A SUMMARY OP CHILDREN *S DISEASES. INFANCY:- the 1st 2 years of life; the frist year is the nost characteristic and important. CHILDHOOD: - the pence, from 2 y e ars to pub e rty. Congenital Disease:- the result of changes "in utero" by k (1) arrest of development, (2) abnormal persistence of intra- uterine conditions. Acquired disease:— occuring after bii hi. FOETAL conditions:- Lungs inert, placenta is foetal lung. Course of foetal circulation:— placenta, umbilical vein, j.oeoal liver and ductus venosus, inferior vena cava, right auricle; blood turned by eustachian valve through foramen ovale into loft vfintriHiex auricle, left ventricle, aorta; subclavian and caro- tid to upper extremities and head; superior vena cava, righn auricle to right ventricle through tricuspid valve; pulmonary artery, lungs ( a small portion of the blooa), trie .Larger portion of the blood goes from the pulmonary artery through the ductus arteriosus into, the aorta, joining the blood here from the left ventricle; common iliacs, internal iliacs, umbilical euueiies «o placenta. Mote results: Head and liver are large, thorax and legs are small. POST-H/!TAL CHANGES: -1. Ductus vcnosus becor.es a fibrous cord, 2-5 days. 2. Eustachian valve disappears. o. Eorsmen ovale closes, week to ten days. 4, Ductus arteriosus is obxi^erateo.,- 4- — 7 days. 5. Umbilical vein becomes obliterated, o, Umoilical arteries:- upper part closes, lower part persists as superior vesicle arteries, 7, Lung s r — become expanded, usually , in f li s« week, and pulmonary artery enlarges. If foramen_ovale or ductus arteriosus remain open after 10 days the condition aonormal. NORMAL CHILD at TERM:- Average head circumference 13 to 13 1/2 inches, thorak 1/2 inch smaller, abdomen 1 in. larger, as a rule. Average WEIGHT: 7 to 7 1/2 lbs. Cord falls off 6th to 7th day. HEART same position as in adult. LIVER larger proportion ally, l/2 to 1 in. below ribs. Testicles descended. BLADDER above pubes ( this is important. HEAD: anterior fontanelie 1 to 2 cm-, long, 1 cm. broad. Mote that depressed fontanelie moans low vitality; bulging fontanello means some inflammatory process). POSTERIOR HARES are very small, therefore easily occluded by congestion of the mucus membrane; simple acute nasal catarrh may cause death by occlusion This is the reason of green danger in "snuffles” of congenital syphilis. EAR: cuter part undevel- oped, mastoid cells not developed at all. Auditory canal: 1st part goes inward and downwards, then comes a change in direction, the rest of the canal going a little upwards and backwards. Therefore to use speculum pull ear downwards and forwards; this is just the opposite of H10 rule for adults. The petroso-squamaSal suture is open in infancy and early childhood, inflammation of the ear in infants and young children may be mistaken for menin- gitis and may lead to brain abscess. 2 SPINE: flexible, no definite curves at birth; lumbar curve first appears at one to two years. No depression along line of spins as in adults. THORAX; Circumference at birth smaller than of head; equals head at one to two years. Bulging of sternum may be caused by en- largement of heart in early life;(if upper part is flat and sternum bulges in the middle, the lesion is of later development. Lungs are largely embryonic in character,i,e, great proportion of bronchial tubes, alveoli small, much connec- tive tissue stroma; blood vessels loosely held. Respiration at birth variable, but averages about 45 under ordinary circumstances. Heart: Upper half high in relation to chest wall; apex impulse slightly higher and nearer mammary line than in adult. Foramen ovale often open at birth. Pulmonary artery larger than descending aorta,- pulmonic sounds louder than aortic in children, reverse in Qdult. Area of relative dulness hard to make out, but is rela- tively larger than in adult. Absolute dulness are can bo covered at birth by the end of a forefinger. Pulso 120 - 140 but irregu- lar. ABDOMEN: relatively very large. Bladder and uterus are abdominal organs. Stomach,- capacity about 25 cc. (5/6 os.) Intestine less fixed than in adilt, therefore intussusception easy. PELVIS & LEGS: relatively small; legs curved. HEIGHT: (average) Male 19 3/4- inches; female 19 1/4. WEIGHT: 11 " Male 3250 - 352o grams (7 1/7 - 7 5/4 lbs) Female 5150 - 3290 grams ( 7 - 7 1/4 lbs. ) In general, weight is and index of vitality. VOICE: every normal child should cry vigorously at birth; helps lungs to expand and aids circulation. EYE: Very sensitive to light; therefore protect new born from strong light. Tear secretions not in first fsw weeks, SALIVA: almost none till 3rd or 4th month. PANCREATIC JUICE: foment probably not at all developed at birth; there is little amylolytic power till toward end of first year. BLOOD: not much fibrin, so blood doesn't coagulate easily* cf. haemophilia (umbilical hemorrhage) of new born. BILE: well developed, cf. Icterus neonatorum. URINE: little or none in first 24 hrs, First is usually dark and thick; soon yellow, slightly acid. Specific gravity about 1010, Uric acid infarction practically normal for first 2-3 weeks; • there is often a deposit of urates or uric acid in the foJfln of a reddish yellow stain upon the napkins in the first few days. Amount of urine first few days about f Occ., 2 1/2 months 250-4-lOcc. 5 months, 400 -300 cc., 2 - 5 years, o00- 800 cc,, 5-8 yrs. 6oo - 1200 cc. 8 - 14 yr?. 1000 - 1500 cc. Urine of adolescence: remember it- is likely to have a trace of. albumin, especially towards noon. INTESTINAL DISCHARGES:- Nixed with meconium (the first discharges after birth) for three days to a v/cek, longer if nutrition is poor. Normal discharge on good milk-diet, breast fed, is golden- yellow, smooth, with a large proportion of water; the color may change to greenish-yellow on exposure to air. Color remains yellow till starchy or albuminous ffod is taken, then changes to brownish. Frequency:- In first months 2-4 dejections daily, decreasing then to 2 and later to 1. UMFILICAL CORF:- separates usually on 7th or 8th day. Umbilicus should be depressed even when infant cries. KEAFt Fontanelies:- posterior usually imperceptible at six weeks. Anterior increases in size to about ninth month, remains stationary 9th - 12th month, completely closed 19th - 20th month. At end of first year anterior fontanelle should be about one inch in diameter (Holt). Fontanelle bulges in meningeal hemorrhage, hydorcephalus, acute and tubercular meningitis. Delayed closure is most commonly a manifestation of rickets, and is seen also in cretinism. TEETH: - Isi< dentition, "Milk-teeth”, 20 in number. 6-8 months - - - - 2 middle lov/cr incisors, 8-10 " - - - -4 upper incisors, 12-14 " - - - - 2 lateral lower incisors, 4 1st molars, 18-20 ” - - - - 4 canines 24-32 ” - - - - 4 2nd molars. Delated dent, it ion most frequent in rickets, seen also in cretins, cf. closure of fontanellss. 2nd Dentition, permanent teeth, 32. 6 years - - - - - - -4 1st molars 7-8 years ------ 0 incisors, 9-10 " ----- 8 bicuspids, 11- ------- 4 canines, 12- " 4 2nd molars, 17-25 u ------ 4 3rd molars and 4 "wisdom teeth". STOMACH:- Capacity, determined by weighing child immediately before and after a full meal: At birth, 1 os. G months, G oz, 2 weeks, 2 oz., 12 months 9 oz., 1 month, 2 l/2 oz., 18 months, 12 oz. 3 months, 3 l/2 - 4 1/2 oz., Artificially fed babies often yet too much to eat. Capacity as a rule varies with weight of child rather than with aye. CAECUrf: position relatively higher than in adult. Sly mo id. flexure at birth is about one half whole length of large intestine. PULS?: rat3: Early weeks, 120-140, Until 2nd year 110, 2-3 years 100, 5-8 years,-- 90, from 8 yrs► to puberty gradually reaches adult rate. RESPIRATION: At birth 45 per minute, until 3rd yr. 15-40 3-5 years, 25, " " 12 yrs., - - - 20. Varies extremely with temperature and excitement. Type chiefly abdominal in early life. HEIGHT: Average child grows 8 in. in first year; height doubled in first 6 yrs. At 14 final height is reached within l/12th. Growth is- most marked in the spring. During the first 3 or 4 days there is a distinct loss of vreight,, due to meconium, removal of vernix caseosa, and urine of til- 1 ix’st day. This loss should be regained by end of the second week. Average total loss of children of primiparae is 8 l/5 oz., of multiparae 7 2/5 oz.; the greater loss in the first class is cue to slower establishment of milk supply in primiparae. These children overtake and keep : ace with those of multiparae after 2nd week. fy. sterna tic we iahina is an index to child’s health and should always be done. Better have scales in the nursery with basket always kept ready for weighing. A distinct loss of weight may preceed other symptoms of sickness by several days or weeks. ago. daily again (take weights for a week to get average) should not be less than 2/3 oz., in normal child born at term, from birth to 5 months; from 5 to 12 mon hs 1/3 to 2/3 02. Initial weight should be doubled at 5 months, trebled at 15 months. Weight at 1 yr. should bo doubled at 7; weight at 7 doubled at 14. Increase