
proteins or of body protein catabolism carry on the toxic condition. This 
would place great emphasis on the importance of the acute loss of water in 
the etiology of intoxication. This conception is supported by the fact that 
detoxication always occurs as soon as water retention is established. 

Diagnosis. The alimentary fever is to be distinguished from fever due 
to infection in that it is always abolished when food is withdrawn, or when 
a marked reduction of food is made. In a general way, this is also true in 
case of alimentary intoxication. But cases with severe toxic symptoms are 
either relieved very slowly or not at all by this reduction. Here, no doubt, 
the continuation of the symptoms is due to the persisting loss of water. If 
it is possible to cause water retention detoxication at once begins. These 
obstinate forms are unquestionably ones in which the intoxication is com- 
plicated with infection, the condition being infectious rather than purely 
alimentary. In other cases the carbohydrate and salt of the diet are so low 
as to prevent water retention. Finally, the bowel condition may be so 
serious that the cessation of feeding alone will not result in sufficient repair 
to prevent further loss of water. 

Prognosis. The prognosis is influenced less by the severity of the 
clinical findings than by the duration of the toxic condition, as well as by the 
status of the child at the incidence of the intoxication. Acute attacks, in 
previously healthy children, frequently encountered in those who are overfed 
upon buttermilk with large additions of sugar, if promptly and energetically 
treated by .correct methods, have, in spite of the severity of symptoms, 
a good prognosis. Long duration of the toxicosis is naturally detrimen- 
tal even to such children. A clinically mild attack of intoxication in 
children suffering with decomposition is very dangerous; because it is liable 
to overcome the remaining tolerance and because the unavoidable hunger- 
period is particularly serious. Every infection causes an irreparable com- 
plication of the condition. The difficulty of dietetic treatment of intoxication 
caused by infection depends (upon the severity of the infection. The 
weight-curve gives the best index of prognosis. On account of the effect of 
water retention upon the weight-curve, the prognosis is more grave the 
longer the time required to bring the weight to the horizontal. 

Treatment. In severe cases, the complete withdrawal of food for the 
removal of toxic conditions cannot be avoided. The free supply of fluids 
must not be interrupted and this is best met by giving large quantities of 
weak tea. Since the greater danger of sugar intoxication is avoided by dis- 
continuing all other feeding, it is well to sweeten the tea with benzosulphi- 
nidum (saccharin). 

In order to arrest the drying out process as speedily as possible, salt 
solutions have been recommended instead of tea; [e. g., physiologic salt 
solution, Heim-Johns' solution (NaCl 5.0, NaHCO 3 5.0, Aq. 1000), 



DISEASES OF THE DIGESTIVE SYSTEM 297 

Mery's vegetable bouillon, or Moro's carrot soup 6 ]. All of these solutions 
have the disadvantage of frequently prolonging the pyrexia through the 
pyogenic action of the salt. In certain circumstances, they even aggravate 
the toxic condition. They should, therefore, be well diluted (1:2 water), 
and should be employed only after the elimation of the poison has begun. 

No objection can be made to subcutaneous injections of a physiologic 
salt solution, if contamination of the water is avoided by distillation. The 
0.3 per cent, solution of the so-called detoxicated salt solution (7 gms. NaCl, 
1 gm. KC1 and 0.2 gm. CaCl in 1000 c.c. water) is preferable to the physio- 
logic solution. This solution is also absorbed very rapidly from the perito- 
neum and may be given under conditions of ordinary surgical asepsis 
in amounts of 500 to 750 c.c., repeated daily. 

The intestine may be emptied rapidly by washing the stomach and 
colon. This, however, is not absolutely necessary. Cathartics should not 
be used in severe diarrhoea; while stimulants, caffein salts, camphor, 
digalen, }/-l drop every three hours; epinephrin, 1 : 1000, 0.5 c.c. (7 minims) 
with pituitrin 0.25 (grs. ii) intramuscularly every three hours: or brandy 
cannot, be dispensed with. Tepid baths should be used to control the high 
temperature; while frequently repeated cold packs should be avoided because 
of the danger of collapse. If the skin is cool, a warm mustard bath may be 
considered. Jactitation, convulsions, and severe attacks of pain make the 
exhibition of narcotics desirable; chloral, however, must be avoided because 
it may produce-a soporific condition lasting for days. Veronal 0.075-.015 gm. 
(1-3 grs.), or sodium diethylbarbituate, 0.05-0.1 gm. (1-2 grs.) per dose, is 
better. Stomach washing and local anesthetics are most useful when there 
is vomiting. (See Pylorospasm.) 

In favorable cases of simple intoxication, the poison is completely 
removed in from twenty-four to thirty-six hours of starvation (Fig. 88). 
Although the child grows weak and thin, it is lively, its eyes are clear and 
the bowel movements are less frequent. After such a period of starvation, 
it is absolutely necessary that feeding be resumed. The prime object of 
treatment should be to keep the symptoms of intoxication in abeyance by 
the smallest possible amounts of. food; increasing it very gradually during 
the first few days, while a plentiful supply of liquids is given. 

The course of treatment most to be commended is the feeding of breast- 
milk. Even with this, it is best to feed small quantities frequently. It ifc 
well to begin by giving the child 5 c.c. five times during the first day, 10 c.c. 
five times or 5 c.c. ten times on the second day; and 10 c.c. ten times on the 
third day; thereafter, at first slowly, and then more rapidly, giving larger 
quantities in fewer feedings. The sooner the danger of inanition is removed 
the better; on the other hand, great care must be exercised to avoid an 
aggravation of the condition by too rapid increase of food. This aggrava- 
tion is shown in the renewed appearance of the toxic symptoms. It is better 

6 Carrot soup is prepared as follows : One pound of carrots scraped, cut into small 
cubes and boiled one to two hours. The soft carrot is passed through a fine sieve, into 
bouillon made with one pound of beef in one litre of cold water; to this is added 
one teaspoonful of table salt. 



298 



TEXT-BOOK OF PEDIATRICS 



to feed the expressed breast-milk from the bottle at first; and often it is 
better cold than warm. After a few days of feeding by this method the 
child may be returned to the breast. 

With the use of artificial food, detoxication may also be accomplished if 
small enough amounts are fed. The mixture must naturally be one in which 
there is a minimum of fermentable carbohydrate and one which affords the 
maximum water retention. A food containing very little fat. and sugar and a 



Weight. 



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and whey (buttermilk). Reduction of 
ich the amount of food is very gradually 



liberal amount of whey fulfils this requirement and buttermilk or skimmed 
milk without additions, are ideal. Whey has also been recommended but 
has no advantage over buttermilk. It is, in fact, less satisfactory because of 
the lack of casein which counteracts fermentation. The dosage and number 
of feedings should be as recommended for breast-milk. Even before the 
weight-curve becomes stationary, carbohydrate may be added and then the 
buttermilk gradually replaced by a whole milk mixture. After this, the 
treatment is that described for dyspepsia. 

In those cases in which the poison is not fully eliminated, cases which 
were formerly classed as forms of mixed alimentary intoxication and infec- 



DISEASES OF THE DIGESTIVE SYSTEM 299 

tion, or those which should be included in the severe type of decomposition, 
the feeding must approximate that recommended above. Further star- 
vation undoubtedly causes death. The only possibility of recovery lies in 
giving the small remnants of functional ability an opportunity to recuperate 
with a dietary as large as they can utilize. With children in the severer 
stages of decomposition this merely prolongs the trouble, while with infec- 
tions, on the other hand, the disorder is frequently overcome and 
convalescence sets in. It is better, therefore, to rise very gradually to food 
quantities which are just sufficient to sustain life and to await results. 
Hopeful progress with these children may be expected from buttermilk with 
thf> addition of breast-milk or protein-milk, with a five per cent, carbohy- 
drate addition. Protein-milk in itself seems to fulfil all the requirements and 
may be used without fear, if given in the same dosage recommended for 
the other foods. 

INFECTION AND NUTRITION 

Attention has been called already to the greater predisposition of the 
child with disturbance of nutrition to infections. As an actual fact, 
in but very few cases does the disturbance run its course without bac- 
terial complications. Of most frequent occurrence are the infections of 
the skin, furunculosis and other pyrodermias, phlegmons and erysipelas; 
next in frequency are diseases of the air passages and lungs; sepsis and 
pyemia with their varied courses follow; pyelocystitis, otitis, and infections 
of cerebral localization also occur. These infections are not only incurred 
more readily, but because of the reduced resistance they run a more severe 
course, tend to spread and may become serious. A furuncle may increase to 
a phlegmon which extends with remarkable rapidity; severe pneumonia 
may follow la grippe, etc. The slow healing of the infected wounds in nutri- 
tionally disturbed children is very noticeable. 

In turn, the course of any disturbance of nutrition is unfavorably influ- 
enced by each infection. A further reduction of functional energy is the 
inevitable result of the intercurrent injury. Every degree of effect may be 
noted, according to the resistance of the patient and the virulence of 
the infection. 

An infection does not necessarily produce a secondary disturbance of 
nutrition, or one, at least of a severe nature. In healthy children, it fre- 
quently passes without loss of weight or even with a continued gain in 
weight. The stools may remain normal (Fig. 89). The bowel movements 
vary in different infections; hard, formed stools may occur in pyemia; while 
la grippe and colon bacillus infections produce thin, mucoid movements, the 
infectious nature of which is recognized by the fact that they are uninflu- 
enced by dietetic therapy. Loss of weight in these cases is usually due rather 
to diarrhoea and vomiting. On the other hand, in constitutionally weak 
children and in those with a disturbance of nutrition, unimportant infec- 
tions (e.g., vaccination, Fig. 90), produce serious alimentary injuries. 
Of course, healthy children may be nutritively affected, either early in the 
course of a highly virulent infection, or later because of the gradual exhaus- 



300 



TEXT-BOOK OF PEDIATRICS 



Week 



Weight 


z. 


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4. 


J>. 




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0<if 


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protein-milk. No marked disturbance of nutrition (contin- 
ued gain in weight, stools but little more frequent and but 
slightly changed). 



tion of their original tolerance. 
The diet is to a certain degree 
important. Other conditions 
being equal, a given infection 
will produce a secondary disturb- 
ance of nutrition more readily 
in children fed upon those diets 
which tend to produce dyspepsia 
(e. g,, milk dilutions with carbo- 
hydrate additions, or buttermilk 
mixtures rich in carbohydrates), 
than in those fed with mother 's 
milk or protein-milk. The con- 
ception of a relationship between 
infections and disturbances of 
nutrition has been already 
reviewed. 

Symptoms. The symptoms 
of mild secondary disturbances 
of nutrition resemble those of 
dyspepsia; that is, besides the 
signs of infection, dyspeptic 
stools occur, which may be im- 
proved by changes in diet while 
the fever continues. In contrast 
to simple inanition we have a 
marked and sudden loss of 
weight even when a fairly large 
quantity of food is being taken. 
This indicates a severe disturb- 
ance of nutrition, the character 
of which gradually comes to 
resemble more and more closely 
alimentary intoxication. The 
threatening loss of weight may 
be overcome, in many cases, by 
the same methods employed in 
a primary alimentary intox- 
ication. The manifestations 
characteristic of the infection, 
however, remain. It is quite 
certain that a large percentage 
of cases running a severe toxemic 
course and formerly classified 
as general septic intoxications, 
were, in fact, no more than com- 



DISEASES OF THE DIGESTIVE SYSTEM 



301 



plications of a severe secondary intoxication which could have been cured 
by dietetic therapy. 

The combination of infection and disturbance of nutrition, that is of 



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2to4<7c 

Dextrin 

Sugar. 



FIG. 90. Severe secondary disturbance of 'nutrition resembling intoxication occurring as the result of 
vaccination. Recovery on diet of protein-milk. + = pathologic stools; I = normal stools. 

alimentary fever and alimentary intoxication, produces many interesting 
complications. For instance, a fever may be partially due to infection and 
in part to alimentary causes; and the necessary changes in diet will then 
cause a lowering of the fever by eliminating the alimentary factor, so that 



302 TEXT-BOOK OF PEDIATRICS 

the hyperpyretic course becomes moderately febrile. Or, that which starts 
as an infective fever may lapse into an alimentary fever, without recogni- 
tion of the change, since the infection has been overcome while the added 
secondary disturbance of nutrition sustains the fever, which yields only to 
a reduction of the food supply. Finally, the child may be so severely 
injured by the infection that the existing toxic condition is maintained, 
even in starvation, by an autotoxicosis. 

After successfully combating an infection, many children, easily nour- 
ished before the infection, remain in a state of exhaustion which is exactly 
like the condition produced by a primary transgression of the limits of 
tolerance. The post-infective disturbances of nutrition, therefore, resemble 
in their symptoms and their reaction to food the picture of dystrophy, 
dyspepsia or decomposition. 

Diagnosis. The most important symptom of a secondary disturbance 
of nutrition, aside from the diarrhoea, the significance of which is not always 
clear, is the continuous loss of weight. If an infected child continues to 
lose weight rapidly, the cause must be a disturbance of nutrition, unless, 
indeed, the child absolutely refuses food. The loss due to slight underfeeding 
would cease in several days, or would be gradual. The reaction to the with- 
drawal of food or to other changes in diet would in itself show what symptoms, 
dependent upon the dietetic influence, could be considered alimentary. 

Treatment. With young infants the hope of overcoming an infection, 
and especially one complicated by disturbances of nutrition, is much 
greater if the child is fed at the breast than it is with the customary methods 
of artificial feeding, so that one must urge the use of breast-milk if it may 
possibly be obtained. Recent experiences have taught us that quite suc- 
cessful results may be obtained by the use of protein-milk (with a 3 to 7 per 
cent, addition of sugar). Under no circumstance, should the child be 
reduced to a state of inanition. Even with the most satisfactory diet, to 
say nothing of the rather generally used flour food, the patient is seriously 
handicapped by an insufficiency of food. As soon as loss of weight ceases, 
or even when the loss is slight, the food may be increased and should always 
be sufficient to allow an excess over the absolute necessity of repair. Only 
when a sudden fall in weight occurs and toxic symptoms appear should the 
food be discontinued for a half -day and then resumed in small quantities, as 
indicated in pure alimentary intoxication. In using protein-milk, a reduc- 
tion of the carbohydrate content below three per cent, should be avoided. 
When the poison is not entirely eliminated by these methods, the food 
quantity must be increased in the same manner as heretofore advised. By 
this means, many children are saved who would certainly be lost under a 
starvation method. Diarrhoea alone is not sufficient reason for reducing 
the quantity in either form of feeding. 

If the child is taking other forms of food at the outset of its sickness, 
and especially within the first three months of life, the change to breast-milk 
or protein-milk is to be recommended. If this is not possible, starvation is 
still to be avoided. If we are forced to reduce the quantity of food because 
of severe diarrhoea, sudden loss of weight, or symptoms of intoxication, the 



DISEASES OF THE DIGESTIVE SYSTEM 303 

case is extreme and the prognosis very questionable; at least among very 
young children but a few can be saved without the change of food. Of 
course, children suffering with infections may recover successfully with other 
food mixtures, but the percentage of unfavorable cases in very young 
infants is, other things being equal, considerably reduced with either the 
natural food or protein-milk. 

THE DISTURBANCES OF NUTRITION OF BREAST-FED INFANTS 

With the exception of actual underfeeding, the most important form of 
disturbance of nutrition of the breast-fed child is indicated by diarrhoea, 
with a "dyspeptic" condition of the stool. We should guard against making 
a diagnosis of a disturbance of nutrition upon the least variation of the 
bowel movement from the usual picture of the normal breast-milk stool, 
which is of a golden yellow and an inoffensive odor. Many children fed at 
the breast have occasionally or continuously green, thin, slimy evacuations 
containing fat flakes, incorrectly called " curds, " which may be increased in 
number or otherwise changed without any special effect upon the general 
well-being. The causes and conditions which bring about such a changed 
consistency of the stools have not been wholly explained, but in no case do 
such stools justify the intervention by the physician and certainly not a 
departure from the method of feeding, either in a change of wet-nurse, a 
reduction of quantity, or, least of all, weaning. The child is to be considered 
diseased only when, besides seemingly abnormal evacuations, other certain 
signs of disturbance of development and of general well-being are found. 