is lessened by dentition, weaning, poor hygiene and disease. JlaJZp should bs of a pink color as soon as born. Icterus neonatorum (jaundice of the nsr-born) practically normal, it occurs so frequently. Commonly begins 2nd to 3rd day; lasts 8-11 days. Abdomen yellowish-brown, some- conjunctival jaundice. Treatment: Bathe skin daily. Erythema neonatorum: uniform redness of whole s#in; begins in 1st 2-3 days, lasts about a week; usually no consti rational symptoms; nay be some slight desquamation if intense; may be simulated by eczema erysipelas and scarlet fever. Treatment:- r/ask without soap and apply powder:- Pulv. Zinci oxidi 3o Pulv. Amyli trit. 120. M. £QTS}.: should be wrapped in dry antiseptic absorbent cotton; no water shotild be aliowed to touch it. £TRgdGTH: New-born unable to hold up head till about 2-3 months. Sits up 7th-9th month; begins to creep lo-12 months, to walk 12th-15th month. TOPOGRAPHISAL ANATOLY of CHILDHOOD: idlt. Iialf year: Heart dulness within mammary line; bounded by 4th rib or third interspace above; no dulness under sternum. Liver large. Transverse colon relatively low; just above umbilicus. Caecum high, near right ant. sup. spine of ± ilium. Left kidney higher than right. Left lung, lower border 10th rib; right lung 9th rib. idl 3 years: Cardiac dulness larger , relatively, as well as abso- lutely than in infant. Relative dulness under sternum; dulness higher in left parasternal line than at any other age; relative dulness above 10 lower border of 2nd rib; absolut, 3rd rib; left dulness to a little beyond mammary line. Liver relatively than in infancy; lower border. In right mammary line a fingers breadth below lower edge of ribs• Colon higher and caecum lower than in infant. At 12 yrs. Liver: lower border not below ribs;trans- verse colon 1/2 way between umbilicus and ensiforrn cartilage* 5 TFE NURSERY: Requisites for a good nursery:- High from ground, out of dairiness; sunny exx'osure, large windows higher than child’s face from floor; not papered or carpeted; no picture mouldings, (dust-catchers) , floor tight, smooth (not hi-illy polished on account of danger of children slipping). Floor, walls and ceiling should be painted; rug in middle of floor, which should be often tal:en otit and Iseaton. Bed iron, painted; pi 11 ov; and mat iress of hair,, cover with rubber sheet. Curtains of simple muslin, often washed. Term erature Go—70 T, Open wood fire best for ventilation, Scales (small platform) in room. BATHS: Every morning unless contraindicated (by blue nails or skins cold, extremities, gasping); if so conerainuicated sues txtute sponging, Pont put baby itf|/water for neck or 10 days, i.e. sill cord is healed and loss of weight- reyeinoci, bus wash i- on nurses lap. Pont have head toward fire, nor feet toe near fire. Tenr.)eratur0 of bat h: 98-100 7, at first t - be dsfinite in v/Iiat you tell the parents. 1st month. 95, 1-6 months 95, 6-15 mo. 9o, 1-2 years 86 ( reduce to 30 in summer); at 3-4 yrs. reduce tem- perature to 75, Avoid (1) Strong light in infant*s eyes, (2) Drafts: best have tub raised, and have fonder for fire. (3) Too vigorous washing of child’s non7 ; dont lot nurse rub it; wash out with a medicine dropper and pure rater* Avoid also with young children any frightful stories, tossing up in arms etc; fright harms the nutrition; this is important, Dont let young babv cry continuously for a long time, — may in- duce umbilical or inguinal hernia. SLEEP: AT FIRST AIL-0ST C0NTINU0UF i ESPECIALLY IN PREMATURE IN) PANTS . Regular periods established in a few weeks, several lours twice a day, later once during the day besides the long sleep at night. “A healthy infant during the first few weeks sleeps twenty to twneoy-two hours out of the twenty-four, waking only from hunger, discomfort or pain. During the first six months from sixteen to eighteen hours a day, the waking periods being only from half an hour to two hours long, .At one year .... fourteen to fifteen hours, vis/ from eleven to twelve hours at night, and two or three hours during the day, usually in two naps, Then two years old usually thirteen to fourteen hours,.... At four years children require from eleven to twelve hours’ sleep. From six to ten years .... ten or eleven hours, and from ten to sixteen years nine hours should be the minimum" (Holt) POSTURE: Font allow children to be made to sit up. At seven or eight months the spine begins to be strong enough. Legs should be free to move when child is on ios back; pressure downward on legs causes strain and curvature of lower spins. Doing carried always on same side may cause lateral curvature. During first year in- fant *s back should be carefully supported by a pillow when sitting up. Round shoulders suggest lateral curvature. Bow legs due to (1) too early standing and walking, (2) Rickets. Knock-knee almost always rachitic; rarely duo to simple weakness. 6 MAr-’rTF: Change often. Don’t let them bo dried out and used over again without being washed. Don’t allow them to be dried in the nursery,; they will contaminate the air and babies are extremely susceptible to vitiated air. fetter use in case of young babies soft, antiseptic absorbent gauze which can be burned when soiled. CLOTNINQ: Have it loose and warm Long stockings are better than short; many a case of abdominal disease has been caused by bare legs. Clothes should go on quickly- saves annoyance to baby and so its vitality. No necessity for flannel band afetr first 2-3 wc ek s, - ti gilt b and a g e t e n a s t o d i sp lace liver and k i dn 3 y s. SHOPS: Always insist on having rights and lefts. OUT-DOOR AIRINGS: In first year don't let baby go out in ■&ena- ture less than 32 F. and then only on sunny days; high winds should keep it in-doors. In 2iid year child may go out with temperature of 20, but again, not in high winds. SCHOOL: Don’t be in a hurry to send children to school, particu- larjy if delicate or nervous. Kindergarten is good for children of phlegmatic temperament, but often a positive harm to bright, nervous children. VACCINATION: Time: - best at 4-5 months t just before first tooth appears; 1.-s trength of child, is sufficient; 2.- any outward symptoms of syphilis will have* appeared if the disease is present, thus pr v7on. in- the accusation of the doctor *s irmoculat ing the disease. Place: Left arm, if nurse is right handed and vice versa. Girls on outside of leg below knee. Vaccine from cows, nade under state supervision. Inoculation in three places, at once makes the chances of efficiency greater. Usual course of the disease:- 3rd, 4th or 5th .day a snail rod point, papule; next day vesicle; Cth day unbilicajfrcd wi;:h faint rod zone; 3th day vesicle complete;Sth, zone increases, pustule forms; 11th or 12th day crust; crus: falls 14th to -2-1 &t day leaving skin intact, or there may be a repetition of the*zpr ocess. v/COINIA (cow-pox) may result rarely. Lesions appear about 5th day; small papule, vesicles or pustules oixdbcdy, limbs or face. After exposure to variola vaccination wititin 48 hrs. is usually protective. s. NUTRITION of children. I. KATEISTAL PEEPING: Gontvaindica: uncontrollable temper- aments, unhappiness, unwillingness to -jsurae the infant, irregular- ity in rest, diet, excercise; chronic or inheritable disease. :.Ti;)T-1.33: if sm 11 or depressed a nippid* shield may remedy. Tender nipples: often passes away in a few days: use a nipple shield, keep due nipple washed with pure water before end after nursing; boric acici ointment is often effectual. Mastitis: (1) rarely a. stasis of the milk;- treat by very gentle- massage toward the nipple, withhold breatri. from child 24 hrs., swathe fchc breast. (2) Inflammation, a surgical matter. : "ilk: Condos it ion of average human milk: Reaction slightly alkaline. Specific gravity 1043 to 1034 (Average 1031) water . ... 87-88;f Total solids 13-13# Total Soildjv (continued) Fat 3*- 4/o Sugar 6-7 Prof.elds 1-2 Total ash s , „ , e 0,1-0,. %% Clinic el examination: - Specific gravity 1023-1034; an increase in fat lovers it* increase of other solids raises it. Sugar main- tains pretty constant proportion; proportions of fats and protsids vary, p£ found by filling glass stoppered graduated cylinder to zero mark, then set away at 70 P, for 24 hours; read the percentage of cream at the top. The % of fat is 3/5 that, of the cream. With the sp.gr, and % of fat and a fairly constant % of sugar, the % of proteld can be easily figured, Quantity of fat is increased by proteid food.. Quantity of milk is decreased by belladonna, active catharsis, and solid iced with very little water. TjLjri8_of feeding. Just as soon as the mother can nurse,usually not within 12 to 36 hours , Agn. Intervals No., in 24 hr3, Night feedings Birth - 4 vhs* 2 hre, 10 1 4- 6 weeks 2 « • 9 3. 6- 3 * 2 l/2 " 8 1 2-4 months 2 l/ 2!l 7 0 •4-10 41 3 u 6 0 10-12 " 3 n 5 0 of foodlng: (Average) Toe frequent feeding lessens the water and increases solids and vice versa. TTlfit of. the mother: Plain mixed diet with moderate excess of fluids and proteids over her accustomed diet. Exercise at reg- ular hours, especially walking is necessary for the production of good milk. Menstruation in some few cases affects the milk unfavo rabl y Management of disturbed lactation* First determine if milk is cause of child's sickness: 1„ Find quantity of milk (Weigh child before and after nursing). 2, Qualitative analysis. To increase total quanti£y.... increase liquid in mother's food,. To decrease total quantity, decrease liquids „ To Increase total solids. shorten intervals, decrease exer- cise, decrease liquids. To decrease total solids, prolong nurs- ing intervals, increase exercise, increase liquids. To increase fats, increase meat in diet. To decrease fat, decrease moat, To increase proto ids, decrease exercise„ To decrease pret e i cl « f in c r e a n e e x o r c i r> e , Quantity of milk decreases usually from 8th-10th month. Lactation normally ceases at about 12 months. Child's digestive powers at 12 months begin to demand other food, e*g, some form of s t a,r ch and unrno d if i e d c o w 5 s mi Ik * 8 lii.xod With insufficient supply of breast milk, prepared food to the amount needed is added. Analysis of maternal milk,- if it agrees with the infant,- shows required food composi- tion. If mother’s milk lacks some qualities, add these to the sub st it ut e e Weaning: Presence of G-S teeth corresponds to full develop- ment of pancreatic juice, i,c. ability to digest starch and fat. Interdental period better than dental; cool T/eather better than hot0 Weaning should be gradual if possible, omitting breast-feed- ings one by one. direct Substitute Psedina: ¥et nurse: Requisites are, 1/ freedom from constitutional disease, especially syphilis; 2„ A quiet temperamenta 3. Aplontiful supply of milk* Have analysis of milk made before engaging the nurse. Nurse *s diet: A good supply of moderately rich milk food, but don't allow any sudden change in her diet* Don't allow the family to use the nurse as a maad of all work. I]?.-:'.irect substitute feeding: Average Oox-r *s Milk: Reaction si. acid Specific gravity...... 1029-1033 Water 86-87/" Total solids 14-13/i Total Solids: Fat . ... 4.00fi Sugar ......... 4„o0% Proto ids ...... 4.OOX Total Ash ..... 0c70;C Cows ’ milk made alkaline by (1) Add- ing an alkali; (2) reeding cows sugar-beets in addition to hay and grain„ Characteristics of coy/s ytith goos infant-mill:; 1, Constitu- tional vigor.2. Adaptability to acclimatization. 3. Notable ability to raise young. 4. freedom from intense inbreeding. 5. Distinctly emulsified fat in milk. iril k from a herd is belter than that from a single cow. Last half of the milking contains fewer bacteria then the first half. Milk should bo caought in clean pails and immediately removed to a milk house free from odors. Jersey and Quernsoy milk contains a larger proportion of f~t and pro ieids than that of Durham, Devon, Aryshire or Holstein cattle, but the former are much more susceptible to tuberculosis, on account of a more intense inbreeding. Therefore avoid the milk of Jersey or Guernsey cov/s for babies, Modified VjJJg: (1) Modified in a milk laboratory, e.g, talker-Gordon in Boston. (2) Home-modificat ion . I. Laboratory '"ilk: Order milk by pro script ion as you v/ould drugs e.g, for a normal healthy child at varying ages: 1 week, -1 month* *1- month.fi i! Q !j J » 2 „ 0 0 *««,.»••••• 0,50 iJ; J 00 Sugar . , . . 5.00 6,50 7,00 Proteids 0.75 1.00 1.25 On the other side of the prescript ion-blank vrv its 9 Number of feedings; amount at cache feeding; weight of child; age of child; alkalinity desired; heat required. For example: 1 week, 1 month, 4 months, No. feedings 10 9 8 Amount 1 oz. (50cc.) 2 l/2 os. 4 os. Weight of child 7 lbs. 5-91bs. 15 lbs. Alkalinity 55$ 5/* Heat desired 167 V. 157 F. 107 p. O-QfltP&r is on of cow’s milk and woman's milk Cows % Mother’s 4 fat 4 4.50 ..Sugar ....7 4 Proteid ..1.25-1.50 Coagulabls part of proteids greater in cow's milk; non-coag- ulable proportion of proteids greater in mother's milk. Diluting cow’s milk does to a certain extent "attenuate” the curd; but diluting it, say, 4 times with water doesn't bring the coagulable part of the proteid down to the human standard; this however is sufficiently close for practical purposes. If the mothers milk, supposing it to agree with the child, but for some reason fails, contains 1.50 proteids, prescribe le25 preteid in the modified milk; this will bring the coaguiable part of the proteid down to about the required standard* The so-called "attenuants ,rs such as barley water, lime water etc do not of themselves reduce this coagulable part; simple dilu- tion 4-5 times does come pretty near the desired result. (The patented and proprietary foods for the most part are directly harmful as they contain greater or less amounts of starch, and the starch converting function is not developed in young infants. Ridge’s Food, e.g., contains 7S,f starch- Retch.) Note that dilution dilutes also the quantity of milk sugar, making it too low for the nutrition of the child - not enough animal heat is produced, and this is absolutely necessary for the vitality of the child. Therefore milk-sugar must be added to bring it up to 7/h The same process is necessary with the fats. The proper alkalinity is produced by adding about 5;i of lime water. Heating: Hannan milk is sterile but not sterilized. We heat the cow's milk to a point which will kill the bacteria but not coagulate the proteids; we must keep it under 171 F., and experience shows that 167 F/ is sufficient. Hons Hod if i cat ion: The acidity of cow's mill: can easily be overcome by the addition of lime-water as in the laboratory product. The milk can be comparatively easily sterilised, and of course, milk-sugar to the proper amount can be added at will. The only difficulty in home modification comes in the proportions of fat and proteidsj for while the % of fat is the same in cow’s milk and that of woman, the % of proteids is much larger in the former. Therefore simple dilution will not accomplish the desired result. The /o of proteids must be reduced while no change is made in the fats. When milk is allowed to stand for some hours the greater part of the fat rises to the top in the form of cream; the pro- te ids and sugar remain pretty evenly distributed throughout. 10 The simplest method of modification, though not quite so accurate as some of the more elaborate methods is based upon the fact that when milk is allowed to stand in a glass Jar, on ice, for several hours, a certain amount of cream rises to the top. Average cow’s milk of good quality when allowed to stand 4 hours produces in its upper third an 8% i#e. cream with 3% fat; after 6 hours the upper onefifth is a 12% cream; when set for !<■., hours or more 1 b/o„ All those different grades of cream have approximately the same proportions of sugar and protoids: Pa«3 Sugar Proteids, O/o cream 8/S 4,50 5.35 12/i " 12/» 4.40 3.75 IC/o " 1 Q>% .......4.20 . 3. SO Suppose a milk for an average healthy baby of 4 months is wanted. Fat 4, Sugar ?. froteids 1.25. An cream when diluted with equal parts of water will give the required amount of fat, but the proe3ids will be 1. S3, which is considerably too high. The 12;t cream diluted with twice its volume of water, making a * one to three dilution would give fats 4, sugar 1.50, proteids le25; the sugar is then easily brought up to the required proportion by adding 5,5;l of the -total amount for the twenty~four hours feeding o of milk-sugar. ... tote that the higher percent croams give the lower proportion of proteids when reduced sufficiently to bring the fats to the proper percent. Onthc- other hand, a dilution of plain milk gives a food lorn in fats and high in proteids; if diluted one to one, there are fat and nearly %% protoid, With these facts in mind it is coiaparat make the ordinary modifications required. About 5/» of lime water gives the proper alkalinity., Sirens of inproper proportions of ingredients: If to ere is not a satisfactory gain in v; eight, and no special indigestion symptoms, all ingredients should be increased, x&hitual o 0,1 i.c: or Curds in stools: Diminish p rote ids, ilogurg it at io,n of sour masses of food: diminish fats, diarrhoea - stools nearly normal in appearance-: decrease fats „ rho eag -stools thin green, very acid: decrease sugar, j?Qiist.ip.qtion: increase fats and protoids, {Holt) J&3BBa&3Eft Infants: Inf ant s born before 27th or 23tli week almost always die within a few hours or days at most. At 30 weeks infant weiglis about 4 lbs; length about 1? inches; may live. Digestive power of premature infants much less than in full term children; therefore feed smaller proportions, especially of pro- teids, birculation:Hcv.rt not fu 11 y dovs 1 oy3d, thereforo keep child perfectly quiet, handling may be fatal to it„ Care of pronature infants. Host important things to guard against are (1) Loss of heat; (2) Loss of neighs. Of course no baths should be given. Baby should be wrapped in soft absorbent cotton,no clothing other than this; use cotton for napkins* Temperature of about 00 T, should be maintained; the simplest form of incubator is a blanket and bureau drawer. There should be little light, handling or sound. feeding! Peed every hour till term a food with about the following proportions: Fat 1050. Sugar 4r Pro.teids 0o 50-0,, 75, Feed by pressing milk into mouth with a medicine dropper. Child shoul have an average gain of weight of 3./3-1./2 oz„ daily;.. 