A distinction must be drawn between the exogenous diseases, i. e., 
diseases due to causes extrinsic to the child itself, such as excessive feeding, 
improper composition of the food, heat, or intercurrent infection and the 
endogenous diseases, due to the constitutional peculiarities of the child which 
cause a pathologic reaction to mother's milk. The former may be recog- 
nized clinically by the fact that they always occur more or less acutely after 
a period of normal development, while the latter appear immediately after 
birth and are chronic. It goes without saying that a disease of the first 
category may occur during the first few days of life. 

Etiology. The diseases due to improper composition of the milk play a 
large part as representatives of the first group. Formerly it was supposed 
that the milk of certain women could not be safely taken by infants. In 
other cases, the breast-milk was thought to be so affected by passing dis- 
turbances in the condition of the nursing mother, such as acute and chronic 
diseases, errors of diet, menstruation, psychic irritation, and even substances 
directly transmitted from the mother's food, as to do serious injury to the 
child. These beliefs, as a whole, must be classed as superstitions. Only in 
the event of menstruation or of intercurrent pregnancy is it possible that 
vomiting, restlessness, dyspeptic stools, may occasionally occur; but even 
then with but a small number of children. These disturbances are under no 
circumstances so serious as to warrant interference with, or change in diet, 
unless, of course, the breast ceases to functionate. 



304 TEXT-BOOK OF PEDIATRICS 

Of far greater importance, as causes of the injuries belonging in this 
category, are overheating, exposure to cold, neglect and, especially, infec- 
tions. The parenteral infections, occurring with enteral or gastro-intestinal 
symptoms (coryza, la grippe ; cystitis, stomatitis, etc.), may develop with 
such clear evidences that a diagnosis is readily made. Very frequently 
their course is so mild that, aside from the dyspeptic manifestations, only 
the most careful observation, as may hardly be had in the home, will give a 
good understanding of the conditions. Such cases are diagnosed incorrectly 
as the result of the harmful action of the breast-milk. 

Overfeeding is another cause of dyspepsia. It seldom occurs with 
regular and infrequent nursing, but rather when the nourishment is irregu- 
larly given and at frequent intervals. The total quantity of the food is 
probably none too great in these cases. 

Finally, hunger, that is, underfeeding, and probably only in certain 
individuals peculiarly susceptible, may bring about the symptom-complex 
of dyspepsia. 

The symptoms of a disturbance of nutrition in the breast-fed child are 
practically the same as those of dyspepsia in the bottle-fed. Severe condi- 
tions are much more infrequent than in children under artificial feeding; 
but they do occur, sometimes with the picture of decomposition and more 
frequently in a transitional form between dyspepsia and intoxication ; that 
is, with fever, apathy, lactosuria, etc. It is very improbable, however, that 
in these serious cases the food alone has had an unfavorable influence. They 
would rather appear in the first instance to be due to unskilful attempts at 
therapeutic starvation, and, second, to be incident to added infection. 

Diagnosis. The diagnosis of the dyspepsia of the overfed is made by 
the history and by determining the excessive quantity of milk. In other 
forms, it must be made by a careful observation of the environment as well 
as of the symptoms and the course of the disease. 

Treatment. Interference in the latter conditions is generally not only 
unnecessary, but strongly contraindicated. It is better to encourage the 
mother and to wait patiently until recovery takes place spontaneously. 
But with the dyspepsia of overfeeding, treatment must be more active. 
Stringent rules of nursing are necessary and, in severe cases, at times a 
marked reduction of the food quantity is required. If the child, being used 
to a large quantity of food, becomes restless, tea with benzosulphinidum, 
(saccharin), may be given; or, if necessary, during the first few days, a mild 
sedative, such as sodium diethylbarbiturate (medinal), chloral hydrate 
one teaspoonful of a one per cent, solution, two or three times a day or, in two 
per cent, solution, one teaspoonful, every two or three hours. Dyspepsia 
due to hunger recovers on the contrary, if sufficient food is given. In cases 
of other etiology, it is usually advisable to wait. Only when severe loss of 
weight occurs and slight somnolence, cyanosis and other indications of a 
more severe condition appear, is it necessary to give the breast-fed child a 
short hunger period and then to increase the food quantity gradually, as in 
the case of the artificiallv-fed babe. 



DISEASES OF THE DIGESTIVE SYSTEM 305 

DISEASES DUE TO ENDOGENOUS (CONSTITUTIONAL) CAUSES 

Symptoms. Children are occasionally seen who, from birth, do not 
develop well with breast feeding. In severe cases, there may be loss of 
weight, due to the lack of appetite, and with this distinct and frequently 
marked signs of dyspepsia. In typical instances, there is anorexia, severe 
flatulence, attacks of colic, frequent eructations, hiccough and regurgitation 
and withal a great general restlessness and emaciation. The stools fre- 
quently show the characteristics of a fat diarrhoea. By a combination of 
all these signs with eczematous and intertriginous changes, serious disease- 
pictures may arise. With many of these children, other signs are found 
which are indicative of a neurotic diathesis, such as : loss of muscle tone or 
hypertonicity, ptotic manifestations (diastasis of the recti, floating tenth 
rib, visceral ptotic, hernias, etc.), a tendency to be readily frightened, an 
increased muscular irritability, vasomotor pallor, etc. Furthermore, the 
history may reveal hereditary nervous stigmata. 

Etiology. Formerly there was a tendency to blame the unfit composi- 
tion of the breast-milk for the disease-picture we have described : that is, the 
milk was supposed to be too rich. While it must be admitted that in 
exceptional cases improvement is had by a change of wet-nurses, it is the 
common rule that such children do not develop properly with any breast- 
milk. Considering, moreover, that the very food which is of so little advan- 
tage in these cases is satisfactory for other children, it is clear that not the 
food is to be blamed, but rather the constitutional peculiarity of the child 
which causes the paradoxical response to natural feeding. In fact, we have 
to do, on the one hand, with neuropathic individuals; and, on the other 
hand, with representatives of that anomalous constitutional quality 
which, at present, we prefer to designate as an exudative diathesis. Both 
of these conditions may appear separately or together. No clear conception 
of the relation between the constitutional disturbance and the symptoms 
referable to the digestive apparatus has yet been formed. 

Treatment. In the treatment of these disturbances, the customary 
change of wet-nurses is not to be recommended. Only rarely is it possible 
to find a wet-nurse whose milk will be better for the child than its mother 's 
and very probably the expected result will not be obtained by even a num- 
ber of changes. An especial warning must be given against the attempt to 
treat dyspeptic symptoms in these cases with starvation. Hunger never 
does any good and is always harmful. On the other hand, we may resort to 
satisfactory measures, the action of which is not to be entirely explained, 
in the way of additions to the human milk of protein preparations, or in 
the complemental feeding of cow's milk. One dram of calcium casein- 
ate in one ounce of mineral water, may be given three to five times a 
day from the bottle, or with a spoon. Of the cow's milk mixtures, the 
buttermilk mixture gives the best results. In mild cases, the addition of 
one meal may be sufficient, while in more severe, two or three may be 
necessary with a corresponding reduction in the quantity of breast -milk. 
The results of both of these methods, in the increase of weight and of appe- 
20 



306 



TEXT-BOOK OF PEDIATRICS 



tite and in the improvement of the general condition are almost always 
astonishing (Fig. 91). In many cases, however, the stools remain slightly 
dyspeptic for a long time. 

Idiosyncrasies. Occasionally a dyspepsia, due to constitutional causes, 
reaches such a grade of severity that we may speak of an idiosyncrasy to 
breast-milk. The patient may even die despite of mixed feeding or weaning. 
This may, of course, be considered as the result of a long continued inanition 
due to the spontaneously inadequate nursing, or to the misdirected attempts 
at remedy on the part of the physician. Another rare form of idiosyncrasy 
to breast-milk is seen in the fainting spells which occur from birth at every 
nursing, or at least several times a day, and which disappear after weaning. 
It is not certain whether the composition of the breast-milk itself produces 



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FIG. 91. Recovery from severe endogenous constitutional dyspepsia by the use of breast-milk 
with addition of dextrin and maltose and mineral water. 

the injury in these cases or, as seems more probable, that the exertion of 
sucking, incident to an abnormal vasomotor irritability, is at fault. 

The idiosyncrasy of some breast-fed children to cow's milk is also of 
importance. These children, having acquired a disturbance of nutrition 
under artificial feeding, when given breast-milk develop satisfactorily, but 
when the attempt at weaning is again made respond to the first addition of 
cow's milk with an abnormal reaction. This has been observed in mixed 
feeding with doses of cow's milk as small as 5 c.c. or less. The symptoms 
vary according to the doses and the sensibility of the child. In mild cases, 
they resemble a slight dyspepsia, with fever, which appears a few hours after 
the cow's milk has been given; in severer cases, the complete picture of an 
intoxication, with even a fatal ending, may be produced. 

Such children must be fed at the breast for a long time until they gradu- 
ally lose their sensitivity. Sometimes it is possible to develop a tolerance by 
increasing the quantity of cow's milk drop by drop. Severe toxic reactions 



DISEASES OF THE DIGESTIVE SYSTEM 307 

must be treated by prompt withdrawal of the food and, later, by such care- 
ful feeding as in intoxication; for even though the cow's milk be wholly 
discontinued and the child be permitted to take as much mother's milk as 
it wants, an unfavorable result may be unavoidable. 

DISTURBANCES OF NUTRITION OF OLDER CHILDREN 

After the first year of life, more particularly after the second year, the 
constitution of the child is, as a rule, so firmly established that the severe 
disturbances of nutrition which so frequently develop in the nursling are 
hardly ever encountered. Its disturbances are usually classified as acute or 
chronic dyspepsias. They correspond in fact, to those conditions which 
have been described above for dyspeptic infants within narrower lines, in 
that their symptoms are entirely those of local fermentation and irritation, 
while the general well-being and the metabolism at large are not altered in 
any noticeably severe degree. Nevertheless, occasionally, even in older 
children, symptoms appear which in their form and mode of onset are 
distinctly those of alimentary fever and alimentary intoxication (see acute 
dyspepsia); and, similarly, chronic (disturbances develop of so severe a 
nature that they fit completely into the picture of decomposition (compare 
chronic digestive insufficiency). The probability of a pathogenetic identity, 
with slight variations between the disturbances of nutrition in these older 
and younger children, is the more readily conceivable when we consider 
that in both the same therapeutic principles give identical results. 

ACUTE DYSPEPSIA AND DYSPEPTIC COMA 

Symptoms. Acute dyspepsia has a sudden onset and is initiated by 
headache, loss of appetite and malaise, with nausea, vomiting, and fever and 
frequently, marked prostration. The tongue is coated, there is strong fetor 
from the mouth, frequently a distinctly acetone odor, slight distention of the 
abdomen, constipation and often, later, diarrhoea. The pulse is rapid and 
may also be variable, or occasionally slow and irregular. Albumin and casts 
are usually found in the urine. 

With proper treatment this condition does not last long; convales- 
cence may set in after two or three days, or even less. In other cases, 
it may drag on for a longer time and a condition which may be called 
"status gastricus" develops. 

In a considerable number of cases, other symptoms are associated with 
those enumerated which make the disease-picture more impressive. These 
symptoms in their variety and intensity are those recognized in the intoxi- 
cation of infants, and, when sufficiently developed, produce dyspeptic 
coma. Before the disturbance of consciousness goes on to coma, symptoms 
of spinal and cerebral irritation may appear, occasionally severe convulsions 
continuing for hours; deep respiration is observed, and sugar, or at least 
strongly reducing substances, may occur in the urine. The acetone odor is 
especially strong and unusually large amounts of acetone can be demon- 
strated in the urine. 

The prompt results which follow in one or two days after emptying the 



308 TEXT-BOOK OF PEDIATRICS 

intestine, show that the cause of these symptoms, as of simple dyspepsia, is 
an intoxication arising in the digestive tract. Nothing further is known 
about the poison. It is very doubtful however whether we have to deal with 
acetone poisoning, as was formerly believed. The clinical resemblance, 
also, to intoxication in the infant indicates that similar conditions are 
causative. A dietetic error, an overloading of the stomach or some similar 
circumstance is usually the .cause of the dyspepsia; but frequently such a 
cause cannot be established. Then, doubtless, an infection of some kind 
has given rise to the appearance of secondary alimentary disturbance, the 
symptoms of which still remain after the removal of the signs of dyspepsia. 
This frequently occurs in the course of influenza. 

The diagnosis is not always easy at the beginning. Typhoid and 
paratyphoid, meningitis and similar conditions may come up for consider- 
ation. Many disturbances diagnosed as dyspepsia are certainly nothing 
more than an infection exhibiting gastro-intestinal symptoms. The surest 
differentiation is given by the prompt results of a thorough empt3dng of the 
stomach and intestine, after which any disturbance that can be classified 
as dyspepsia must disappear; if symptoms remain, it is certainly not pri- 
mary dyspepsia, but only dyspepsia accompanying some other disease. 

The treatment consists in the removal of the gastro-intestinal con- 
tents as rapidly as possible. Calomel 0.05-0.1 gm. (1-2 grs.), repeated two 
or three times; castor oil, rhubarb, etc., are used for n catharsis; enteroclysis, 
or glycerin enemata are useful. Occasionally gastric lavage may be em- 
ployed. Emetics, such as syr. ipecac 4 c.c. (1 dram), wine of antimony a 
teaspoonful, are not of much use. This treatment should be followed by a 
liquid diet; for several days small amounts of food should be given and 
finally a tonic. 

An "asthmatic dyspepsia" must also be described. This is a condition 
which begins suddenly with dyspnoea, lasting for hours or days, and is 
relieved by emptying the intestinal tract. How much of the effect is 
mechanical and due to meteorism, or the high position of the diaphragm, 
and how much is due to reflex action and intoxication imposed upon a ner- 
vous constitution is not clear. 

CHRONIC DYSPEPSIA 

(Chronic gastro-intestinal catarrh, chronic intestinal and colonic 
catarrh.) 

In the majority of cases, chronic dyspepsia develops from an acute 
intestinal disturbance, usually of infective origin which may be either 
enteral or parenteral. A primary acute dyspepsia is less frequently causa- 
tive. In certain patients the onset is very gradual and neither the period of 
incidence nor any external influence is recognized. In these cases, constitu- 
tional faults are of probable importance, since there are no dietetic errors to 
explain the congenital or even the familial disabilityof the digestivefunctions. 

The greater number of cases occur during the second to the fourth 
year. At later age disorders of this class are more infrequent. Many 



DISEASES OF THE DIGESTIVE SYSTEM 309 

chronic intestinal disturbances of older children have their beginning, how- 
ever, in infancy. Various forms of chronic dyspepsia are seen. 

Chronic dyspepsia of gastric origin is infrequent compared with other 
forms. It occurs in lean, pale, capricious, morose children where the one 
symptom indicative of gastric disorder is a marked anorexia. To this may 
be added occasional eructation and vomiting and sometimes the abdomen is 
distended in its upper portion. With the test-meal, we find abnormal 
chronic conditions in the way of a slight catarrh and a particularly marked 
motor insufficiency of the stomach which, in severer cases, is combined with 
atony or even gastro-paresis. 

Gastro-paresis is a condition of hypotonicity, in consequence of which 
distention of the stomach becomes abnormally great even with moderate 
amounts of food. The most extreme degree is atony or atonic dilatation, 
in which the stomach cannot regain its normal size even when empty. It 
contrasts with the mechanical distention of organic stenosis in that it 
exhibits no anatomic changes in the gastric walls. Mild degrees of gastro- 
paresis are frequently found in cases of general debility and improve when 
this is removed. Only those cases are of importance to the physician in 
which the insufficiency of the organ is so great as to be the chief cause of 
existing symptoms. 