1 l/2 oz. a week is doing fairly well; a Ices on' 1 oz, is serious e Amount at each feeding should be 1 drachmo Later: increase fats. Still hater: increase protends. Sugar is easily adjusted. Always begin with a weak prescrip- tion Don 'ttake child out to feed it. Vary quality and quantity according to digestion, hunger, and gain or loss of voiglt,. Weigh baby daily. The best brooders have oho child;s basket p1acod upon sma11 platform scales 1ns ide brooder„ Stimulants: 1 drop of brandy every hour, if baby is very feeble. Nurse: have if possible tr;os one for day and one at night, Period of viability: Wioh proper treatment an infant should be viable after 231h vcek. Temperature in children: All disturbances of health which in adults produce a rise of temp- erature s cause a much greater rise in children, are many cases of high temperature from trivial causes, ,;Xt is the continuous high temperature which indicates serious illness ;h GASTRO.-ENTERIC DISEASE.? „ -Vomit ijgg as a symptom (1) From over-fillins of stomach; In nursing infants comes on within a few minutes after nursing; the food is practically un- changed. Treatment:- Diminish quantity of food, (2) Acuto Gastric Indigestion Delayed some time after feeding* May be preceded by fever and marked prostration* 13) Acuto intestinal obstruction: Vomiting usually persistent, and oftonest associated with constipation. Obstruction in new- born is oftonest in duodenum. In Intussusception vomiting is forcible, excised immediately by food; at first bilious, may later become faecal, (4) o eno r a 1 F 3 r i t oni - i t: abdomlna 1 c. 1 s t cnt ion and t ende rnc* s s 3. and f evor i s p ro3ent, (5) Contain nervous diseases, especially brain surnors and nonin- git is* simple or tubercular c. Play be the first; and for some time the only symptom of these diseases * (6) Onset of acme infccties diseases, notably scarlet favor_u pneumonia and malaria. (7) Absorption of ptomaines or other toxins in food; or accumula- tion of toxic materials in blood as in uraemiac (8) Reflex vomiting: irritation in pharynx, intestinal worms., (9) habit Aeticj Inpropex* food, - In infants cow Ss mill \ioz enouh diluted i, e.. with too r-uch casein Sudden weaning. Too :.arly ula of solid -food. Overloading stomach.. Fatigue, nervous depression* 12 SMElSBS.* Vomiting, often preceded by nausea, pain and constitu- tional depression. Temperafore 100-102 F., sometimes 104-105. Diarrhoea, often in infants. ILijkmQ-sjjj: Gastralgla: shorter duration and more frequent attacks. Iliaatr^Gnt: 1. 'Empty stomach completely;- washing out best; or heye child drink warn water which provokes free vomiting. 2, Rest for stomach. 24 hrs. fasting; then barley water./ beef juice or light broths; no milk for at least 3 days; then give it peptonized.. Keep child on low diet for 4-6 clays. In nursing infants withheld breast 24 hrs., then 2 minutes at 5 hr., internals, gradually increase to 3, 5, 10 minutes, :h Drugs: Calomel gr.l/lO every hr. till bowMs move ~s.is irood except in very younx or very delicate islants, in v/htu T/hom it may be fatal. Chronic Ca3trie Indite311on: Aslialogx: ilay follow acute attacks or (2) be chronic from the start, Uhon chronic from the outset principal causes are 1- Continued use of improper food or bed habits of feeding i;iay iollov any acuc-G inf oc’oious disease .• 3, Often coniplieates constiwational diseases! i*ick2o3s syphilis* tuberculosis, mal— nut ri uion and marasinus» Infants: 1, Vomit ing, - most marked symptom. Vomit us contain food 5*-8 hours old and mucusPood remains long in stomach; (Normally stomach is empty in 2-3 hrs.) 2. Undigested food, especially casein, in stools. 5. Children become irritable. 4. No gain in weight, or even distinct loss. Older children. 1. Vomiting,-most constant; regularly after meals or only in morning before breakfast, 2,. Gastric flatulence and pain. 5* Constipation more often than diarrhoea; •Intestinal disturbance not so common as in young children). 4C Mainutrition: anaemia, fretfulnoss, poor sleep. Prognosis Depends on age, duration of trouble, and treatment No tendency to spontaneous recovery. Infants under 3 months: prog- noeis as to life bad; 7~8 months and over, may recover with good treatment. Danger lies in predisposition to acute diarrhoea in summer. : Infants: 1. Hygiene,— fresh air day and night, sunlight; keep patient warm, particularly the feet. 2. Stomach washing,- as iirst daily, later every 2nd or 3rd day* about 3 hours after feeding* 3. Hies.: modified milk with low fat and very low pro- teids. Never feed oftoner than once in 3 hrs., and in children aftn over 3 months, not oftener than every 4 hrs. Older children:— 1.Hygiene: out of door lifo; regular hut very moderate exorcise (be sure not to over fatigue) a 2 . Hot water with 3.5-20 gr. Soda bicarbonate, 6~8 oz. an hour before meals. 3. Diet; ... Kill: diluted at least 5 times; kumysa: -or matzoon; beef juic'Oj. dry bread* Avoid sweet fruits, pashy.. sweets, nuts & candies0 -Drugs; — Nux vomica or simple bitters oefore meals: hi lure HOI gtt.. V-VIII after each meal. Diarrhoea, Aetiology: Age.- Young children peculiarly susceptible, especial- ly from 6-IS months„ In 3000 cases among N.Y. children. 4/5 occur- red during the 1st 2 yrs. Season:- Summer, particularly July. Pood:- Of 1943 cases reported by Holt, only 3,5 had been breast-fed. Impure milk quickly excites diarrhoea. Anything producing chronic indigestion, — over-feeding, too frequent feeding, and habitual use of improper food,-- predisposes to diarrhoea.. 13 Aetiology: - Pradispos ing causes: - surrmer, delicate const ituion, feeble digestion; previous attacks of acute or chronic indigestion. Exciting causes:- Over feeding, improper feeding, sudden change, as in meaning; onset of any acute disease. Symptoms:- Gastric symptoms may or may not be present. Local:- colicky pains, sometimes tympanites, diarrhoea - stools frequent, thin, in infants becoming green. Constitutional:- Lever. Io2~105 in infants, 100-103 in older children. Prostration, greatest in infants, Diagnosis: Cholera infantum (Castro-enteric Infection) has more marked nervous symptoms and usually more frequent vomiting. £E3En.os.i.s: - For life good, except in very young or delicate, when it may be fatal. Danger lies in predisposition to more serious intestinal disturbancese - Ip general same as for acute gastric indigestion (p.ll) 1. Empty bowels thoroughly- Calomel l/4 gr. doses every hour till full effect. 2. No food at all for 24 hrs. 3. Brandy if prostration is extreme. 4. After all offending materials have been removed from bowels, and not before, give Opium to con- trol peristal-sis; Dover's powder, gr0 1/4 after eash stool, for child of 1 yr0 5. Feeding:- Same as for gastric indigestion except that in nursing infants, or infants of that age, all pro- portions must be greatly reduced; c.g. Fat 0o4, Sugar 5.0, froteids 0„5S 1 part milk to 7 parts water; or even 1-12. Intervals of nursing should bo 6 hours and the time at the breast limited at first to 5 minutes; give the modified food between. Acute. Intest Inal Indigestion. Aetiology: Same as chronic gastric indigestion (p.12). Host com- mon in 1st 6 months, Protoids in the milk are usually in excess; or milk may be too rich., i. g „ both fat and protsids ooo high. In young infants„ Symptoms:- Those of malnutrition: Stationary or losing weight, anaemia, poor circulation* fretfulness, poor sleep; temperature often subnormal. Appetite good, often ravenous. May be diarrhoea, or a iarrhoa a alto rnat ing with c ons tipation . Di arrhoe a1 stools:- thin, green, with lumps or flakes of curds; 3-10 in 24 hrs. Stools of constipation gray or white, pasty or hard. Colic and flatulence often go with constipation, 'Diagnosis: - The diagnosis is easy, but it is necessary for intel- ligent treatment to discover what the disturbing elements of the food are. See whether child has been given starch* e,g. in a pro- prietary food. Too much casein shown by colic, constipation more Chronic Intestinal Indigestion. 14 often than diarrhoea; curds in stools. Too much fat:- diarrhoea, yellowish color, or vomiting or rogorgitation of small quantities of food. Too much sugar: colic and diarrhoea, with thin* sour irritating stools. Starch shown by much flatulence and colic,dia- rrhoea alternating with constipation, and offensive stools. Erosnoila: Depends on how early and how well cases are treated. Little tendency to spontaneous improvement. Treptment: Diet and hygiene. In older children. Common from 1-4 yrs. Usually an excess of carbohydrates has been given, 3epdaily potato and oatmeal. : Patients usually thin, small extremities, protuberant abdomens„ Much flatulence. Children anaemic and sallow, irritable; usually under normal weight and. height. Bowels usually constipa- ted: stools very offensive. May be in some cases an offensive diarrhoea. Appetite poor, and usually capricious. Children are nervously irritable, reflexes usually increased: nerve symptoms very variable. Slight fever common; 99-100.5 may persist for many wool So Urine contains a great excess of indie an. Intercurrent attacks of acute indigestion are frequent. SCddihttirh: 1. Diet: this is the essential part of the treatment. In 2nd and 3rd yr. stop all starch for a t ine ■ give exclusive diet of rare beef or beef juice and milk, with a little malted foods if there seem to ds too little carbohydrate. Give 5 feedings a. day for 2nd y r. s 4 in 3rd and 4th yrs., at regular intervals*, Allow absolutely nothing between meals. An orange an hour before break- fast may be given after the first week. After a month, if improve- ment continues, add stale bread in small amount, once a day*. One of the green vegetables may be added after 5-4- months, spinach, stewed celery or asparagus. In 2-5 months more, well cooked rice or macaroni once a week or twice. Forbid potato and oatmeal for a long time,, 2. Drugs.:- Calomel once every 5-G days if there it any tendency to constipation. General tonic: Mux Vomica, Eyg.ig.ne: Regular exercise in open air. cool sleeping rooms, sponging with cold water every morning. Awte Gastro-enteric Infectiop . Synonyms? Summer diarrhoeas Gastro-Entsrit is, Gastro-intestinal Catarrh, Cholera Infantum. Aetiology: Predisposing causes:- Summer: July especially* Age: under two years. Feeble constitution. Unhygienic surroundings. Mal-nutrition depending on improper food and feeding,.. Exciting causes:- Acute Indigestion. 2 distinct forms; I. Simple gastro-entaric infset ion;II.True Choi c r a inf ant urn. I» Simple form. A. Mild cases Onset gradual, little or no fever5 no gastric dis- turbance ; diarrhoeal dischages; children somewhat fretful, special- ly at night,. Stools gradually become more frequent: thin, yellow green or browns and always contain undigested food. Child grows pals, sleeps badly, and loses weight (1-2 lbs a week). Under proper treatment recovery takes place in 1-3 weeks„ 15 BP Severe form. i&nptoms: Child becomes restless, seems in distress. Temperature rises to 102-103 or even 105 in some cases. Infant may lie in a dull stupor or be very excited and have convulsions* Great thirst. Vomiting: 4-6 hours from onset. Diarrhoea soon follows, with much flatus. Stools thin, yellow, offensive. Colicky pains and gas - preceding the discharges, and the foul odor are characteristic. Favorable cases: Recovery in a week or ten days. Unfavorable cases: Temperature remains high; vomiting continues. Prostration increases and death takes place in stupor or convul- sions. Or some improvement may take place, but the infant wastes steadily; recurrent -attacks at intervals of 7-10 days may termi- nate in ileo-colit is. In children over two years recovery is more common; ileo- colitis not so frequent. Diagnosis: Acute indigestion: temperature lower, less nervous disturb- ance; stools not so fluid and offensive. Scarlet fever:- Look for erupt ion and character1sticthtooat. Pneumonia:- Rapid respiration and physical signs. Malaria:- Remittent temperature and enlarged spleen. pronr.osis: Simple cases not often fatal in children over 3 months unless already suffering from marasmus. Danger lies in probabil- ity of serious intestinal lesions. .Xi:©atn}.ent: Prophylaxis:- Clean streets and more open parks in cities* Fresh air and sunlight in homes; less crowding; cleanliness Napkins in summer should be washed at once or put in antiseptic solution* Infants should be breast fed if T)ossible0 Don’t wean in summer. All water drunk by children should be first boiled. Scrupulous cars of milk and bottles in artificially fed infants* Hygienic treatment:— if attack occurs in city, send child to country if possible; child must be kept away till well* Fresh air is absolutely essential. Baths,- to reduce temperature and in- sure cleanliness; 100 F. when child is first put in, gradually reducing temperature with ice to 85 or SO- duration of bath 10 to 2o minuteso Pl.Gt.* Withhold food so long as tendency to vomit remains; no food in any case for 12 hors; barley or albumin water for thirst. After 24 hrs. breast at 4 hr, intervals; allow only S~3 minutes nursing at first; between nursings give cold whey, barley or albumin water. Artificially fed infants, particularly if under 4 months:- No cow !s mill: during acute symptoms and for several days longer* When begun, reduce fat and casein greatly; dilute at least 6-10 times; e,g* fat 0*45, Sugar 4.00, Proteins 0,50, In older children:- stop all food till vomiting ceases, then broth and beef-juice; later milk or thin gruels made with milk. No aolid food till stools have been normal several days. Drug and mechanical treatment: 1. Empty stomach and bowels, riever begin by checking diarrhoea. Wash stomach in infants; give plenty of boiled water to older children; this is vomited and clean out stomach. Calomel, gr. 1/4 every hour for 8 doses, or till chai ac 0eristic green stoois« Castor oil may be used, where stomach isn't disturbed, 2 drachms to a child of one year, a half os, to child of 4. ~ * ; , h; Irrif;ale_. first day and then once daily. Stimulants old brandy best* a half ounce to ons ounce in 24 hrs0 for a child of a yearo Always dilute with at least 6 parts of water, give coldr in small quantities and at short intervals. 11 • True ciiolora I;n£antum. Rare compared with simple gastro-enteric infection. Usually there is an antecedent intestinal disorder« Salterns:Prostration and steadily rising temperature, often coming before the vomiting and purging. In other cases the latter may come first. Diarrhoea, — stools large, fluid, very frequent (12-15 or even more in half a day)* usually odorless,. Loss of weight: more rapid than in any other disease of childhood. Fontanel depressed; facial expression anxious and drawn, eyes sunken; Nervous symptoms:- At first irritation, later dulness, stupor, relaxation and coma ar convulsions. Temperature high in proportion to severity of attack; in cases which recover, 102-103; in fatal cases 104-106 or even 108 just before death. Pulse rapid, weak, often irregular and at times imperceptible* Respiration:- frequent, irrcgu1ar: may be stertorous, Abdomen soft and sunken. Insatiable thirst. In cases which recover, after the first day of severe symp- toms the discharges diminish and nervous symptoms become more prominent; these gradually abate. Disappearance of nervous symp- toms always a favorable sigh. May nos is: Prominent symptoms. :“Bad in young infants; fully 2/3 cases die no matter wha t t h e t r e a t me n t „ ; Prophylaxis: - - Same as for simple form. Never neglect a case of diarrhoea in summer because 11 child is teething1', 1'- Tjmpty stomach and intestines by washing and irrigation,--no tirne to spend wait ing for cathartics to act. Morphine sulphate sub—cu. gr. 1/100 for a cliilcl of a year, or atropine gr. l/S00 every hour till vomiting and purging have materially diminished. Molt considers morphine to be also a valuab1e heart s t imulant, 3n Supply the fluid to the blood which is being drained off by zho aiscnargesInject sub-cu. in buttocks or back sterile salt solution (common salt 45 gr.,. boiled or distilled water 1 pint), at least half a pint in every 12 hrs. Its useless to give fluids by the mouth, 4, Reduce temperature:- Graduated bath, 10-30 minutes, used every hour if symptoms are threatening. Ice-water rectel inject tions are valuable as an aid in reducing fever, o. Simulants by mouth;- Iced champagne or brandy. After violent symptoms subside* same treatment of diet and. medicine as in acute intestinal indigestion. 17 COILC OF INFANCY. Aetiology. Age:- this form belongs essentially-to the first G months; most frequent in first 3 months. Is seen at any time when digestion is feeble. Exciting cause: food:- In 4/5 of the cases it is due to the proteids; these are either in excess or digested with special difficulty. FyriTtoms: Mild attacks:- Child is fretful and can not sleep„ Severer attacks:- Violent, paroxysmal cry, (Cry of hunger is ,yporcv;T prolonged and continuous.) Contracted features. Drawing up of lower extremities. Abdomen usually hard and tens e during the attack„ Treatment; Help child to expel the gas:- Injection of 4-5 ozc of luko-warm water; if unsuccessful, two oz, cold water with half a teaspoonful of glycerine. Hot flannels (dry) or hot water bag to abdomen. Between the attacks treat the indigestion. INTUSSUSCEPTION, Aet iology: - UrQcnov.ni in children. Age: First five years. 