Constipation is common, although gastric fermentation may produce 
intestinal irritation and chronic diarrhoea. This must always be considered 
as gastric in its origin. 

Severe grades of the disease may lead to marked exhaustion and may 
even result in death. With careful treatment, the prognosis of even the 
more advanced cases is quite favorable. A considerable time may elapse, 
however, before complete recovery results. In its diagnosis, nervous ano- 
rexia must be considered. Usually it may be differentiated without the use 
of the stomach-tube, since children with nervous anorexia are lively and the 
appetite for some kinds of food is good. With existing diarrhoea, the differ- 
entiation from other forms of dyspepsia must be made with the stomach- tube. 

In the common form of chronic dyspepsia disturbance of the gastric 
function is not so prominent a symptom. In the disease-picture the intes- 
tinal symptoms, and especially diarrhoea, overshadow all others. Lancinat- 
ing and colicky pains may occur. The appetite is variable ; it may even be 
good. The evacuations are commonly not very numerous and contain 
more or less mucus. The stools present variable special findings. Their 
reaction may be either acid or alkaline. Undigested food particles may con- 
sist of fat, starch and vegetable shreds. Connective tissue shreds are found 
only after the ingestion of raw or partially cooked meats; muscle fibres are 
rarely seen. Foamy fermentation is present a fermentation so intense that 
it continues after the evacuation of the discharges. The general health is 
affected in proportion to the difficulty of feeding; nutrition is more or less 
unsatisfactory. Mild anemia is common and, in younger children, rickets. 
The majority of cases show symptoms of nervous irritability and in infants 
latent spasmophilia is common. 



310 TEXT-BOOK OF PEDIATRICS 

The repeated occurrence of exacerbation is very characteristic of this 
disease. An aggravation may be brought on by other intercurrent diseases 
(respiratory catarrh, etc.), or by overfeeding or improper food. A repeti- 
tional attack may be accompanied by severe diarrhoea with blood and 
mucus, accompanied by fever, with serious impairment of the general 
health. Even choreiform or typical attacks of tetany may occur. Many 
undigested particles, or even larger masses of food which have not properly 
been broken up, may be found in the stools at this time. 

Of the cases belonging to this group, quite a large number are in the 
nature of fermentation dyspepsia, due to imperfect digestion of carbohy- 
drates (A. Schmidt). In these, the evacuations are thin or pasty, of varying 
consistency, containing variable amounts of mucus; they are light in color 
and filled with bubbles. i Their reaction is acid and the odor, sour. The iodine 
test gives a strong starch reaction. Microscopically, one may discover, 
besides the starch cells, many iodophilic bacteria. Careful chemical analysis 
shows that, on the average, the carbohydrate content of the feces is more than 
doubled. In the saccharimeter, fermentation occurs after twenty-four hours. 

Typical cases of this kind can be readily diagnosed; indeterminate forms 
in which the consistency of the stools is not so characteristic are probably 
more common. In these, one may have stools of darker color, of changing 
reaction, with no response to the starch test. In spite of these findings, it 
must be remembered, in seeking proper therapeutic measures, that some 
carbohydrate is the initial cause of the fermentation dyspepsia. While the 
carbohydrate may have been so well digested that no free starch is found in 
the colon, we may still have acid formation. The acid reaction may be neu- 
tralized by the secretion of the large quantities of the alkaline intestinal fluids. 

It is probably true of older children, as well as of infants, that a disturb- 
ance of carbohydrate digestion is the primary cause of dyspepsia; that the 
disturbance of fat and protein digestion is secondary to the amylolytic and 
glycolytic failure, and that the absorptive and peristaltic failure are caused 
by the acids of carbohydrate fermentation. The supposition that a 
primary fat or protein digestive disturbance is the basis of this lienteric 
condition is, in general, unjustified. 

Mucous Colitis. Only in one special form of disease which should be 
classed not as a dyspepsia, but rather as a catarrh due to local irritation, 
does the protein digestion play a particular role. This is mucous colitis. 
This disease, which runs its course without important suggestive symptoms, 
is characterized by the passage of large quantities of mucus, at times 
jesembling casts of the intestine and again covering the fecal masses. In 
this condition, children have usually been fed large quantities of meat and 
eggs, while the vegetables and carbohydrates of the diet have been reduced. 
The constipation thus produced is usually the cause of the catarrh of the 
colon which results in this excessive mucoid secretion. Mucous colitis must 
not be mistaken for membranous enteritis or mucous colic, a condition in 
which long white shreds and tubular casts of the intestinal tube are passed 
under extremely severe pain. These shreds and casts consist of mucin; the 



DISEASES O* THE DIGESTIVE SYSTEM 311 

disease involves no inflammation of the mucous membrane. Their evacua- 
tion occurs at intervals of weeks or months. The disorder is probably in the 
nature of a secretory neurosis. 



Those not infrequent cases which are termed severe chronic digestive 
insufficiency in older children must be regarded as chronic dyspepsia in its 
most severe forms. Children affected with this condition usually come from 
families with a severe neuropathic taint and often show neuropathic symp- 
toms themselves. While some of them have passed infancy without notice- 
able disturbances; others have shown, even at this time, lowered resistance, 
and digestive failure. The actual disease begins insidiously or as a sequel 
to acute dyspepsia or to an infection. Its chief characteristic is the marked 
liability to digestive disturbances. Slight dietetic errors, or unimportant 
infections promptly produce intestinal symptoms severe in themselves and 
of severe effect upon the general well-being. It is not uncommon to see a 
loss of several pounds in weight within a few days in connection with a 
slight coryza, a vaccination, or following the ingestion of some unaccus- 
tomed food. Extreme weakness and debility are cause for anxiety. A 
choleric alimentary intoxication with all its typical symptoms may develop. 
A second characteristic peculiarity is the stunted growth and retarded gain 
in weight. The occurrence of long periods with no gain in weight, even 
though there is no intercurrent disease, show how greatly the growth suffers. 
Children of four years, but with the weight of a twelve months old infant 
and with size corresponding to weight are not uncommon; so that we may be 
justified, to a certain extent, in speaking of this as a type of infantilism. A 
third characteristic may be mentioned in the abnormally reduced capacity 
for repair. 

While it is possible in ordinary forms of dyspepsia to restore the intes- 
tine to normal functional ability after several weeks of careful dieting, in 
these severe forms a sensitivity remains, even after the bowel movements 
have been normal for a long time. A slight change in, or increase of diet 
may immediately cause an aggravation of the disease. 

The number of evacuations, excepting during these times of intercur- 
rent aggravation, is normal or but slightly increased. The massiveness of 
the stool is especially noticeable; it may weigh a pound or more; the reaction 
is usually acid and there is a strong tendency to fermentation, which fre- 
quently continues after evacuation. The food substances are poorly 
digested; that is, large percentages of fat and, in severe cases, of the starches 
also, are excreted. The protein digestion, on the contrary, is not noticeably 
reduced, excepting at the time of acute aggravation, when large amounts of 
undigested meat shreds are found in the stool. Protein digestion is also 
unfavorably affected in those children in whom the test-meal shows an exist- 
ing achylia. 

The nutritional condition of the patient is poor. The abdomen is always 
distended (Fig. 92). During the periods of diarrhoea, we may have a 



312 



TEXT-BOOK OF PEDIATRICS 



picture of pseudo-ascites, because the convolutions of the bowel, filled with 
fluid, are drawn to the dependant portion of the abdomen and cause dulness 
and fluctuation. 

The disease may continue for years; periods of improvement and aggra- 
vation alternate; growth and weight are retarded for months and even years. 
With puberty, the disease may recover spontaneously, excepting for a slight 

sensitiveness. Of course, growth remains 
below the normal in a large number of cases. 
A fatal outcome is not infrequent. 

The diagnosis of chronic dyspepsia is 
based principally upon examination of the 
stools. The reaction and the test for starch 
with iodine are, aside from simple inspec- 
tion, the chief methods of macroscopic diag- 
nosis. For the more careful determination 
of the results of digestion of meat, fat, vege- 
tables and starch a microscopic preparation 
is essential. The test-meal (A. Schmidt) , 
appears necessary only in exceptional cases. 
To determine the integrity of gastric func- 
tion, it may be necessary, particularly in 
those conditions which do not yield to ther- 
apy, to give a test breakfast. 

In the treatment of dyspepsias of gastric 
origin, careful attention should be given to 
the avoidance of recurrences and to the 
increase of the functional capacity of the 
stomach. It is well to begin with stomach 
washing accompanied for several days by 
very scant feeding, without resort, however, 
to actual hunger therapy. Gradually the 
diet is increased, making use of butter or 
cream, prepared flours, meats and vegeta- 
bles passed through a fine sieve. Renewed 
anorexia necessitates further reduction of 
the diet. Frequent use of the stomach-tube 
and of lavage at times becomes necessary. 
With continued care the functional ability 
may be greatly increased and the diarrhoea 
disappears. In severe cases, however, a year or more may pass before com- 
plete recovery takes place. As to medication: pepsin and hydrochloric 
acid; tr. rhei, 20 c.c. (5 drams), with tr. nux vomica 2.0-5 .0 c.c. (3^-1 dram), 
5 to 20 drops, before each meal may be useful. 

The usual treatment of the ordinary forms of chronic dyspepsia is 
dietetic. The basis of the diet is flour soup. It is customary to give cocoa, 
oatmeal water, proprietary foods, cereals, boiled rice, with the addition of 
meat juices and protein powders; and, later on, to add a pap of measured 




Fia. 92. Intestinal infantilism. Girl 
of three years, 76 cm. (30 inches) tall, 
weight eight kilos (17.6 pounds), large 
abdomen, old face. (Children's Hospital, 
Zurich, Prof. Feer.) 



DISEASES OF THE DIGESTIVE SYSTEM 313 

vegetables and finally meat soups. For younger children, Liebig's malt 
soup is to be recommended. In quite a number of cases, the intestine 
actually recovers so far that a transition to mixed diet is possible. It is 
clear, however, that this course is not proper in dyspepsia due to carbo- 
hydrate fermentation; but that, on the contrary, carbohydrates must be 
reduced. It is better than to give chiefly meats, white cheese, eggs, vege- 
table soup, well-mashed vegetables, spinach, lettuce and fruit. Carbohy- 
drates are best given in the form of toast, white bread, and soups, with very 
fine flour in quantities adjusted to the reduced tolerance. Taka-diastase 
in tablet form is frequently useful. The diet should be increased according 
to the indications given by examination of the feces. 

Such a method of treatment is advantageous in typical cases, and is to 
be advocated whenever the carbohydrate treatment is not satisfactory. 
When the stools are acid or contain starch, this is especially advisable. The 
results are usually certain. Milk is hardly ever satisfactory and it is better 
to discontinue it entirely or to reduce it to as small a quantity as possible. 
Care should be taken in the allowance of sugar or sugared foods; stewed 
fruits should be prepared without sugar. Potatoes are frequently injurious. 
At first, meat should be given in chopped form and vegetables should be 
passed through a fine sieve. Course vegetables frequently maintain an 
irritating fermentation because the contained starch, surrounded by cellu- 
lose, escapes digestion in the upper part of the intestine. In children in the 
second year, protein-milk may be useful. 

Similar rules apply to the treatment of severe digestive insufficiency. 
Varied diets are generally of great value in these cases because the status of 
these children is, to a large extent, dependent upon psychic factors, and a 
monotony of diet increases the suffering. The variety of foods which these 
children will bear is surprising and nothing is more harmful to them than an 
unbalanced flour and milk diet. Further indications may be gained by 
examination of the stools and the stomach contents. Frequently it is 
necessary to reduce the fats; in cases of achylia, the meat; and often again 
the eggs. With evident fermentation, at the beginning of an acute aggrava- 
tion, the best results are obtained by a temporary reduction of the carbohy- 
drates and even of the other food-stuffs. Days of hunger, or longer periods 
of underfeeding are hazardous. Little assistance can be expected from the 
digestive ferments. 

It is hardly necessary to add that in regulating the diet of the patient, 
not only the quality, but also the quantity of the food and of its individual 
food components must be given careful consideration. Failure of treatment 
is frequently due to too much or too little food. . A great influence for 
recovery is also employed by psychic stimulation and change of climate. 

In the treatment of mucous colitis, it is necessary to increase the carbo- 
hydrate element in the diet, reducing meat, eggs, cheese and the like, and 
giving fruit, coarse vegetables and other foods containing large amounts of 
indigestible residue. Gentle intestinal lavage and occasional treatment 
with oil are useful. 



314 TEXT-BOOK OF PEDIATRICS 

The recovery from all forms of chronic dyspepsia is hastened by the 
improvement of the general health and especially by proper climatic condi- 
tions. In the severer types, one occasionally sees great improvement at the 
seashore or in the country. A water cure (Karlsbad) may at times be useful. 
So far as medication is to be considered at all, the methods recommended 
in infective intestinal catarrh may be employed. 

ACUTE INFECTIOUS DISEASES OF THE GASTRO-INTESTINAL 

TRACT 

Aside from the actual disturbances of nutrition, we find many diseases 
in childhood and especially in infancy which must be looked upon as infec- 
tions of the digestive tract caused by the invasion of pathogenic organisms. 
The infection is often carried by the food; the disease-producing organism 
may come from diseased cattle (streptococci from abscess in the udder, or 
colon bacilli from diarrhrea), or the pathogenic organisms of human disease 
may have been introduced in some manner during its journey to the con- 
sumer. Numerous cases are seen in which the infection is carried directly 
from other individuals. Observations of house epidemics and especially 
ol the epidemic-like outbreak of gastro-enteritis in children 's hospitals and 
in institutions for the care of infants give definite proof of this. 

The most common etiologic factor of infectious intestinal catarrh is 
doubtless grippe. Gastro-intestinal forms of this malady in varying degrees 
of severity are at times epidemic in extent. In other cases, blame must be 
placed upon varieties of the colon group, upon streptococci, paratyphoid or 
dysentery bacilli, and occasionally upon the pneumococcus, the B. pyocya- 
neus, the B. proteus, etc. 

The symptomatology of the diseases produced by these different organ- 
isms is usually so variable and so little characteristic of any causative 
group that it is hardly possible to classify cases etiologicaUy. It seems more 
to the point to differentiate them clinically. 

Catarrhal gastro-enteritis is to be distinguished by its mucopurulent and 
occasionally, slightly bloody diarrhoea, without indications of colitis. The 
attack occurs suddenly and is accompanied by a rise of temperature. 
According to the height of the fever, the severity of the diarrhoea and the 
effect upon the general health, we may distinguish mild from severe cases. 
The mild forms may resemble an obstinate dyspepsia and the severer may 
present a serious disease-picture with the appearance of cholera-like symp- 
toms. With proper treatment, the disease usually does not last longer 
than one to three weeks. 

Most of the cases may be traced to a grippal infection as shown by the 
coincidence of symptoms of respiratory disorder (coryza, pharyngitis, 
bronchitis, etc.). On this account they are frequently termed broncho- 
entero-catarrh. In young infants, more especially in the new-born, and but 
rarely in older children, one sees similar disease of septic origin in which the 
upper portion of the intestine presents a hemorrhagic, purulent, even ulcer- 
ative inflammation of the mucous membrane, caused by streptococci or 



DISEASES OF THE DIGESTIVE SYSTEM 315 

similar organisms. Such forms usually run a very severe course and fre- 
quently have a fatal termination. 

In epidemics of Asiatic cholera, children, especially within the first ten 
years of life, are attacked in great numbers and the mortality up to the 
fifth year is very high. Of infants sick with cholera about eighty per cent, 
die; during the second five years, only about fifty per cent, are lost. The 
clinical picture differs little from that in the adult. Both in mild and more 
fully developed forms, the disease appears with the algid stage; and as 
in typhoid. The resemblance to ordinary diarrhoea with vomiting, and 
to alimentary intoxication, may be great, so that the diagnosis, excepting 
in epidemics is very difficult. 