54 % occur during first year, especially from 4—G months. Occurs in healthy babies. Sex:- Boys three times as often as in girls. Pathology:-Upt-er part always slips into the lower; most common at ileo-caeca! valve, but may occur in course of ileum or of colon. Gives same effect as strangulated hernia. Death usually in 2-5 days, from shock, before sloughing can occur. Pressure on upper part cuts off circulation, giving hemorrhage, necrosis* and inflammation# Adhesions may form at neck. In extremely rare cases the inner part sloughs and is passed per rectum. Symptoms:-- 1st stage: 24-36 hours from onset. Onset sudden, comes in previously healthy baby. Severe abdominal pain and vomiting; paroxysms several times a day with quietness between, for first day. Temperature not much elevated. Patient doesn’t seem tiery ill. Sausage-shaped tumor- in abdomen in some cases, to left of median line* near umbilicus. Tumor sometimes palpable per rectum, but not usually. Tenderness not localized. Tenesmus in some cases. Movements of bowels diagnostic:- At first mixed with bio'.:!; then blood alone (6-12 hours.) -"Currant jelly" stools. £nd stage: after 56-43 hours. Symptoms of collapse (same as in strangulated hernia):- pinched face, sunken eyes; cold extremities; pulse and respiration in- creased; vomiting -- perhaps stercoraceous; abdomen tense. Diagnosis: Age, onset, symptoms of 1st 24-36 hours. Volvulus, hernia etc rare at this age; no currant jelly stools. Symptoms of strangulated hernia not so extreme. Prognosis:- Bad under best conditions. Depends on early diagnosis and treatment. Laparotomy after 2-5 days would be unsuccessful. Occasionally they reduce spontaneously; hut you can’t wait for Ah -.t m -\n c e, Treatment:-. Early reduction of the intussusception. Try first by water (usually fails); raise buttocks and irrigate with luke- warm water by fountain syringe with 6 ft, pressure, not more** Inject through velvet cat her reaching well to sigmoid flexure,.. If this failss don't wait; have- immediate operation*, Delay is dangerous. Twelve hours usually a fatal delay,. Do laparotomy., Points ip. remember: 1. Make your diagnosis and dont. give cathar- tics* 2, Stimulants: brandy and ice, strychnia etc to sustain strength! * THE EXAITTHEMATA. SCARLET E E V E R, Aetiology:Probably a micro-organism; but the specific organism has not yet been demonstrated. Age:- Children much more suscep- tibel than adults; but probably not more than one half the chil- dren exposed take the disease. Susceptibility not great in first year, but increases steadily till fifth year when it begins to diminish* Incubat ion:2-4 days as a rule, may extend to six or seven days* Short incubation more common in severe cases. Mode of infection: scales during dosquamation, discharges from mucus membranes, and probably from all excretions* sometimes spread by food, especially milk. Infection takes place from the clothing -of uhe patient, and from carpets or furniture of the sick room* Infovtion moat active (probably) during febrile period,--2nd to 5th day, and next to this in the stage of active desquamation. Duration of infective period:- until desquamation is complete, usually about 6 weeks. Symptoms: Prodromata:-- Onset sudden;-3 important symptoms: Vomiting, rise in temperature and so re throat0 In young infants - there may be convulsions. Temperature o*f 103-105 in severe casee,- Throat:-Erythematous blush on pharynx, tonsils and fauces, on the hal’d palate minute red points Erupt ion:-Usual! ” in 12-36 hours after beginning symptoms*, Rashh lasts 3-7 days. Starts on front of neck and chest and extends • over rest of body, limbs and face. Continues to spread 2-3days„ R- six may be absent in (1) very mild cases; (2) where throat symp- toms are severe,(3) in malignant cases. Delirium frequent in this stage. Desquamation:- begins about 7 th day; at first small flakes, then the characteristic "lamellae" (Moaslo has a fine desquamation) Usually begins at the junction of finger tips with nails: seen as a white line. Desquamation of trunk usually complete in 1-3 weeks; desquamation persists on foot and hands forthree to six and some- times 8 weeks. Urine:- Lessened in prodromal stage, normal in amount 9in uncom- plicated cases) during the eruption, normal at the end* Small amount of albumin in eruption with high fever. ?fStrawberry Tongue11: anri important evidence of the disease; in cases without the rash it may be the one- symptom that makes you suspect scarlet fever before the time of desquamation. 19 The tongue is red, especially at the edges, and the papillae are enlarged and elevated. 1„ Mild form:) Ohset usually abrupt with vomiting and tempera- ture of 100-103* -Tonsils and pharynx congested; palate shows punctate eruption,* Within 24 hours as a rule, rash appears., first on neck and chest; fades on 3rd or 4th day; usually disappeared by 5th day. Temperature: highest during first 36 hrs: gradually falls to normal by 4th or 5th day. In mildest cases temperature may never exceed 100; and rash may be faint and last but one day3 Desquamation often faint on body; but“unmistakable on hands and f eet * Begins about end of first - week; a1way s mo st ’ marked. whore erupt io n has b e en mo st intens e, lmi.3 of the disease: Mildest cases usually uncomplicated; but always remember and be on watch for otitis and late nephritis. 2. Moderately severe- cages:- Onset sudden: Vomiting, usually repeated or convulsions» Temperature rises rapidly,-104 or 105 by end of first day. Rash usually comes within 24 hrsM first on neck and chest, spreads to body extremities and face in few hrs. It remains with little change for 5 days rapio-lj- laox-h, disappearing by 7th or 8th day • Thro a c: 1 ij" e met Id fo2ius hub i ed— ness is more intense; often swelling of tonsils, fauces ana uvula and pain on swallowing. Often small yellowish ' etches on uonsilc by 2nd or 3rd day. Usually discharge- of sere-purulent matter from nose0 Glands at angle of jaw swollen. Strawberry tongue. Temperature at its height by 2nd or 3rd day and usually fairs after 4th or 5th day; but even in uncomplicated cases doesn^t i x j "| -i i / -)-n ist i r P * *? i * 0 pc f i r 3 r a a i cl an a f m. r 1 , reach normal till i£-tit oa ijvji * x > later its weak. . x._. , Complications of this trps a1’® broncho-pneumonia ana oti-is(us- ually double). Nephritis is a common sequel. _ , * 3, Severe cases; Tesiperaturo higher and la»n ion,.01, o cationUparticularly of throat are On 3rd or 4th day patches soft palate uvula ana '"“ ands of the neck swell rapidly, the Eustachian tube to ear. 103 and 105; fever Temperature steadily hiah, r> fatal oases generally lasts 3-4 weeks in cases xM3t3K tenrperature way be s.eaoi .. g!", , Lo..f delirium nr apathy. recover Duration oixao&ic Broncho-pneumonia o.-wfo® - -.-sually contains a begwu to discharge by end ol -uac moderate amount of albumin. are rer0. Death usually 4. Malignant, or cerebraa owu. - „ 11r„ COn- _ within -first 48 hours. Onset very suc.am, uouax -* . occUxo wnuin —x . P-reat prostration and very high v”3 s ions ’ then comes suupor xJX ° 20 temperature,-105-107 F. Rash may be late or entirely absent. There are often repeated convulsions and cyanosis. Death occurs from toxaemia. S-econdary lesjons of scarlet,- Complications and Sequelae* I® Otitis media; transmitted through Eustachian cube. Characteristics: Severity; Difficulty of recovery Symptoms when present:- Aural pain, restlessness; only symptoms may be somnolence and fretfulness. The younger the child the greatcr tne pliability to otitis In young children there is always danger of meningitis by extension through open pet 1*030-squamosal suture„ Treatment:- Doubtful if anything will prevent the trouble. But keep the rhino-pharynx as clean as possible by syringing the mouth and nose two or three times a day. If symptoms appear put in the ear 3-4 drops of a warm solution of atropine sulphate, 1 grain to a drachm each of glycerin and distilled mter every 5 hours to relieve the pain. Control congestion with small, frequent doses of KBim Aseptic puncturing of the membrana tympani is often neces- sary; syringe every 4 hours with warm 1-5000 corrosive solution or saturated boric acid. Don’t plug it with cotton, A sudden rise in the temperature usually means that drainage is imperfect, 2- .adenitis: - Suppuration may occur. Treatment: Ice collar if it can be procured; hot fomentations may be substituted, So Throat:- Probably most of the secondary affections start here. Always take cultures to make sure that there is no diphther- ia bacillus in the membrane. Most often it is due to streptococcus or staphylococcus or a combination. Treatment:-Keep throat clean* 4 ojlteY * - Nearly all cases of scarlet vever have some albuminu- ria. The severe forms have an acute exudative nephritis; rarely any dropsy with this form,. The most severe and important form of nephritis is the so-called "post-scarlatinal nephritis", a diffuse form occurring during the third week of the disease. It is accompanied by general dropsy; urine is scanty or suppressed altogethero Death may take p>lace from uraemic poisoning; or there may follow permanent damage to the kidneys. Symptoms: Vomiting or oedema about the eyes often an early sign, 18th -24th day. The severity is greater the earlier it ap- pears Amount of urine more important than the albumin. Oedema may become general and persist for weeks. Retinitis and even comp plete loss of eyesight (usually temporary) may be present. Secondary to the nephritis may be a hypertrophy of the left ve-ntri els of the heart, or dilatation; this is most common between the ages of 5 and Ga Distinguish from the endocarditis secondary to the scarlatina. Death may occur in these cases of nephritis from oedema of the lungs (the most frequent cause). 3* Heart:- Endocarditis at the height of the fever; not partic- ularly common. Caused by the soluble toxins in the blood It may be simp 1 e or ma 1 ignant. Pericarditis is also 5ometim,c3 s0en„ In the severe cases, particularly the fatal ones, there is a certain degree of myocarditis; this may be the cause of death. Diagnosis of scarlet fever: Onset, usually with vomising, marked elevation of temperature, throat, appearance of the rash within 24 hours. Where the rash is wanting the desquamation is 21 the only means of making a positive diagnosis. Be on the watch for it at the finger tips, underneath the nails„ Where throat symptoms are most prominent, make a bacteriological examination to rule out diphtheria. The two are often associated. The eruption may be simulatod. by other skin affections of chi 1 drcn; o.g. thg erythema arising from use of belladonna, quinine, and occasionally ant ipyrine; also urtic ar ia. Prognosis: Favorable for benign and regular forms, the mortal- ity being in some epidemics as low as 3-4/>. In oho severe or malig- nant type it may be as high as 40/a. The disease is as a rule- most fatal in the youngest infants. The general mortality at all ages is from 12-14/6. Under five years it is 20-30/?. Holt gives 3 classes of se fatal cases:1.Those due to a late nephritis; 2. Septic cases, usually associated withsevere throat symptoms, and dying most often in the 2nd v/oek from exhaustion or some local complication; 3. halignant cases which are overpowered by the toxins in the first 2-3 days. Treatment Absolute isolation (required by law) in even the mildest cases for six weeks or till desquamation is complete. Upper room in house,- if child can’t be sent to contagious hospi- tal. Room should have open fire-place, no paper on walls(walls painted); remove carpets hangings, stuffed furniture, pictures; "clear decks for action"; iron bod. Nurse must be quarantined with the child; should leave all her street clothes in a room separate from the sick room and wear special clothes while nursing. The bath room used for che scarlet fever patient and nurse should be used by no one else Nurse should use an antiseptic gargle 4-5 times a day and nasal spray at least twice a day. (All other per- sons having to do with patient must use same recautions. Physi- cian’s duty to the- community:- he should never go directly to another patient, especially to a child. Should have special clothes to visit patient; after visit should change clothes, take a bath and shampoo. Children in house who have not been exposed should be at once sent away; those- who have been exposed should be quar- antined for at least a week. After an attack:- Walls of room should be wiped with a damp cloth wrung out of 1 to 2000 bichloride solution; or better rubbed down carefully with bread. Alll hangings washed in corrosive or carbolic acid; e.g. soak in 1 to 20 carbolic solution, then boil and wash with soft soap and water. Wash floors with corrosive sol. Keep windows wide open for at least 3 days. Note:- A physician in attendance on a scarlet fever case must never attend an obstetric case or one with open wounds Treatment of the attack:- Scarlet fever is a self limiting disease; there is no specific remedy known; therefore remember to treat the patient rather than the disease. Mild attacks require little, if any medicine. Treatment consists essentially of rest in bed, keeping up the strength, reduction of the tempera ture by cold sponging, pack or bath if it reaches 103-105, and the treatment of any compileat ions or sequelae which may arise. Children should be kept in bed for at least a week after hie fever has subsided, and upon milk diet for .at least three wsks in all 22 cases. This should be insisted upon as a preventive of nephritis. Give patient plenty of water so drink,-- relieves the stasis of kidney and lowers temperature. Don ft use chlorate of potash; all the mineral salts of K irritate the kidneys; the vegetable salts are non-irritating,- converted into the carbonate before reaching the kidney. Moisten skin with carbolized vaseline after the rash has disappeared,-- facilitates desquamation and disinfects the scales. Stimulants: — As soon as the pulse ducobigs weak oi iix ogu— lar or first sounds feeble, give stimulants, no i.avcor whaw the stage of the disease,brandy or whiskey in distilled water, strych- nine gr. l/200 to start in child of 5. Cardiac stimulant; Roach uses infusion of digitalis on ground that its less irritating uo stomach than the tincture. Pose: 1 drachm t.i.ci. xo 5l.1i ds/j It on *it h. First soon behind the ears, on neck or at scalp line ox forehead. These are at first macules, becoming papules later. Its full devel- opment on face takes about 36 hours as a rule; iw spreads to the trunk and limbs, developing on these as it fades in the parts 23 in which it developed first, ?igmenoacion:- As ohe rash fades it leaves behind in typical cases a brownish discoloration which often lasts nearly a week. .h.'j£0.'.hhi, Jl^siiesg-- 1,Entire body nay be covered in a few hrs, 2„, Hash my be hemorrhagic ("black measles W older writers); a bad but no~ always fatal sign. 3. Rash may be very faint and of short duration,. 4. bay resemble scarlet fever; but note that scarlet fever rasn more often simulates measles. 5„ May be scanty and late in the so-called malignant cases. 6. Temporary recession of the * ash daring Mis height of the disease is usually a sign of hsaisf*** failure.,. ®©gins almost as soon as rash has subsided: neck and race f±±$ t; duration 5. .10 days. The flakes are f ine9 ‘“'furfur aceoas" During this stage the cough often persists and the pa- tient feels weaka Total duration of measles about three weeks0 M?...severe cases:- Course of who disease more regular in children over three than in infants „ Syppyorns come gradually ; temperature rises steadily till eruption appears, usually on 3rd or 4th day; fall in temperature most often by lysis., not uncommon- ly b- crisis*, Fever lasts in such cases 5-9 days, average 1 week# Highest temperature nearly always coincident with full eruption on face; usually 1 OS-104 in older children, 3.04-105 in infants* Temperature not infrequently rises at once to 102 or even 104 and falls nearly or quite to normal on 2nd day, then rises grad« ually as in ordinary case (ro% of Holt’s cases). IMore frequent in infantsc Eruption is late and fever continues for some days after rash has begun uo fade0 The prolonged course and high temperature usually due to broncho- pneumonia -QQIH&Llcat i,oit.s and _3 equ^elj^e: - 1, Broncho-pneumonia, most coiTimon0 20 Ileo-colit is3„ Pertussis 0 4„ Tuberculosis: General miliary; Joints; Viscera,- Lungs:- tuberculous broncho- pneumonia, 50 Otitis. 60 Membrahous laryngitis. Broncho-pneumonia:- Most frequent in children under 2 yrsa About 10% of cases in children at all ages. Should always be sus- pected where temperature continues high after full appearance of rash, Most frequent and fatal in spring and winter. Lobar pneu—moh ia though rare does sometimes occur in children over 3 yrs* Ileoj col it is :-Mos t often seen in summer and in children under 2* Pertussis:- Often occurs following measles. Tuberculosis:- Measles furnishes conditions favorable to the growth of tubercle bacilli. Acute general miliary tub. may follow closely„ death occurring in from 3 to S weeks. As a late manifest- ation, hip disease is most frequent. Measles in a child with tu- berculous antecedents should always give rise to grave apprehen- sion. Otitis: Not so frequent a complication as in scarlet fever; less often leads to permanent defect of hearing. Both ears as a rule. 24 Membranous laryngitis:- More coimnon than in scarlet fever,. When at height of disease is usually due to streptococcus; later due usually to diphtheria bacillus. ,T}iazw.S.is : - - Increasing coryza, gradual rise in temperature; maculo-papular eruption, first on face and neck; condition of ayes; fine, red spots upon hard palate. Look for beginning rash behind cars o Pi.s* — Average mortality at all ages 4-o/oj average mortal- ity in children under 2, about 20/*; higher in institutions* In the individual case:-Initial temperature above 103, or one remaining high till eruption appears, is a bad symptom.. Also one which rises after a full eruption, or which does not fall as erup- tion subside&c Favorable eruption:- bright color, covering the body* remaining discrete, and spreading gradually* Unfavorable;- eruption appearing late; very faint, scanty or hemorrhagic; one vrhich suddenly recodes, - due to weal: heart* prcnh.ylaxi &: - Isolation: Under ordinary conditions the quaran- tine of a. ease of measles should last 4 weeks from beginning of invasion; longer if there is pneumoniav otitis or discharge from noso0 Sick-room should be thoroughly cleansed and disinfected aft® an attack and remain vacant at least two weeks* Treat serious symptoms as they arise5 and so far as possible prevent complications• Keep sick-room at 68--70 P«, well ventilated and darkened (to protect eyes from light)* Keep child in bed till desquamation is almost complete. Keep child covered lightly during febrile 'period. If conjunctivitis is severe apply cloths soaked in ice-cold saturated solution of boric acid. Relieve itching of skin by simple or carbolized vaselinee For cough, if distressing, small doses of morphine or codeia vhich is less constipating), For nervous attacks and high temperature, cold baths or.packs and ice cap to head. To diminish chances of pneumonia, keep patient in bed during attack, give plenty of fresh air„ Diet:-Milk diet with bread till temperature has reached normal; then increase to regular diet gradually. RUBELLA« {G e man Me a s 1 e s) Tha existence of rubella as a separate disease is questionnad by Botch and Me Co Homo PERTUSSISo t jWhooping-cough) A contagious* epidemic disease, occurring at any age. but chiefly in young children; as a rule it appears bu ones in same person0 Characteristics;--Spasmodic cough; marked nervous irrita- bility.