Typhoid-like gaslro-enteritis, so-called gastric fever, is especially dis- 
tinguished by high fever, while the bowel movements may be only slightly 
diarrhceal. Other symptoms, excepting a coated tongue and anorexia, may 
be absent, or the spleen may be enlarged, while the patient may be ex- 
tremely languid and may suffer headaches and vomiting. At tunes icterus 
may occur. After a period of from eight days to three weeks, during which 
a remittent fever usually persists, recovery sets in by lysis. The resem- 
blance to real typhoid is often great and only the continued absence of the 
Widal reaction and the negative bacterial findings, make differential diag- 
nosis possible. 

Dysentery-like enteritis (Enterocolili s) . The most important causative 
factors of infectious intestinal disease, with a predominance of oolitic symp- 
toms, are the streptococcus, derived probably from the inflamed udder of 
the cow (the streptococcus enteritis of Escherich) and a species of the 
colon group (coli colitis) . There are occasional cases in which other organ- 
isms are found. This dysentery-like disease is rather common during the 
first year and has been called follicular enteritis. Its onset is acute, with 
moderate or high fever, general symptoms of a serious nature and se- 
vere mucous, bloody or purulent diarrhoea. The mucous quality of the evac- 
uations and the tenesmus accompanying them, show that the seat of 
the trouble is in the large bowel. In favorable cases, the fever disappears in 
from one to five days and recovery begins. Other and numerous cases are 
seen which take a different course. At times, cholera-like conditions arise, 
or an attempt at recovery is incomplete and the mucous diarrhoea continues. 
Sometimes we see intermittent periods of aggravation with recurrence of all 
symptoms. Again, with the long continuance of muco-sanguineous evac- 
uations, a severe cachexia may gradually develop, which may end fatally 
with the picture of extreme atrophy. In still other cases the local disease 
spreads with unusual rapidity and produces severe, necrotic inflammatory 
lesions which in some cases run their course with a high remitting fever. 

The anatomic findings of the disease are those of a sero-hemorrhagic or 
seropurulent hemorrhagic inflammation of the lymph follicles of the large 
intestine. The follicles may become eroded and thus lead to the formation 
of small ulcers. In serious forms real dysenteric changes in the mucous 
membrane, of greater or less area, are seen. 



316 TEXT-BOOK OF PEDIATRICS 

DYSENTERY 

Dysentery has recently appeared in epidemic form in various countries 
and, as such, has taken its toll among the children of all ages. It is inter- 
esting to note that the epidemic incidence of the disease according to statis- 
tics follows very closely the incidence of summer diarrhoea of other types. 
Its morbidity rises gradually in July and drops to an isolated case in the late 
autumn. For this reason, every increase of intestinal disorder during this 
period should arouse our suspicion. 

Etiologically, it is customary to distinguish two types or forms (1) 
true dysentery, caused by the Shiga's bacillus and (2) pseudodysentery, 
caused by the Flexner and Y-bacilli. This etiologic differentiation does not 
signify that the pseudodysentery is less serious or of shorter duration. In 
spite of the lower toxicity developed by the Flexner and Y-types in animals, 
there is no great difference in the clinical picture of the two varieties. 
Possibly the primary toxic forms of the disease is more grave and the num- 
ber of the relapses greater with the Shiga type of infection. The demon- 
stration of the causative organism is possible in fresh specimens only and 
even then not in all of the cases. If the bacteriologic demonstration of the 
organism is impossible, the agglutination test with the appropriate organism 
will be of great use. As a rule, the agglutination with dilutions as high as 
1 : 400 is obtained even after recovery and will give the differential diag- 
nosis. In infants the agglutination may be delayed or fail entirely. The 
incubation period is short, usually from five to seven days. The onset, gen- 
erally without prodromes or with a day or so of non-characteristic diarrhoea, 
is sudden. 

It is convenient to distinguish two forms according to the course the 
disease takes. (1) A form in which the infectious symptoms of diarrhoea 
and fever predominate, and (2) the form in which the toxic symptoms are 
paramount. The extreme dehydration and tendency to collapse simulate 
cholera. This type is less frequent but much more serious than the first. 
Among the infectious type of cases, a large mimber of mild attacks are seen. 
In these the fever may last for only a few days, the consciousness is not 
affected and the diarrhoea and symptoms of intestinal irritation are slight. 
In more severe cases the fever persists, diarrhoea, tenesmus and pain is 
very distressing and continues for a long time. The severe cases are 
characterized by extreme intestinal manifestations. There is vomiting, 
anorexia and prostration. These cases are the transitional stages to the 
cholera-like forms, in which the vomiting and terrific purgation form the 
clinical picture. In these the temperature, mildly febrile for a short time, 
becomes subnormal in collapse and the patient presents all the signs of a 
general intoxication. The tendency to collapse and subnormal temperature 
distinguishes this form from those cases of the first group in which there is 
high fever, restlessness, delirium and even convulsions but which soon 
become convalescent. 

Very mild cases are also encountered. In these the temperature is never 
very high and the bloody mucous stools persist for only a day or two. 



DISEASES OF THE DIGESTIVE SYSTEM 



317 



Some of these, however, go on to a chronic stage in which the stools always 
contain some mucus and from time to time contain a little blood. On 
the basis of this persisting disturbance, acute relapses may occur at 
any time. 

These chronic recurring cases are es- 
pecially common in weak infants. Dysen- 
tery in infants has several other 
characteristics; the cases with acute 
cholera-like course are common, and a 
large part of them have gastric symptoms. 
On the other hand, the very mild cases, 
usually rather persistent and with colitis, 
may resemble the more common chronic 
dyspepsia so closely as to be completely 
overlooked and thus form a source of 
danger to other infants. 

In the course of dysentery in children, 
slight rises of temperature (100 to 101) 
may continue for several daj^s. Goeppert 
finds recurrences in about fifteen per cent, 
of the cases. In true dysentery, these are 
said to be especially severe. Undoubtedly 
this second attack as in scarlet fever is 
a result of the action of the dysentery 
toxin. Complications and sequelae, such 
as conjunctivitis and arthritis, are much 
less common than in adults. Edema, 
however, is very common especially in 
undernourished infants. After the dysen- 
tery is completely cured, there may still 
remain a certain sensitiveness of the diges- 
tive tract which will require careful 
regulation of the diet for months. 

Pathologic changes do not differ from 
those in the adult. The prognosis varies 
according to the epidemic and age of the 
patient. The mortality among children 
of one to two years is twenty-five to thirty 
per cent. In older children it is lower. 

A special danger of the infectious 
gastro-intestinal diseases lies in their 
tendency to complications. The most im- 
portant of these are nephritis and pneu- 
monia, pyemia, cystopyelitis, the more variable pyodermias, and a general 
septicemia arising from the mucosa of the diseased intestine. More impor- 
tant than all of these is the association of a secondary disturbance of nutri- 
tion with the infective disease. It may be readily understood that the 




318 



TEXT-BOOK OF PEDIATRICS 



normal metabolic functions of the intestine do not take place in the seriously 
diseased organ and that acid fermentation, which causes dyspepsia, occurs 
easily. This secondary dyspepsia may go on to alimentary decomposition 
and alimentary intoxication, which will overshadow the original disease, and 
may carry the patient to the point of hazard. Inanition, due to the custom- 
ary carbohydrate feeding, may add its menace. It may hardly be doubted 
that not only numerous cholera-like aggravations, but also a larger per- 
centage of resultant atrophic conditions, are not due to infection, but to 
starvation and to other forms of secondary disturbance of nutrition. Very 
probably, a certain number of the severe ulcerative type, with its various 
complications, are due to the same cause. Underfeeding alone will weaken 
the total resistance of the body, reduce the general defense against bacteria 
and permit a local infection to spread unimpeded. 

The diagnosis of intestinal infections in general offers no great difficulty. 
It is important, first of all, to differentiate them from alimentary intoxi- 
cation and to establish definitely the importance, of the part played by a 




FIG. 94. Chart of a case of severe dysentery in a child of four. Fatal termination. 
Subnormal temperature. 

complicating dyspepsia or a toxic disturbance of nutrition. The results of a 
discontinuance of the food supply give a great deal of information. Expe- 
rience shows that in the infant a diagnosis of the milder dyspepsia-like 
forms causes some difficulty. The obstinacy of the diarrhrea, in spite of the 
usual treatment for dyspepsia, should, arouse suspicion. If fever does not 
disappear when the food is withdrawn, a final decision must be made in favor 
of infection. 

The etiologic factors can be determined only by careful bacteriologic 
examination of the feces and of the blood together with agglutination tests. 
The prognosis of the various forms of gastro-enteritis in older children is 
generally favorable. In dysentery and cholera, it is of course, characteristic 
of those diseases. In younger children, the prognosis is dependent upon the 
ability of the physician to apply proper dietetic measures. If he is successful 
in avoiding a serious secondary disturbance of nutrition, which is possible 
to-day in a great number of cases, he will have a surprisingly large percent- 
age of recoveries; if he fails, his statistics will be far from gratifying. 

Treatment should begin by emptying the intestine [calomel 0.05-0.1 gm. 
(grs. 1-2), in three or four doses]. In the dysenteric forms, one-fourth to 
one-half of a teaspoonful of castor oil, every two hours, for twenty-four to 



DISEASES OF THE DIGESTIVE SYSTEM 319 

thirty-six hours, is recommended. The subsequent treatment is chiefly 
a question of diet. The general concensus of opinion among authorities is 
favorable to flour feeding? with the addition of Liebig 's malt soup as signs 
of improvement appear, a'nd with a gradual and careful return to a mixed 
diet. The procedure should be practically the same as that advised for 
dyspepsia. Usually the condition of the stools is made to govern the quali- 
tative and quantitative increase of food. If this is followed out too carefully, 
the patient is usually underfed for rather long periods and, as has already 
been said, this is extremely hazardous. More recent experiences show that 
the increase of the food need not be very gradual. In fact, much better 
results are obtained, especially in children in the second and third years in 
whom the infectious symptoms predominate, if liberal amounts of food are 
given. The only precaution necessary is to see that the food is easily 
digested, and that it will not leave undigestible portions that may irritate 
the colon. Milk, sugar, flour, prepared cereals, finely chopped meat, egg, 
broth and fruit juices may be given in quantities large enough to prevent 
loss of weight. Coarse food should not be given until the stool has been 
normal for several weeks. In infants, too, the food requirement must be 
fulfilled as soon as possible. These younger children should be treated as 
prescribed for chronic dyspepsia and decomposition. Piotein-milk or its 
various substitutes are of great value. 

In the cases with the severe cholera-like course, on the contrary, the 
replacement of the water lost by the severe dehydration must be the first 
consideration. For this purpose some authors advise the use of diluted 
whey (1 : 1 oatmeal gruel) in gradually increasing amounts according to age. 
Better still is buttermilk, at first without carbohydrate additions. Subcu- 
taneous or intraperitoneal injection of physiologic salt solution or procto- 
clysis may be necessary. The persistent vomiting is to be combated by the 
use of gastric lavage, or medicinally, by atropin, novocaine, etc. As soon as 
the case has improved sufficiently to permit the ingestion of food, the regime 
described for intoxication should be instituted in young infants. In older 
children, the food should be given in liberal amounts as soon as possible 

In the way of medication, good results are obtained early in the disease 
with opium [0.001-0.02 gm.(M'o-/ / 3gr.) according to age, 3-5 times daily] ; later 
tannigen or tannalbin [up to 2.0 gms. (30 grs.) per day]; quinine tannate 
[0.1-0.3 gm. (2-5 grs.) three times daily]; lead acetate, [0.003-0.005 gm. 
(/ / 2Q-}'l2 g r O three times daily]; etc., may be used. In the later stages, 
those who still believe in irrigation may use lavage of the large intestine w^th 
a solution of aluminum acetate (1-500), albargin (1-1000), physiologic salt 
solution, or bismuth salicylate (1-8 per cent.) in gruel. To this should be 
added counterirritant measures and hydrotherapy to quiet abdominal pains 
and restlessness and to reduce high temperature. 

The excreta ehould be disinfected in the customary way. It is well to 
use materials for diapers and bed-pads that can be burned immediately. 
Nurses and others in contact with the patient should be instructed as to the 
danger to which they themselves and the community are exposed in the 



320 



TEXT-BOOK OF PEDIATRICS 



spread of infection; since adults may contract either dysentery or dysentery- 
like diarrhoea. In groups of cases, the source of the infection (food, water, 
germ-carriers) must be investigated. 



Secondary tuberculous disease of the intestine is usually brought on by 
swallowing tubercle bacilli which have come from the lung. It is as fre- 
quent in children of every age as it is in later life. Primary intestinal tuber- 
culosis in which the intestine is the original and the only seat of the disease 
is much less common. Great difference of opinion obtains among pathol- 
ogists as to the frequency of the primary forms; nevertheless, the occur- 
rence of primary pulmonary tuberculosis more than doubles the highest 
estimate of the intestinal form. The younger the child, the less frequent is 
the primary intestinal infection; in infancy only a few cases are recorded. 

The food is, in many cases, the source of a primary infection of the bowel 
in others, it is a question of dirt infection. Whether animal tuberculosis 




FIQ. 95. Rigidity of the abdominal muscles seen in tuberculous stenosis. 
Child of two years. 

from the use of the meat, and especially from the use of the milk of tuber- 
culous cattle, may infect the child is a question of special interest. In all 
probability, it is a minor matter as compared with the transmission of 
human tuberculosis. 

Pathologic examination shows that intestinal tuberculosis begins with 
small tubercles, which break down and form ulcers with undermined edges. 
By the confluence of these, larger loss of substance occurs, aro.und which 
new tubercles arise. The intestine is frequently covered with circular 
ulcers. In the immediate neighborhood, peritoneal adhesions are formed 
and infection extends to the mesenteric lymph nodes, (q. v.}. Frequently 
these ulcers cicatrize and thus give rise to stenosis. Kinks of the intestine 
may be caused by peritoneal adhesions. The most important changes are 
seen in the small intestine and in the caecum, while the colon is little, if at 
all affected. 

Symptoms. Early in the illness the child is fretful, tires readily, has 
irregular fever, and soon develops diarrhoea and abdominal pains. The 



DISEASES OF THE DIGESTIVE SYSTEM 321 

intestine is sensitive at points to pressure; the abdomen is usually little, if at 
all, distended. In the stools one 1 may find mucus and, by microscopic 
examination, blood. The disease is of long duration, is marked, in severe 
cases, by extreme cachexia and hectic fever; and usually terminates fatally. 
Remissions may, however, occur and even a complete recovery is possible. 
Scar tissue, intestinal stenosis due to the contraction of scar tissue, com- 
pression of the lumen of the bowel caused by adhesions or kinks, may remain 
and demand special treatment (Fig. 95). Complications by way of the per- 
foration of ulcers with accompanying acute peritonitis, bleeding from eroded 
intestinal vessels, tuberculous peritonitis, general miliary tuberculosis and 
tuberculous meningitis may be noted. 

The diagnosis is not always easy. It turns upon the long continued 
fever, the obstinate diarrhoea, the synchronous presence of other symptoms 
of tuberculosis, and the demonstration of the bacillus by sedimentation 
methods. A positive von Pirquet reaction does not prove definitely that 
the symptoms are due to intestinal tuberculosis, for it may be produced by 
other latent foci. 

In the treatment, one must strive to counteract tne extreme cachexia, 
and to prevent, by suitable diet, the occurrence of secondary fermentation 
dyspepsia. For the rest, general measures (climatic treatment, etc.), 
which give any promise of reeults, may be adopted. Of medicinal remedies, 
the heavy metals are recommended. Bismuth salicylate or subgallate 
[0.5-1.0 gm. (7-15 grs.), several times daily], lead acetate, [0.003-0.005 gm. 
(M'(rM'o gr.) for several days], ferric pyrophosphate, (1^ per cent, solu- 
tion, a teaspoonful, twice a day), may be tried. Opium and the vegetable 
astringents may be used. 

INTESTINAL POLYPOSIS 

Symptoms. In children, the passage of several drops or even of larger 
quantities of fresh blood from the anus, usually with the bowel movement, 
but more rarely alone, has been frequently observed. Barring the readily 
recognized bleeding, caused in the presence of fissures by the passage of a 
hard stool, and the very rare bleeding from hemorrhoids and malignant 
tumors, such blood comes from small benign tumors of the rectum. .They 
are papillomatous in structure and occur in three varieties. The so-called 
rectal polypus, which has a pedicle and grows to about the size of a cherry, 
is one form. This may appear at times in the anus. The oozing of blood 
from one or more points of an apparently unchanged mucous membrane, 
which, upon closer examination, shows small wart-like hyperplasise, con- 
stitutes another type. In the third and more severe class of cases, a real 
intestinal polyposis exists; the entire lower portion of the intestine, or even 
the entire bowel being covered with innumerable and relatively large wart- 
like polypoid tumors. 

For absolute diagnosis, digital examination is only occasionally satis- 
factory, because the tumors are small and very soft and, therefore cannot be 
recognized by touch. One should make use of a rectoscope of small calibre. 

Single tumors are harmless. The true polyposis, on the other hand, may 
21 



322 TEXT-BOOK OF PEDIATRICS 

cause a dangerous anemia because of the constant loss of blood. This may 
even occur when the loss of blood is very small. Major cases often take a 
course similar to that of chronic colitis, in the later stages of which severe 
cachexia and edema may appear in addition to the anemia. In these cases, 
the prognosis is very unfavorable. 

The treatment consists in the removal of the polypi with the scissors 
or snare under a local anesthetic. Bleeding from the smaller tubercles may 
be controlled by the use of caustics or corrosives, trichloracetic acid, or 
hydrogen peroxide. In intestinal polyposis the repeated use of both 
methods may be successful. When a large portion of the colon is affected 
and to a high point, very little can be expected from treatment. 

NERVOUS GASTRO-INTESTINAL DISEASES 

CONGENITAL SPASTIC PYLORIC STENOSIS 

Hypertrophic Stenosis of the Pylorus. The most noticeable symptom 
of this condition is violent, persistent vomiting, accompanied in severe 
cases by pain, spasmic deglutition and choking. While symptoms usually 
begin during the second or third week of life, they may develop earlier or 
later and may not occur before the third or fourth month. The vomitus 
does not contain bile and is usually extremely sour, giving a strong re- 
action for free hydrochloric acid. The patients usually show either no 
gain in weight, or a gradually progressive emaciation. They pass small 
amounts of urine and are obstinately constipated. The abdomen is re- 
tracted, but prominent at the epigastrium. Epigastric rigidity is observed 
and marked peristaltic waves, passing from left to right (Fig. 96), suggest 
the conclusion that the emptying of the organ is obstructed. As a matter 
of confirmation one may find, upon careful palpation, a small, movable, 
cylindrical mass at the right border of the rectus under the liver. 

Pathologic Anatomy. At autopsy, the tumor above described is found 
to be the thickened pylorus, surrounded by a hypertrophied musculature 
and the hypertrophied pars pylorica, firmly contracted to form a hard, 
almost cartilaginous, tumor-like mass, several centimetres long (Fig. 97). 
This contracture causes a stenosis of the stomach exit, which accounts for 
the clinical findings. Much greater pressure is necessary to force this 
contracture than is required in the normal systolic stomach at autopsy. 
Rare cases of "simple pylorospasm" are also seen. These present all the 
clinical symptoms of a hypertrophy, but show no pathology at autopsy. 

A positive explanation of the anatomic findings has not been given. 
Most observers are of the opinion that it is a condition of primary pyloro- 
spasm with a secondary compensatory muscular hypertrophy. The actual 
cause of the disease is still under very active discussion. It is doubtless a 
neurosis which, according to the history, is dependent upon a hereditary 
nervous tendency which produces first pylorospasms and latterly hyper- 
aesthesia, hyperkinesis, and probably, also, hypersecretion. 

The disease is found especially in breast-fed infants and even in those 



DISEASES OF THE DIGESTIVE SYSTEM 323 

who have not suffered from any errors in the feeding technic. It has often 
been observed in successive children of the same family. In a certain per- 
centage of cases, one sees ptotic conditions, not only of the stomach but of the 
remaining abdominal organs, and a general muscular atony is demonstrable. 

The diagnosis is readily made because of the early appearance of the 
disorder and its typical symptoms. The simple nonhypertrophic pyloro- 
spasm is much more liable to lead to confusion. In rare cases a similar 
picture is produced by congenital stenosis, by the pressure of a ptotic liver 
upon the duodenum, and by compression from peritoneal adhesions, etc. 
The absence of bile from the vomited matter contraindicates stenosis in the 
lower part of the duodenum. 

The course and termination of the disease are dependent upon its 
severity, which, in turn, is governed by the completeness of the stenosis and 
the persis'tence of vomiting. Mild cases may be recognized by the fact that 
the loss of weight is relatively gradual. The weight may be even stationary. 




FIG. 96. Gastric peristalsis in spastic plyoric stenosis. (University, Heidelberg, Prof. Feer.) 

A bowel movement occurs at least every second day. In these conditions, 
one may be certain of recovery. After several weeks, at least after two or 
three months or more, the vomiting becomes less frequent and the bowel 
movements more numerous and, with the increasing possibility of adequate 
feeding, a rapid increase of weight takes place and complete recovery 
finally follows. Nor do these children show any particular tendency to 
gastric disorders in later life. In the more serious cases, the loss of weight is 
rapid from the beginning, the bowel movements occur at long intervals, 
and the large daily losses of weight do not cease even when the remission 
of the spasm permits of a temporary increase of the food supply. Usually 
these patients soon reach a peculiar state of apathy, eliminate sugar in the 
urine, upon taking even small quantities of food, and simply cannot be fed. 
The condition is nothing more than one of extreme inanition. At this 
stage, it is absolutely impossible to save the patient; excepting, per chance, 
by operation. 

In the treatment of pylorospasm, the parents must be warned first 
against the customary attempt to quiet the stomach by the withdrawal of 



324 TEXT-BOOK OF PEDIATRICS 

food, or the substitution of tea or gruels. Starvation gives no results, and 
the risk of injuring the young and poorly resistant child by a period of 
hunger, and of converting a mild case into a serious one, is very great. 

No method of feeding is known which is certain to relieve the vomiting. 
The best plan is to feed breast-milk, for with this the danger of a disturb- 
ance of nutrition complicating the inanition is, to say the least, reduced to 
a minimum. 

Various methods of feeding are advised by various physicians. Heub- 
ner advocates regular three-hour feedings, permitting the child to ingest as 
much as it wishes without considering the vomiting. Ibrahim does not 
put the infant to the breast at once, but gives very small quantities of 
expressed breast-milk, cooled in ice, at frequent feedings; allowing at first, 
10 c.c. every hour; then, with correspondingly increasing intermissions, 15, 




FIG. 97. Stomach in spastic pyloric stenosis. CSemidiagrammatic.) 



20, 25 c.c., and so on. With the ingestion of 300 c.c. the danger of death from 
starvation is over. Of methods of artificial feeding, the fat-free prepa- 
rations (buttermilk, skim-milk) , are entitled to first consideration, because 
of the experience with them in simple pylorospasm; but their successful use, 
if there be any, is by no means so well understood in this form of disease. 
Sometimes results are attained with concentrated food. There are no 
contraindications to this A tablespoonful of Karlsbad water before each 
meal is useful. Hot applications for periods of two hours, three times a day, 
may be directed. Medication is of very little use. Tincture of opium, 
Mo-Ko drop to the dose, cocaine, novocaine, alypin (Ko of gr. to the dose, 
shortly before feeding), anesthesin (3 per cent, in mucilage acacia; one 
teaspoonful, before feeding) and similar remedies may be tried. Stomach 
washing is recommended by some and opposed by others. To counteract the 
tendency to the undue loss of water, injections of physiologic saline solu- 
tion may be used. 



DISEASES OF THE DIGESTIVE SYSTEM 325 

Enteroclysis may well be substituted for hypodermoclysis by means of a 
long tube or thin Nelaton catheter, held in place by adhesive plaster. The 
following solution may be used: sodium chloride 7.0, potassium chloride 0.1, 
calcium chloride 0.2, water 1000 grams. It is possible, with care, to give the 
enteroclysis twice a day for two hours each time, at the rate of 30 drops 
per minute; in this way the patient receives upwards of 400 c.c. (18 ounces), 
of fluid per day. In some cases this seems to have a directly favorable in- 
fluence upon the vomiting. Used for so short a time, the tube will hardly 
cause decubitus. 

As the stomach retains larger quantities, it is advisable to increase 
the food very gradually at first. Some children are so severely injured 
by the long inanition that, upon receiving large amounts of food too 
early, they become the victims of a severe disturbance of nutrition, which 
takes the form of an alimentary intoxication which might have been 
avoided by better care. 

Recently, very good results have been obtained by passing a catheter 
into the duodenum, according to the method of Alfred Hess. The long 
Nelaton tube is carefully pushed through the stomach until it passes the 
pylorus. This can be recognized by the fact that, upon moving it gently to 
and fro, the resistance is greater than it is in the stomach. Food is slowly 
introduced through the catheter, the procedure being carried out several 
times daily. Frequently an increase in weight begins almost immediately 
and usually the condition so improves that in a short time progress may be 
made without the tube. 

If duodenal catheterization is not successful and the child loses weight 
rapidly, surgical interference must bo considered. The best and most 
rapid method seems to be longitudinal incision of the hypertrophic pylorus 
leaving the mucous membrane intact without suturing (Ramstedt). It is 
difficult at present to state the indications for operation definitely. This 
course seems advisable when the tissue loss approaches one-third of the 
previous body-weight. When rapid weight-loss is progressive it may be 
better to operate earlier, because with so severe an inanition a serious 
weakening of the organism is quickly threatened and a longer period 
of waiting may make the possibility of repair doubtful. Children who 
have passed into the comatose condition above described are lost under 
any circumstance. 

HABITUAL AND UNCONTROLLABLE VOMITING OF INFANTS 

SIMPLE PYLOROSPASM 

Many infants habitually vomit large or small quantities of food. If 
this is a means of getting rid of an excess, it can hardly be called a disease ; 
it must be considered as such, however, when it continues in spite of care- 
fully regulated or scant quantities of food. This vomiting may occur with- 
out any preceding gastric disorder. In many cases, the habit associates 
itself with dyspepsia and continues for a long time after recovery from that 
disease. As a rule, an accompanying mild ischochymia (gastric dilatation), 
is demonstrable. 



326 TEXT-BOOK OF PEDIATRICS 

In some cases, the vomiting becomes so severe that inanition results 
even to so serious a degree as in hypertrophic stenosis. The peristaltic 
waves, however, are not seen, there is no pyloric tumor and the constipa- 
tion is not so obstinate. On the contrary, mucous watery stools are usual, 
in spite of the small quantities of nourishment that pass into the bowel. 

This condition, like the hypertrophic form, is probably dependent upon 
an abnormal nervous irritability. Whether this is merely a hypersesthesia 
of the mucous membrane, or whether pylorospasm is coexistent, is a moot 
question. Hypertrophy of the pyloric musculature is not found at autopsy. 

The prognosis is favorable under suitable treatment; if errors are made 
the patient may die of starvation. Two or three months of time is necessary 
to complete the recovery. 

Treatment. Those cases which develop under artificial feeding are 
quite certain to be cured with breast -milk; but, as in the hypertrophic 
form, considerable time may be necessary before improvement is noticeable. 
Usually results are more rapidly obtained by giving a fat-free diet (skim- 
milk or buttermilk), with the necessary carbohydrate additions. Alkali 
waters (Karlsbad), are sometimes useful. Gastric lavage is not certainly 
helpful. Mild cases may sometimes be favorably influenced by the use of 
milk treated with a coagulating ferment, e. g., pegnin, according to the 
method of V. Dungern. For young infants concentrated food, and with 
older children, a solid diet is often beneficial. In addition to remedies noted 
for the hypertrophic form, sodium citrate (2 per cent, solution, one table- 
spoonful, before each feeding), and protargol (0.2 per cent, solution, one tea- 
spoonful, before feeding), are also recommended. Often the vomiting has 
disappeared under the use of fat-free food. Two or three months are 
usually necessary before an ordinary diet can be employed without recur- 
rences of vomiting. 

THE PERIODIC VOMITING OF OLDER CHILDREN 

This term applies to repeated paroxysms of vomiting, rarely lasting over 
a few days or a week, accompanied, as a rule, by fever and other disturbances 
of digestion. Very frequently, indeed almost constantly, acetonemia, 
acetonuria and an acetone odor to the breath are noted. Milder forms 
closely resemble dyspepsia, with constipation and a tendency to vomiting. 
It is questionable whether cases have been observed in early infancy. In 
the second year, however, the condition has been known. Between the ages 
of four and eight years it occurs commonly; with puberty, the predisposi- 
tion ceases. 

Each attack begins with premonitory symptoms; such as change in dis- 
position, gastric symptoms or diarrhoea; then, the vomiting begins suddenly 
and is repeated at short intervals. Nothing will stop it and the child is 
apparently in a seriously exhausted state. A strong acetone odor is notice- 
able in the urine and in the expired air: hence, the French phrase " Vomisse- 
ment incoercibles avee acetoncemie." Constipation is usual; icterus is 
sometimes present; temperature is usually slightly increased. After con- 
tinuing unabated for a varying period, the attack passes suddenly; the 



DISEASES OF THE DIGESTIVE SYSTEM 327 

patient makes a rapid recovery, to suffer, after a week or a month or more, 
another attack. The exact nature of the condition is not understood. 
It rests, undoubtedly, upon a constitutionally nervous quality. This is 
shown by the frequent occurrence of cases among the well-to-do, by the 
usual presence of other neuropathic symptoms, and by the occasional bene- 
ficial effects of suggestive treatment. Some authors class the disease as a 
form of hysteria, but this does not add much to its etiology. It is probably 
a question of crisis in the metabolic functions, but the significance of the 
anomalies of metabolism which have been observed is not yet clear. Hecker 
believes it to be a disturbance of intermediate fat metabqlism. The recent 
observation that attacks are often brought on by the withdrawal of carbo- 
hydrates from the food, tends in the same direction. At many points a 
relationship to migraine is indicated. 

In the first attack, great care should be taken in diagnosis, for peritonitis, 
appendicitis, or meningeal disease may have a similar onset. A history of 
previous attacks is of value in diagnosis, but even this may be misleading, 
for brain diseases may cause recurrent attacks due to variations of intra- 
cranial pressure. The prognosis of the individual attack is good. Probably 
a few deaths have been wrongfully ascribed to this condition. In treatment, 
ordinary methods, as hot applications, small quantities of iced drinks, 
narcotics [chloroform water, cocaine, or better still, novocaine or alypin 
3-5 milligrams (HirHo g 1 "-) etc.], may be tried. Water should be supplied 
by rectum or subcutaneously. Suggestive methods may avail, a subcuta- 
neous injection of sterile water possibly having such an effect. During inter- 
vals between the attacks the neuropathic tendency should be treated by 
hygienic, dietetic and pedagogic methods. 

NERVOUS VOMITING 

In many sensitive and constitutionally nervous children, an habitual 
vomiting, due to external influences, may appear from time to time; this 
does not create any constitutional disturbance but is most disagreeable. 
Excitement may be a cause, as in the well-known vomiting of school chil- 
dren, occurring on their way to school in the morning. In others, a peculiar 
sensitiveness of the pharyngeal reflex, responsive to certain sensations in the 
pharynx, has probably some relation. Agajn, the cause is sometimes purely 
psychic, being produced by an abnormal repugnance to certain foods. If 
the vomiting is repeated often enough, it probably becomes a reflex habit 
which may appear responsively to a feeling of dislike or even, in extreme ^ 
cases, to pleasurable excitement. Very frequently children vomit at will, 
knowing that it will have an impressive effect upon spectators. 

Common as this condition is, great care must be taken in diagnosis; all 
other possibilities, as gastric diseases and especially brain diseases, being 
considered. Many a case of brain tubercle has gone on for months under a 
diagnosis of harmless nervous vomiting, until other symptoms have indi- 
cated the actual condition. Disturbances of vision (strabismus, astig- 
matism), may now and then cause the vomiting, which will disappear after 
their correction. The general condition of the child should be considered 



328 TEXT-BOOK OF PEDIATRICS 

first. If it is not entirely well, otherwise, great care should beexercised. The 
treatment should be general and directed to the nervous cause. Skilful 
educational influence, energetic verbal suggestion, coupled with such occa- 
sional suggestive treatment as faradization, plaster applications, etc., may 
bring about recovery in a short time. 

NERVOUS ANOREXIA 

Loss of appetite, to which no other cause revealed in the pathologic 
findings of the digestive apparatus can be assigned, and reason for which 
must be sought in the neurotic field, is commonly called nervous anorexia. 
In only a part of such cases is a general neuropathic constitution an ade- 
quate cause. 

These cases vary widely in character and a careful analysis of conditions 
is necessary. Frequently, the sufficiently well-fed appearance of children, 
who are brought to the physician because of loss of appetite, proves that no 
anomaly is present, but rather that the parents expect the children to eat 
too much. In other instances, children eat little because they are forced to 
drink large quantities of milk, which reduces the appetite for other food- 
The anorexia disappears so soon as milk is discontinued. A monotonous 
or an unbalanced dietary may have been given and its substitution by 
appetizing and varied meals, consisting of green vegetables, coarse bread, 
fruit, cabbage, etc., produces wonderful results. Such children may take 
too little exercise or not get enough fresh air. In true nervous anorexia, 
these, causes do not obtain, but there appears to be an actual absence of 
appetite or of the sensation of hunger, frequently seen even in infancy, when 
only with great difficulty, can enough food be given the infant to maintain 
growth. In older children, the amount of food taken may be small gener- 
ally or the appetite may be capricious and certain foods only may be taken; 
while others, quite similar, are refused. With many of these cases, the gen- 
eral nutritive condition is so good that no noticeable deficiency in the caloric 
supply can exist. Only exceptional cases occur, in which so strong an 
aversion to all forms of food exists, that serious inanition results. Doubtless 
these are always based upon a status hystericus. 

In a certain percentage of cases, the loss of appetite seems to be con- 
nected with a disturbance of mastication and resulting difficulty in eating 
solid foocL At times it appears that certain foods actually produce nausea 
because they suggest some perverse association. 

The probability of a nervous foundation for the condition is indicated by 
negative gastric findings. A degree of motor insufficiency may be present, 
or some hypoacidity with slight hypotonia, existing as part of a frequent 
general ptosis. With the anorexia, it is usually possible to demonstrate 
other nervous symptoms, e. g., the facialis phenomenon, vasomotor irrita- 
bility, ready exhaustion and psychopathic tendency, etc. Upon close 
inquiry into the family history, f amilial neuropathy and mental inefficiency 
can usually be established. Such a relation fails to explain, of course, -the 
ultimate processes which actually cause the reduced appetite. 

The treatment of those forms of anorexia that are caused by an im- 



DISEASES OF THE DIGESTIVE SYSTEM 329 

proper dietary offer no difficulties. A rational and balanced dietary, varied 
as much as possible, reduction of milk to a minimum, and regulation of the 
child 's general hygiene bring good results. In the true nervous form, these 
measures are only preparatory to the real treatment, which lies in the 
exercise of a proper pedagogic influence. If the environment is such as to 
make it advisable, the most radical, but satisfactory method is to remove 
the child from its parents and to find for it a home with sensible people 
and intercourse with normal healthy children. Frequently, a quiet but 
energetic nurse or governess may accomplish much, if she has such full 
control that her orders are not countermanded by the parents. Treatment 
in sanatoria is not recommended, for pedagogic reasons, unless serious 
psychic disturbance is involved cr a severe degree of inanition has resulted 
from the hysterical refusal of food. Only in the latter event are we justified 
in attempting forced feeding, entirely unnecessary in other cases and, as a 
rule, wholly without results. 

We cannot expect by any method we employ to recover a normal 
appetite. We must be satisfied if the child obediently takes the necessary 
quantities of food without resistance or show of caprice. Gastric treatment, 
often presented by stomach specialists, is useless. Medicinally, we may 
use, besides pepsin and orexine tannate, strychnine [tr. nux vomica, grams 
2-5.0 (15-30 minims), tr. rhei vin, grams 20.0 (5 drams); ten drops of this 
mixture in orange juice twice daily, a short time before meals]. In mild 
and even in somewhat severe cases spontaneous recovery may be expected 
at puberty. 

OBSTRUCTION OF THE INTESTINAL CANAL 
CONGENITAL INTESTINAL STENOSIS 

Congenital intestinal occlusion has certain points of election; immedi- 
ately above or immediately below the papilla of vater, at the duodeno- 
jejunal junction, or just above the ca3cum. It occurs less frequently in 
other portions of the small intestine or the colon. The obstruction is 
caused by a membranous septum or by scar-tissue, or by the existence of 
long imperforate loops of the intestine. Extensive portions of the intestine 
may even be absent. Constriction by bands, diverticulae or compression 
tumors may occur. At times, multiple obstructions are present, when 
other external and internal malformations are often observed. The forma- 
tion of intestinal atresias is probably due to the temporary closure of the 
intestinal canal, which is normally well-formed and patent between the 
fifth and tenth week of fetal life, a closure which, in rare or exceptional 
cases, persists. 

The diagnosis of atresia is made upon the occurrence of vomiting imme- 
diately after birth, upon the absence of stools containing fecal matter and 
other symptoms of ileus. Most of these cases die during the first or second 
week; only occasionally do they live longer. From the nature of the ob- 
struction, it is clear that only in exceptional cases may results be expected 
from surgical interference. 



330 TEXT-BOOK OF PEDIATRICS 

The prognosis of congenital occlusions of the rectum or the anus is 
more favorable. Operations have proved successful in about one-third of 
these cases. 

In rare instances, we have to deal, not with complete atresia, but with a 
reduction of the calibre of the intestine, the symptoms of which resemble 
those of chronic acquired ileus. 

DILATATION AND HYPERTROPHY OF THE COLON 

(HlRSCHSPRUNG 's DISEASE) 

This term is applied to a disease that may be demonstrated clinically 
immediately after birth or, at least, in early infancy, and is characterized by 
the extreme dilatation and longitudinal extension of all or a part of the 
colon, with marked hypertrophy of its musculature. The ordinary ana- 
tomic findings resulting from intestinal obstruction are not present. 

This anomaly may be due to various causes. Possibly a congenital 
megacolon, a primary congenital malformation comparable to congenital 




FIG. 98. Eighteen-month-old boy with dilatation and hypertrophy of colon (Hirschsprung's 
disease). (Prof. Finklestein.) 

dilatation of the esophagus, may exist. This, however, is a very rare con- 
dition. More commonly we find obstruction due to a valvular mechanism, 
which can be demonstrated only by a very careful topographic examination. 

Normally in the infant the sigmoid flexure is relatively longer than in 
the adult. Occasionally it is so long that several loops are formed. It will 
be readily seen that scybalse and a large volume of gas may gather in these 
loops, and cause them to become twisted. If this be long continued or 
frequently repeated, the loops gradually become dilated and later show 
compensatory hypertrophy. 

In other cases the cause is to be found in the rectum or anus, provoked 
either by spasm of idiopathic or fissural origin, by a simple coprostasis 
which has been neglected, or by a paralysis of the lower section of the 
bowel, with consequent constipation. 

Intestinal dilation due to congenital or acquired circular stenosis of the 
lower section of the colon is differentiated from Hirschsprung's disease by 
the existence of readily recognized obstruction. 

The first indications of the disease, which may appear during the first 
few days of life, are distention of the abdomen and obstinate constipation 
(Fig. 98). For a time, these are the most noticeable symptoms. Usually 



331 

the circumference of the hugely distended loops of the colon, which con- 
tract forcibly from time to time, can be made out. The "dough phenome- 
non of Gersuny" in the fecal mass can frequently be demonstrated. 

The anomaly and its results may be borne without much discomfort 
for a time, but serious symptoms soon appear. Attacks of ileus are charac- 
teristic, with colic, vomiting, and collapse; or, again, we may occasionally 
have foul-smelling diarrhoeic stools containing blood or pus. Death results 
from peritonitis or exhaustion, incident to the attacks of ileus, and usually 
in early childhood. But few such children live to be more than ten years old. 

Treatment consists in the removal of fecal masses and the prevention 
of their renewed formation. Enemata are most useful for this purpose, 
while cathartics are hazardous. Meteorism may be prevented by placing 
a drainage tube in the rectum, the tube being forced above the valve or 
kink. With continuous treatment satisfactory results may be obtained. 




FIG. 99. Hirschspi ung's disease in an infant. 

If this method is not successful, if the attacks of ileus become frequent or if 
ulcerative colitis occurs, surgical interference may be of assistance. 

CONSTIPATION 

The diagnosis of purely functional constipation may be made, even in 
children, only after a careful exclusion of all other possible conditions of 
disease, which might lead to the retention of feces, (e.g., abdominal or 
pelvic tumors, paralysis, strictures; constitutional anomalies, such as 
myxedema, idiocy, etc.). Cases which are not traceable to any of these 
causes must still be considered from many and various points of view. 

The constipation of breast-fed infants is due in some cases to insuffi- 
cient quantities of food and is relieved by their increase. This is especially 
true of children who are being fed from a breast yielding but little milk, who 
are in a condition of actual underfeeding, and who are not gaining, or are 
even losing weight. Even with normally developing children, whose weight 
before and after feeding shows that they are receiving sufficient quantities, 
there may still be a relative insufficiency. In these cases, the milk is so 
completely absorbed in the upper part of the alimentary canal that there is 



332 TEXT-BOOK OF PEDIATRICS 

no material for fermentation, which causing an acid reaction stimulates, 
peristalsis. These forms of constipation are best relieved by giving thick 
gruels made of coarse cereals or oatmeal. After the sixth month, the con- 
dition indicates the necessity of adding vegetables to the diet. Cathartics 
or enemata should be used only in cases with a long sigmoid flexure as 
described below. 

The constipation of artifically-f ed infants is usually the consequence of 
a faulty diet. In younger children, exclusive milk feeding plays the most 
important role and a reduction of milk with the addition to the diet of 
vegetable (flour) foods, or of large quantities of malt soup extract, bring 
about an improvement. In the second and third year of life too long 
continued absence of solid food is a large factor. 

Constipation of older children is, in many cases, due to an excessive 
meat diet, which, as in the breast-fed child, gives too little material for 
fermentation in the colon. A reduction of meat and fish, eggs, cheese and 
milk, with an increase of vegetable foods, especially in the form of coarse 
breads, unstrained vegetables containing large amounts of cellulose, fruit, 
lettuce, e.tc., or with the feeding of large amounts of fat, will prove useful. 
As an aid in the production of free catharsis, lemonade, sweetened with large 
amounts of milk-sugar, and taken cold upon an empty stomach, or sour 
grape juice, may be recommended. 

If results are not secured by these methods, we must consider whether 
the pressure of the abdominal musculature is properly applied. Very 
many children and especially young children do not know how to use, while 
some do not take the trouble to use, their abdominal muscles. It is possible 
that not infrequently there may be a disturbance of the complicated reflex 
mechanism of defecation, due to errors in the formation of habit, to fear of 
pain, etc. It is probable that such a condition exists when it is found, upon 
rectal examination, that fecal masses accumulates immediately behind the 
sphincter. Careful education alone can bring certain relief to these children. 
Many cases of obstinate constipation are cured in a short time by a change 
of the nurse, by strict prohibition of cathartics and enemata, or by cor- 
recting the conscious neglect of the act. Results are sometimes obtained by 
a change in the surroundings of the child. At first, it is often necessary to 
help the child by some anti-obstructive measures, such as the old fashioned 
sulphur treatment (sulphur, milk-sugar, aa 5ss, once or twice a day), 
which prevents the formation of hard scybala3. 

In exceptional cases, the cause of difficult defecation is to be found in 
the existence of fissures, or in the recurrence of painful spasms of the anal- 
sphincter, upon the removal of which constipation disappears. 

The diagnosis of essential obstipation, based upon peculiar anatomic 
and functional conditions, may be made when all the methods of treatment 
discussed above have failed. The long sigmoid flexure, already referred to, 
causing a condition resembling Hirschsprung's disease, comes in for con- 
sideration. Again the condition may be but a single manifestation of a 
general ptosis, expressed in the atony of the colon. It may be due to a 
relative insufficiency of the motor mechanisms of the bowel, as a result 



DISEASES OF THE DIGESTIVE SYSTEM 333 

of which variations of motility occur. In these cases only, are we justified 
in using massage, oil, and cathartics. Of the latter, the milder infusions, 
[frangula 15.0 grams (^ ounce), boiled with 250 c. c. (8 ounces) water, for 
fifteen minutes], or tamarind, aloin pills, and rhubarb are used. Treatment 
for the improvement of the general health and exercise of the abdominal 
muscles, etc., should be employed. 

INTUSSUSCEPTION 

While other forms of intestinal occlusion (volvulus, strangulation ob- 
struction by adhesions or by compression), occur during childhood, they 
are relatively rare as compared with intussusception. About one-half 
of the cases are recorded in infancy, one-fourth in the first fourteen years 
of life, and the other fourth in older persons. 

Intussusception is the involution of a portion of the intestine, the intus- 
susceptum, into a lower part, the intussuscipiens. The mesenteric attach- 
ment and its vessels are dragged into the layers. There are four common 
forms, ileal, ileocsecal, ileocolic and colic; the second form, the involution 
of the ileum into the caecum, is by far the most frequent. 

The mechanism of intussusception is as follows: a portion of the intes- 
tine, in which there is very active peristalsis, forces its way into a portion 
in which the peristalsis is inhibited. This may occur physiologically. The 
condition becomes pathologic when the upper part is imprisoned and sub- 
sequent changes occur in it and its mesentery. It is not easy to deter- 
mine either the cause of the reduced peristalsis in the lower segment, or of 
the failure of its physiologic return. In some cases, traumata, play a part ; 
in others, it may be a question of local meteorism or of peculiarities in the 
mesenteric attachment. More appreciable causes are the presence of a 
polyp, of an epiploic appendage, or a foreign body attached to the entering 
point of intussusceptum. No satisfactory explanation has been found for 
the frequency of the condition in childhood. The suggestion of an excessive 
peristalsis is not very satisfying. In a certain number of rarer cases, the 
invaginated portion does not show any signs of injury for quite a long time. 
Usually, however, the obstruction of the mesenteric vessels produces venous 
congestion, edema, hemorrhage and, later, gangrene of the intussusceptum, 
with local or general peritonitis or general septic infection. 

Extremely acute cases, ending fatally on the first or second day, are seen. 
An acute or subacute course, of from two to seven or even fourteen days 
duration, is more common. The chronic forms are rare. 

Symptoms. The symptoms of the acute type are as follows: Sudden 
onset of pain, frequently of a very severe nature ; vomiting, first of gastric 
and, later, of intestinal contents; mucous and bloody diarrhoea, which often 
occurs with severe tenesmus, but which may be absent if the lesion is in the 
upper portion of the intestine. Sometimes the general condition is only 
slightly disturbed for a time, while, in others, serious shock occurs at the 
very beginning. It is usually the increased peristalsis and painful hardening 
of the involved segment which attracts attention to the obstruction ; while 
meteorism may not at first be prominent. Occasionally, free passage of the 



334 



TEXT-BOOK OF PEDIATRICS 



bowels is observed, but bowel movements and the exit of gas are usually 
suspended. In three-fourths of the cases the intussusception itself may be 
palpated as a U-shaped sausage-like tumor. Commonly it is found on the 
left side but in case of imagination of the small intestine it may be dis- 
covered in other parts of the abdomen. Extreme distention of the 
abdomen may make the examination difficult and, because of the pain, an 
anesthetic may be necessary. At times, the intussusceptum may be pal- 
pated in the rectum or may even protrude. 

Course. The younger the child, the more rapid the course of the disease. 
About one-half of the cases in infancy die during the first three days and 
four-fifths during the first week. The mortality of untreated cases is 
eighty per cent. The causes of death are shock, ileus, peritonitis, and sepsis 
of intestinal origin. Spontaneous recovery, by sloughing of the invagi- 




FIG. 100. Intestinal tumor showing through intestinal wall in intussusception. 

nated portion of the intestine occurs in two per cent, of the cases in children 
in the first year of life, and in six per cent, between the second and fifth year. 
In later life it is more common. Even this event does not always escape 
severe symptoms. Many patients suffer from serious peritonitis or septic 
thrombosis during or after the sloughing, and girdle strictures may remain 
and subsequently produce ileus. After recovery, whether spontaneous or 
by interference, relapses are not infrequent. 

The symptoms of the very rare chronic cases are : palpable tumor, pain 
and the signs of the partial obstruction of the bowel. The anatomic basis of 
this sequel is an involution resulting in comparatively mild changes in the 
intestine and in the mesenteric vessels. 

Diagnosis. With careful consideration of all the symptoms, a diag- 
nosis is usually made readily. Difficulties may be encountered in its differ- 
entiation from hemorrhagic gastro-enteritis and from the severe intestinal 
hemorrhages which begin with the colic-like pains of purpura. In rare cases, 
seemingly typical symptoms of intussusception may be due to an unsus- 



DISEASES OF THE DIGESTIVE SYSTEM 335 

pected volvulus of the caecum or sigmoid. If blood-stained stools are absent 
and the tumor lies at McBurney's point, appendicitis must be considered, 
a disease, however, which is much less frequent than intussusception during 
the first two years of life. 

Treatment. The non-surgical treatment of intussusception consists in a 
reduction by massage or by dilation with air or water. The first method is 
indicated in cases where the tumor is palpable,. It must be done very 
gently as in the replacement of a hernia. The alternative methods are use- 
ful only when the lesion is in the lower segment of the bowel. Any of them 
must be employed early to give results. Hirschsprung reports over seventy 
per cent, of recoveries in cases treated within twenty-four hours and only 
thirty per cent, in those in which the condition had existed longer. An objec- 
tion to these methods lies in the operator's inability to control the apparent 
results; the disappearance of the tumor may be due to a change in position. 
Moreover recurrences are common and there is grave danger of rupture. 
Under any circumstances, these methods, safely done only under an 
anesthetic, should be tried but once, and that upon the operating table; 
so that if absolutely certain restitution has not been obtained, a laparotomy 
may be performed immediately. If the replacement has been successful, the 
patient must be very carefully watched for a reappearance of the tumor or 
of the spastic intestine. The results of prompt surgical interference within 
the first twenty-four hours are very satisfactory. 

PROLAPSE OF THE RECTUM 

Symptoms. Prolapse of the lower bowel segments resembles intus- 
susception very closely. It is an evagination rather than an invagination. 
It may include only the mucous membrane or a greater or smaller portion 
of the rectum itself (Fig. 101). 

Even in children otherwise well, anal prolapse may be caused by exces- 
sive dilatation of the sphincter with large scybalae and under excessive 
pressure of the abdominal muscles. Rectal prolapse, on the contrary, is 
always caused by atony of the perineal muscles, as it is found in congenital 
ptosis or in spinal paralysis (as in spina bifida), or it may be acquired in the 
course of chronic disturbances of nutrition. 

While in anal prolapse only the mucous membrane is extruded, in severe 
cases of rectal prolapse a conical mass, 10-14 cm. (4-6 inches) long, swollen 
and congested because of the compressed veins, may be found. The mass is 
hyperemic and bleeds readily; it is usually covered with pus and may be 
ulcerated. At its apex, the lumen of the bowel is visible. By the applica- 
tion of cold and by the use of gauze, the mass is readily replaced but usually 
reappears immediately or after a short time. 

Treatment. While the prolapse itself is not dangerous, it offers a port 
of entry for local and general septic infection and for this reason it should 
be removed as soon as possible. The bowels should be regulated so as to 
avoid constipation or to relieve existing diarrhoea. Further extrusion should 
be prevented if possible, for this purpose adhesive strips being applied so as 
to compress the buttocks, renewing these after each bowel movement. 



336 TEXT-BOOK OF PEDIATRICS 

As an alternative the cylindrical balloon pessaries, resting upon an external 
plate, may be tried. In milder cases, treatment with astringents, the 
mucous membrane being painted with a one per cent, solution of silver 
nitrate, or enemata or suppositories of tannin or aluminum acetate being 
employed, may give relief. These remedies have little or no effect uponseverer 
cases. In these, surgical treatment should be resorted to; as, for instance, 
by imbedding a fine silver wire, according to the method of Thiersch, or, as 
recently recommended, implanting a ring of fascia from the thigh. The 
protrusion however is often forced through the ring. Lately the injection 
of two pillars of paraffin into the perirectal tissue, or their insertion by 
means of a trocar, has been suggested. The repeated injection of alcohol 
into the surrounding tissues for the purpose of shrinkage may also be 




. 

FIG. 101. Prolapse of rectum in eighteen-month-old boy. 

mentioned. All of these are doubtful methods, including that of amputa- 
tion, and appear unnecessary, if it is possible to improve the general condi- 
tion and to relieve the atony of the perineal musculature by proper diet. 
The case shown in Fig. 101 was treated in this manner and the prolapse 
completely disappeared within three months, the child gaining rapidly 
after recovery. 

HERNIAS 

Congenital inguinal hernia, or inguinal hernia appearing shortly after 
birth, is very common, especially in boys, because the inguinal canal has 
not closed or its closure is incomplete, the vaginal process of the peritoneum 
persisting for a long time. Accordingly, the sac does not lie beside the 
testicle as in acquired hernia, but the intestine and testicle are enclosed in 
the same sac of peritoneum, unless the lower part of the vaginal process 



DISEASES OF THE DIGESTIVE SYSTEM 337 

is practically obliterated (funicular vaginal hernia). By the second year, 
the number of inguinal herniae decreases. Typical acquired herniae are com- 
paratively rare. The sac containing the intestine may, in girls, include 
also the ovary. Strangulation is comparatively rare in children. 

The greater percentage of these ruptures may be cured by bandaging. 
Instead of the usual truss, long strands of soft yarn passing around the thigh 
and pelvis and knotted over the ring, are practical in very small infants. 
Only after the first year, when the rupture, failing to heal, becomes larger, 
is a radical operation indicated. 

Umbilical hernia, or hernia through the linea alba above the umbilicus, 
hardly ever becomes large. Strangulations are exceptional. Careful 
bandaging, begun early and applied continuously, usually results in com- 
plete closure during the first six months or, at least, reduces the opening so 
that the intestine may no longer pass. A flat button, not a round one, 
sewed to a bandage of webbing or held in place by a strip of adhesive, may 
be used. The best results, however, are obtained by the use of several 
strips of adhesive, overlapping like shingles, which hold the hernia back 
under two longitudinal folds of skin over the umbilicus. This should be 
renewed whenever it becomes loose. 

Diaphragmatic Hernia. 'The passage of the intestine into the thoracic 
cavity through congenital openings in the diaphragm, which may be very 
large, is rare. In exceptional cases, the hernia is so great that only the liver 
and stomach remain in the abdominal cavity. The hernia is usually found 
on the left side, because the liver forms a barrier on the right. The con- 
dition may be present at birth or may occur immediately after birth. 
The symptoms are those of severe asphyxia, occurring paroxysmally, and in 
many cases resulting in death soon after birth. Tympany and absence of 
respiratory sounds, are noted on the affected side of the thorax and cardiac 
dulness disappears or is pushed to the right. The retraction of the abdomen 
is characteristic. In some cases, the condition gives no premonitory symp- 
toms but develops suddenly with evidences of internal strangulation. In 
the new-born, nothing is to be hoped for from treatment ; in older children 
only very extensive operations, involving resection of ribs, replacement of 
the hernial content and closure of the opening, are successful. 

ENTOZOA 

Ascaris Lumbricoides (round worms, resembling the angleworm). 
The female may be 30 to 40 cm. (12-16 inches) and the male 20-25 cm. 
(8-10 inches) in length. They may be found singly or in very large numbers, 
in the small intestine, where they deposit their eggs. The eggs, which are 
oval, of double contour and surrounded by a gelatinous, fringed, rough 
capsule are found in the stools. The infection occurs by means of food, 
or by contact with dirt which contains the eggs. The diagnosis is made 
when a worm is passed or by the presence of ova in the stools, demonstrated 
by the microscope. Symptoms, such as abdominal pain, nausea, irritation 
22 



338 TEXT-BOOK OF PEDIATRICS 

and unhealthy appearance of the skin are cited, but are by no means cer- 
tainly present. In rare instances, large ball-like masses of entangled worms 
may produce symptoms of ileus, or the worms may reach the stomach and 
be vomited. They have been known to reach the larynx and cause asphyxia. 
A purulent cholangitis due to the irritation of the ascaris in the bile-duct, 
has been demonstrated. In treatment, the anthelmintic in general use is 
santonin, given twice daily 0.25 gm. (M-H2 gr.), for two days, in conjunc- 
tion with a cathartic (calomel or castor oil) . Larger doses of santonin may 
produce poisoning. 

The oxyuris vermicularis (pin-worms or thread worms), also inhabit 
the small intestine, and resemble a fine white thread in color and appearance. 
The male is 3-4 cm. (1-1^ inches) long and the female, 8-12 cm. (3-5 inches). 
The sexually mature female passes into the large intestine or out of the 
body and deposits oval eggs. The infection is carried by dirt adhering to 
the fingers or by food. From the feces, the eggs are again carried to the 
mouth by the fingers and with the food into the intestine, which is the cause 
of the obstinacy of the infection. Itching around the anus is the most 
important symptom. This may become very severe whenever a new group 
of worms passes into the colon. The diagnosis is established by the finding 
of worms in the stools. When worms are suspected, inspection of the anus, 
the passage of a catheter into the bowel, or an enema will produce the worms 
more readily than an examination of the stools. The ova are found more 
readily by microscopic examination of the material scraped from the skin 
surrounding the anus than in the feces. 

The worms are removed by the use of cathartics and enemata, the best 
results being obtained with a five days' treatment. The first day, with a 
light diet, a cathartic is given in the afternoon, followed in an hour by a soap 
enema; the second day, no food is given and santonin is administered two or 
three times at two hour intervals, with again a cathartic in the afternoon; on 
the third to the fifth day, a warm daily bath and soap enemata, twice daily, 
are given. During this time and afterwards, reinfection must be prevented 
by cleanliness of the hands, finger-nails and anus. The stools should be 
disinfected. Naphthalin treatment 0.3-0.4 grams (6 grs.), threeror four times 
daily, for two days, repeated in two weeks, is recommended. Fats must be 
avoided during treatment. The other members of the family should be 
examined and, if necessary, treated. Usually, there are several persons in- 
fected in the same family, which makes the results of treatment of only 
one member doubtful. 

Tenia saginata is the most common of tape-worms. The treatment of 
the infection is the same as in adults, with fluid extract of aspidium 0.5 
c.c. (5 minims) for each year of age, up to 4.0 c.c. (1 dram) with equal parts of 
powdered senna leaves and powdered tamarind bark. Older children may 
be given the remedy in gelatin capsules. Rest in bed is advantageous in 
all treatment of tape-worm and it is well to rest the intestine after complete 
removal of the parasite. 



DISEASES OF THE DIGESTIVE SYSTEM 339 

DISEASES OF THE LIVER 
CATARRHAL JAUNDICE 

The most common disease of the liver in childhood, catarrhal icterus, 
usually occurs in epidemic groups and in children over two years of age. It 
is hardly ever seen in infants. This gives some indication of the etiology, 
of which nothing further is known. The disease usually has an acute onset, 
with slight or high fever and occasionally gastro-intestinal symptoms. 
The jaundice appears after the second or third day with coincident changes 
in the urine and white acholic stools. The liver and spleen may be swollen 
and itching of the skin may be noted. In older children, a reduction of the 
pulse-rate is demonstrable. The tongue is coated and the appetite poor. 
The course is, as a rule, short. The fever disappears after several days and 
within one to two weeks complete recovery is made. Only exceptionally, 
and for some unknown reason, does the icterus continue. Rare cases 
with cholemic symptoms and acute atrophy of the liver have been observed. 

Treatment. The diet forms the most important part of the treatment. 
Considering the absence of bile, it is customaiy to give food as free from fat 
as possible; that is, a diet consisting chiefly of carbohydrates (flour soup, 
rice, gruels, etc.). Skim-milk or buttermilk, vegetables, fruit stewed or raw, 
and finely divided, may be added. Protein is preferably given in the form 
of skim-milk or cheese, rather than as meat and fish. The usual constipa- 
tion should be overcome by mild cathartics (rhubarb, or Rochelle salts). 
Mild laxative teas and aperient waters may be tried. If the case is of long 
duration, high enemata of Karlsbad water may be advised. Small doses of 
calomel, combined with podophyllin [calomel 0.0025-0.005 gram (Mo-Mo 
gr.); podophyllin 0.005-0.01 gram (Mo-Vs gr.) two or three times a day] is 
also very useful. To increase the appetite, various bitter tonics may be 
given [tr. rhei; 20.0 grams (4 drams) with tr. nucis vomicce, 5.0 grams 
(1 dram) ten to twenty drops, of this mixture two or three times daily]. 

OTHER FORMS OF ACUTE JAUNDICE 

Other, and rarer forms of acute icterus occur in childhood. Weil's 
disease, which is probably due to infection with a member of the proteus 
group, and occurs with severe general symptoms, high fever, tendency to 
hemorrhage, and nephritis, is one of these. Acute yellow atrophy, liver 
abscess with sepsis, appendicitis, gastro-enteritis and hepatitis, developing 
in the course of general septic disease, are complicated with jaundice. 
Gall-stone disease is probably extremely rare. 

CIRRHOSIS OF THE LIVER 

Syphilitic Cirrhosis. Cirrhosis of the liver is most common in infants 
during the first months of life. It may be congenital and, in this event, is 
doubtless always caused by syphilis. We distinguish three main forms. 
The most common is the diffuse portal cirrhosis, which arises from a general 
portal infiltration, and is chiefly characterized by marked swelling and 



340 TEXT-BOOK OF PEDIATRICS 

hardening, with or without slight icterus, and enlargement of the spleen. 
This goes on to granulation and shrinkage of the liver tissue, with ascites. 

The knotty, gummatous form is also seen; and finally, the icteric cir- 
rhosis, probably due to a gummatous cholangitis, and leading to marked 
enlargement and icterus. All of these forms occur also in later life, and 
although actually rare, are still relatively more frequent than any other 
types of cirrhosis. 

Of these other forms, occurring even in two and three-year-old children, 
alcoholic cirrhosis has been seen: also, cirrhosis, with tuberculous perito- 
nitis and rare cases of the hypertrophic icteric cirrhosis of Hanot, of uncertain 
origin, have been reported. Congestive cirrhosis with enlargement of the 
liver and spleen, with ascites, clinically distinguished from other forms by a 
marked general cyanosis, is somewhat more frequent. The cause of the 
congestive feature, as of its cyanotic result, is often, but not always, of a 
pericardial or tuberculous nature. This relationship to the changes seen in 
the liver is not yet clearly understood. 

In addition to simple cirrhosis of the liver due to pericarditis, the type of 
lardaceous liver, characterized by hard cartilage- like deposits in the con- 
nective tissue, may, at times, develop under similar cii cumstances. 

Cirrhosis of the liver rarely occurs in connection with general infectious 
diseases (e. g., measles or scarlet fever). In tropical climates, an icteric 
cirrhosis, in connection with malaria and a biliary cirrhosis of unknown 
etiology (the so-called infantile liver), have been observed. 

TUMORS OF THE LIVER 

Among various tumors of the liver, the very malignant, partially dif- 
fused, infiltrating, and semi-tuberous carcinoma and sarcoma, must be 
mentioned. They are frequently secondary to the kidney or adrenal affec- 
tion. Of the rare primary forms, the greater part may be traced to mis- 
placed germ cells. Operation is impossible. In diagnosis they must be 
differentiated from gummata. 

Cystic tumors of the liver are congenital or, at least, may be traced to a 
congenital matrix. They appear either as solitary tumors or, more com- 
monly, as multiple cysts in the liver and may reach a great size. Finally 
the echinococcus cyst has been observed in childhood. 

CONGENITAL OBSTRUCTION OF THE BILE DUCTS 

Congenital obstruction of the large bile passages is a rare disease. It has 
its origin in a malformation, consequent upon an extensive or total separa- 
tion of the germ centre of the liver from that of the intestine, as a result of 
which the bile passages are either rudimentary and imperforate or are 
entirely absent. As a result of obstruction to the flow of bile, a biliary cir- 
rhosis is formed by distention of the bile passages and hypertrophy of the 
connective tissue. The malformation may exist in varying degree. Its 
most serious form is the complete absence of all the bile passages ; the slight- 
est and the most important for practical purposes is a simple occlusion of 
the opening of the bile-duct into the intestine. The disease is in no way 
related to syphilis. 



DISEASES OF THE DIGESTIVE SYSTEM 341 

Symptoms. Children with this malformation are born with icterus, or 
become icteric after a very few days. The discoloration gradually reaches 
its highest possible degree. In the meantime, the liver and spleen become 
large and hard. The urinary findings correspond to the discoloration of the 
skin. (The stools are acholic from birth.) 

Course. The disease ends fatally during the ninth or tenth month, 
at the very latest (commonly before the fourth month), often with cholemic 
symptoms and those of a hemorrhagic diathesis. The possibility of forming 
a connection between the biliaiy system and the bowel obtains only in cases 
of atresia of the papilla, which, of course, cannot be diagnosed, and are 
rare as compared with the incurable forms. 

In older children, serious and long sustained cases of icterus, due to 
diseases of the bile passages, such as congenital stenosis and cystic develop- 
ment, in particular, occur. 



PURULENT PERITONITIS 

Purulent Peritonitis of the New-born. The greatest prevalence of peri- 
toneal disease is found in the new-born, and corresponds with the large 
percentage of other septic infections common to this age. Infections extend- 
ing from the umbilical vessels are most common. Next in frequency are 
the metastatic infections and, finally, infections arising in the thora.cic 
organs. Peritonitis in infancy from other causes, and especially from per- 
foration, is rare. The diagnosis is very difficult at this age because the 
characteristic symptoms are not very definite and meteorism, vomiting and 
sudden loss of weight, so commonly depend upon other causes than perito- 
nitis. The recognition of the disease is of much less importance in infants 
than in older children, because the age of the patient and the nature of 
the disorder forbid operative interference. 

PERITONITIS IN OLDER CHILDREN FOLLOWING APPENDICITIS 

Appendicitis is extremely rare in the first year of life and is observed only 
exceptionally during the second year. From this time on, however, it 
rapidly becomes more frequent, together with secondary peritonitis incident 
to it. To one acquainted with the disease in adults, its manifestations in 
children do not present any peculiarities. The diagnosis is made difficult, 
however, by the uncertainty of the subjective symptoms, and by the fre- 
quency of other intestinal disturbances, which tend to lead the diagnosti- 
cian in other directions. In the differential diagnosis we must consider, 
aside from acute intestinal catarrh and gastric conditions with painful 
colic, the following facts. In children, with separation of the recti and 
other signs of ptosis, attacks of severe abdominal pain occasionally occur 
and are relievable by properly applied bandages or adhesive straps. In 
their onset, diseases of the respiratory passages, and especially pneu- 
monia, run an initial course attended by pain, which is frequently localized 



342 TEXT-BOOK OF PEDIATRICS 

by the child in the lower abdomen. Similarly, we sometimes find in influenza 
and other general infections, areas of hyperaesthesia and zones of head in this 
region. In childhood, an habitual torsion of the movable caecum is common 
and is characterized by tumor, pain, and occasional diarrhoea of blood- 
stained stools. In chronic fermentative dyspepsia, also (q. v.), severe pains 
and local tympany are observed. 

OTHER FORMS OF PURULENT PERITONITIS IN OLDER CHILDREN 

Those forms of peritonitis which do not arise from the appendix are 
comparatively unimportant in older children, when we consider that those 
cases which may be regarded as purely peritonitic give hope of remedy 
from surgical interference. In this group, are included peritonitis from 
perforation of a typhoid, tuberculous, duodenal or ventricular ulcer; 
peritonitis due to transmigration in enteritis and ileus; and peritonitis 
following the strangulation of a hernia. The majority of cases observed 
belong, however, to a group arising from pulmonary and pleuritic infections, 
or to the type of metastatic peritonites, in so far as these appear as primary 
localizations of an infection, or even as an apparently primary disease. 

Peritonitis due to infection with pneumococcus occurs as a phase 
of a multiple purulent inflammation of the serous membranes (Heubner's 
disease), or polyserositis, polyorrhomenitis, affecting the pleura, menin- 
ges and joints, which is seen quite frequently, even in infants. In older chil- 
dren it is of greater individual importance and is, therefore, a direct object of 
diagnosis and therapy. The pneumococcus peritonitis of older children, 
chiefly affecting girls, although no definite infection from the genitals can 
be traced, may be regarded as a migratory peritonitis derived from the 
intestine or from the pleura. Probably most cases might show a hemato- 
genous origin from some primary focus, as, for instance, an angina. 

The disease begins suddenly with high fever, vomiting, diarrhoea and 
severe abdominal pains. After several days the condition improves but 
the diarrhoea continues, and gradually signs develop in the abdomen which 
point to the presence of an exudate. Distention, dulness and possible 
fluctuation are observed. The dulness is usually not that of a general 
exudation, but rather resembles that of a large walled-off abscess filled 
with thin pus, containing pneumococci. Left alone, it gradually extrudes 
through the umbilicus and finally ruptures it. Alternatives of rupture into 
the genitals, the colon or the urinary bladder may occur. A diffuse, puru- 
lent peritonitiswithmovable exudate ismore rare than the encapsulated form. 

The diagnosis is difficult. In the beginning, appendicitis is usually 
suspected; differential signs, viz., severe diarrhoea, localization of pain, and 
absence of muscular rigidity, on the one hand, are hardly constant, and, on 
the other, scarcely serve as a sufficient basis for differentiation. In its 
distinction from typhoid, the severe pain and violent vomiting at the outset 
and the absence of leucopenia are valuable. In the later stages, the appear- 
ance of an exudate is distinctive. With the large quantity of exudate 
eventually present, tuberculous peritonitis might be suspected, but the 



DISEASES OF THE DIGESTIVE SYSTEM 343 

acute course and a bacteriologic examination of the pus, obtained by explor- 
atory puncture, should rule this out. 

Streptococcus peritonitis similarly caused, and with symptoms similar 
to those described above, excepting that the tendency to encapsulation is 
wanting, and that its course is much more acute and more malignant. In 
bacterial diagnosis, not only the pus, but the venous blood obtained by 
puncture may be used. 

Gonococcus Peritonitis. In girls showing a gonorrheal discharge 
circumscribed pelvic peritoneal inflammations are occasionally seen. 
These occur with symptoms similar to those met in adults. Exceptionally 
the inflammatory process continues for weeks with high fever and extends 
over the whole abdomen. This is distinguished from other forms of peri- 
tonitis by the relatively slight effect it has upon the general condition. 
A provisional diagnosis is based upon the presence o'f vulvo-vaginitis and 
upon the demonstration, by rectal examination, of a major genital disease. 
It should be remembered, however, that a child with vaginal discharge 
may have a coincidental non-gonorrhoeal peritonitis. 

The disease is relatively benign. Even the diffuse form is in most cases 
self-limited. Cases with fatal termination, however, are known. 

The treatment of purulent peritonitis in childhood, and especially its 
operative treatment, is founded upon the rules applicable to adults. In 
general, the earliest possible opening of the abdomen is indicated. Only 
in gonorrhceal peritonitis may spontaneous recovery be expected. In the 
pneumococcus peritonitis it is of advantage to operate after the abscess has 
been encapsulated. This advice, however, which can hardly be followed in 
cases with severe symptoms and of uncertain etiology. 



TUBERCULOSIS OF THE MESENTERIC AND RETROPERITONEAL LYMPH NODES 

As tuberculous infection of any locality produces tuberculosis of the 
regional lymph nodes, so those of the mesentery and of the retro peritoneal 
spaces may become diseased from a tuberculous lesion in the intestinal 
mucosa, which may be completely healed while the secondary process in 
the nodes continues and spreads. The nodes enlarge and caseate, and 
extensive confluent lymph tumors re formed by adhesive inflammation. 
The mesentery and omentum may become knotted and adherent and knob- 
like granulation tumors, resembling a string of beads, may develop in the 
intestinal serosa and in the mesentery. Many of these forms are pro- 
duced by bacilli of the bovine type. It is then possible to palpate multiple, 
cylindrical and nodular masses of marked resistance in the abdomen. The 
abdomen is distended (Fig. 102), and usually the spleen is greatly enlarged. 
The process is insidious beginning with indefinite pains and later giving 
high and often hectic fever. Nutrition is seriously affected and cachectic 
edema is common. These general manifestations may continue for a 
long time before findings on palpation are possible. The prognosis is un- 
favorable ; but recovery occasionally takes place even in severe cases. 



344 TEXT-BOOK OF PEDIATRICS 

The Adhesive Form of Tuberculous Peritonitis. This greatly resembles 
the form just described. It has its origin in a tuberculous infection of the 
peritoneum, which gradually develops from crops of miliary tubercles to 
large masses of diffuse, scattered, caseous, granular masses, binding loops of 
intestine together by adhesions. Finally, the intestinal loops become adher- 
ent to each other and to the parietal peritoneum in an inextricable mass. 
The caseous masses between the intestinal loops may break down and rup- 
ture into the bowel, into the pelvic organs, or even externally. The abdom- 
inal cavity may become infected with pus organisms, when a septic and 
inhorous infection and general intoxication are added to the tuberculosis. 

Symptoms. Clinically, the disease begins with languor and indefinite 
symptoms, such as slight abdominal pain? and occasional vomiting. With 
these there may be a slight temperature. The abdomen gradually becomes 
irregularly distended and is hard to palpate. Percussion and palpation 
lead to the suspicion of tumors. There is no free ascites. As the disease 




FIG. 102. Tuberculous peritonitis. (Gisela Children's Hospital, Munich, Prof. Ibrahim.) 

goes on the fever continues; and diarrhoea and anorexia considerably reduce 
the weight. Occasionally symptoms of partial intestinal obstruction occur. 
The situation becomes hopeless if the softening tubercles become infected or 
rupture. The prognosis is the same as in abdominal tuberculous adenitis. 

The Exudative Form of Tuberculous Peritonitis. This condition 
results from a crop of miliary or sub-miliary tubercles, "which do not caseate 
but remain in the stage of granulation and degenerate. The tubercles are 
accompanied by a serous exudate, of which several litres may be formed. 
This type, which has a relatively good prognosis, begins insidiously, with 
slight temperature and mild indications of abdominal disturbance. Later, 
the abdomen increases in size and the presence of a movable exudate be- 
comes definite. The patient 's general health is but slightly affected. Hard, 
light-colored stools are usual, but diarrhoea may be present. 

A large percentage of these cases are amenable to treatment, even 
though they go on for months and recurrences or exacerbations occur. 

The diagnosis of tuberculous diseases of the peritoneum is dependent 
upon the history and the demonstration of other accompanying symptoms 
of tuberculosis (lichen scrofulosum, tuberculides, lymph nodes, etc.). 



DISEASES OF THE DIGESTIVE SYSTEM 345 

Even if these are not present, tuberculosis is probable, because other 
peritoneal diseases are more rare in children. The abdominal tumors should 
not be mistaken for masses of fecal matter. Rectal examination may, at 
times, reveal enlarged nodes high in the abdominal cavity and small 
nodular irregularities in the pouch of Douglas. In the presence of large 
quantities of free exudate, diseases of the liver, heart lesions, and pneumo- 
coccus peritonitis must be excluded. In these cases, a bacteriologic and 
cytologic examination of the fluid obtainable by puncture is necessary. A 
lymphocytosis is strongly indicative of tuberculosis. Bacteria can be 
demonstrated only in the centrifuged material or by injection into labora- 
tory animals. Pseudo-ascites, in the course of severe chronic digestive 
insufficiency, may be recognized by close observation of the digestion, by 
the variation in its quantity, by the difference in the areas of dulness, 
which do not resemble those of a free general exudate, and by examination 
of the fluid obtained by puncture. 

In the treatment of all forms of tuberculosis of the peritoneum, the 
hygienic and climatic factors, indicated in all forms of tuberculosis, should 
receive first consideration. To these are to be added methods which will 
increase local absorptions; i. e., heat in all forms (hot applications, electric 
pads and local electric light baths), and action of the sun's rays upon the 
abdomen. The exposure to the sun should last only for a few minutes at 
first and the time should be gradually lengthened. In mountain resorts 
and at the seaside, these sun-baths may produce surprising cures; while in 
advanced cases they may cause serious recurrences and even fail entirely. 
Soft soap treatments and salt may be useful (see scrofula) . In many cases 
the resorption of the exudate seems to be hastened by a salt-free diet. A 
generous mixed diet should be allowed, but actual overfeeding must be 
avoided. Diarrhoea should be treated according to the methods described 
for intestinal catarrh. Medicinally, the treatment is that recommended 
for scrofula and general tuberculosis. Iodine is especially useful. 

The value of surgical treatment has probably been overestimated. Its 
best results are seen in forms associated with ascites, in which fairly good 
results may also be obtained by the methods of internal medicine. Nor 
does operation promise much in other forms. It is of chief use in children 
for whom a physical, dietetic, and climatic method cannot be applied, 
because of surrounding influences. Opening of the abdomen and removal 
of fluid is sufficient; sometimes, simple puncture is effectual. 

FETAL PERITONITIS 

At autopsies on the still-born or on children who have died immediately 
after birth, the residue of a fetal, aseptic peritonitis is found in the form of 
adhesions and bands of connective tissue. Such children, may live and 
show symptoms of intestinal obstruction from birth. Fetal peritonitis 
may be the result of a malformation of the intestinal tract or the genital 
apparatus; of the passage of the fetal intestinal contents through a perfor- 
ation into the abdominal cavity; or it may be due to the placental trans- 



346 TEXT-BOOK OF PEDIATRICS 

mission of substances producing inflammation. Syphilis may be considered 
as a causative factor in a number of cases. 

Syphilitic peritonitis, with pseudomembranous exudation is no uncom- 
mon symptom of the first irruption of the disease in the infant. In ex- 
ceptional cases, it produces typical symptoms of peritonitis, vomiting, 
meteorism, and ileus due to scar-formation and kinking. 

TUMORS 

Among benign tumors of the peritoneum, simple cysts, echinococcus, 
fetal inclusions and dermoid cysts, may be mentioned; among the malig- 
nant, medullary carcinoma and sarcoma. The symptoms of the latter 
resemble the tumor-forming and exudative tuberculous peritonitis. 



IV. 
DISEASES OF THE RESPIRATORY ORGANS 

BY 

C. FRH. VON PIRQUET, 

Vienna. 

REVISED AND EDITED BY 

WALTER H. O. HOFFMANN, M. D., 

Associate Attending Physician Children's Memorial Hospital, Chicago. 



THE child 's no