- shown in infants by convulsions*, EtiojLogy* -probably a micro-organism; not yet discovered* Predisposition: Age;- One half cases occur in first 2 years* Season: Twice as common in winter and spring as in summer and autumn. Susceptibility to the disease as great as measles... Infective period:- Prom the very beginning of the catarrhal staple; lasts probably at least two months 0 Usual source of con- 25 tagion is the patient himself„ rarely the room or clothing<, Incubation: - Probably 7-14 days, about the same -.s measles <> Synptoms3 stages, the catarrhal, spasmodic, stage of decline. Catarrhal stage:-About 10 days on the average, rhoigh it varies considerably0 At first indistinguishable from an ordinary sub- acute bronchitis; after 5-6 days ohe cough increases in severity and becomes paroxysmal, at first mild, occuriing 2-3 tines a day* Paroxysms increase in severity and frequency till typical whoop which marks beginning of paroxysmal stage or spasmodic stage0 Of- ten slight elevation of temperature in first stage.. Spasmodic stage: — Series of- explosive coughs, 10-20 in number; face becomes deep red or purple, veins of face and scalp prominent, eyes suffused, then the whoop. Then another succession of rapid coughs and another whoop. Paroxysm may last 2-3 minutes, have half a dozen whoops, and at end raises mass of mucusa Vomiting a frequeht accompaniment, particularly in young children* Epistaxis (usually slight) often occurs. Number of severe parox- ysms varies from half a dozen to 40 or 50 in 24 hrs.5 with milder ones between* More frequent during night and in a closed room than in open air.. Cause of paroxysm supposed to be plug of mucus in trachea. Spasmodic stage lasts about 1 month; increases in sever- ity for one or tv/o weeks, remains stationary for another week and then gradually diminishes. St a ff.e of decline:—Usually lasts about three weeks but may last all winter. Complications—1.Hemorrhages: Epistaxis zhe most common form, selfom severe enotigh to require local treatment. 2. Conjunctival hemorrhages: usualy slight, and less frequent. 3. Intra-cranial hemorrhages though not common, have occurred and in some cases have produced death. Usually meningeal.. May produce hemiplegia, monoplegia* facial paralysis, disturbances of hearing or vision, according to their extent and location. These hemorrhages general- ly result directly from the paroxysms of coughing. II*- Respiratory system:— Largest proportion of deaths caused by broncho-pneumonia. Most often develops at the height or towards close of the spasmodic stage,i.e.4th to 5th week. There is always considerable emphysema present. III.— Digestive system:- Diarrhoea very frequeht in summer, often going on to ileocolitis. Intestinal in summer may be as serious an the respiratory disturbances in winter. Vomiting even more common than diarrhoea; may be so frequent as to inter*, fere seriously with the nutrition, causing mal-nutrition or maras- mus; then child falls easy prey to pneumonia. Iva Nervous system:— Most serious complication is convulsions; especially dangerous if there is pneumonia. If they continue sev- eral hours suspect meningeal hemorrhage, especially if there is general rigidity or hemiplegia. Diageosis; — Impossible at first. Later the gradual increase in severity in spite of treatment, tendency to paroxysms, and the vomiting and suffusion of the eyos should suggest pertussis. 26 A history of exposure if prsent, is evidence to be condideucPU Differentiate spasmodic cough due to enlarged tracheal or bron- chial lymph nodes, simple or tuberculous; these by pressure irri- tate the pneumogastric or recurrent laryngeal nerves. The duration is more prolonged, paroxysms less severe, and couse less typical than in true pertussis. P.rognosis;--Aac: During infancy few diseases more fatal; due to the complications: broncho-piaeumonia, diarrhoea, and convul- sions. Two-thirds of the deaths occur in first year* Prognosis very bad in infants under 3 months; in winter: in rachitic chil- dren; those who have had pneumonia, or with a tendency to tuber- culosis a As a predisposing cause of tuberculosis pertussis is second only to measles. Prophylaxis: - Iso 1 at Don’t allow a child v/ith pertussis to attend school, Quarantine should continue 6 weeks or till the spasmodic stage is past. Treatment:—Plenty of fresh air (paroxysms less frequent and severe). Send child to sea-shore in summer if possible. Sea: voyage even better. Leave windows open at night unless child has pneumonia or bronchitis„ But child should not go out doors if temperature is above 100 F. Rooms occupied by patients should bo frequently aired, changed and fumigated. Feeding: For children over 2 years, milk diet. For infants milk should be diluted and often partly peptonized* Feeding mutt be often and in small quantities on account of the frequent vomiting. Local treatment: Holt considers inhalations of creosote vapor by far the best. VARIOLA. (Emall-pox) Etiology: Unknown, supposed to be a micro-organism* Hot essen- tially a children5s disease„ Incubation: 12-14 days* SMO.Qias.:-' Discrete form:- Prodromta:-Vomitings restlessness (convulsions in infants); pulse rapid; temperature high* 104-106o (I'any deaths from toxaemia at this stage) „ Evanescent erytema on lower abdomen* thighs, axillae and sides of tliorak* Erupt ion:-- -On 3rd or 4th day small red macules or papules on forehead or face* later on limbs and trunk* Temperature now falls; pulse becomes less frequent* Papules feel like shot under skin, this is important* On about 3rd day from beginning of eruption the papules have changed to vesicles, complete by 5th or 6th day* Vesicles are distinctly umbilicaled* About the 8th day pustules form- and with these the temperature again rises (’'secondary fever"); fever remains 24-48 hours, then subsides to normal by 12th-13th day* Crusts form* Desquamation complete on 14th - 15th dayday* Extensive scars are left behind* Confluent form:--more severe; lesions coalesce* Differences:- Lesions coalesce about 4th day; skin reddened, face often distort- ed* No fail in temperaturea Diarrhoea common in children* Larynx 27 and pharynx may be involved* salivation, glossitis, aphonia or oedema of larynx which may cause death. Desquamation is much slow- er 0 hemorrhagic form:- Most virulent* almost always fatal. Onset sudden, very violent vomiting, horrible back-ache, dyspnoea. Hemorrhages about 5th day; subconjunctival ecchymoses, with vio- len+ apistaxi.Ss and at last bloody discharges from mouth, intes- tines, bronchial tuber, and ears. Mild form: Modified by vaccination. The nearer the beginning of the attack vaccination takes place the greater its effect. Complications:-Broncho-pneumonia,(lobar very rarely). Acute otitis, causing intense pain during suppuration. Oedema of glot- tis, death by suffocation. Diagnosis:--Constitutional symptoms, .initial and secondary fevers, scattered macules and shotty-feeling papules; umbilicated vesicles becoming pustules. Differentiate Vaccinia:— Appears after vaccination; short and mild course; mostly papules and ves- icles; few pustules,f irregularly situated. Treatment, Isolation, absolute from the first moment the disease is suspected. Give plenty of fresh air; ’’free, even violent, ven- tilation of the room should be insisted upon, so as to prevent any condensation of the poison”. All carpets, hangings, etc., should bo removed from room; all bed and body linen changed often and dropped at once into corrosive sublimate solution, or into boiling watery Keep crusts soft with carbolic acid and glycerine. For the tempersture, cold baths. Stimulate to keep up the strength Diet:-- feed patient to limit of digestion, milk, eggs,(unless in ycung cnildron) broths, VARICELLAo (Chicken Pox) Etio40&x: ■ ~ The coritagium seems to be contained in the vesicles. Disease contracted by direct exposure or by a third person. At- tacks all ages of children; one attack usually protective. Incubation: - 14-16 days. Symptoms:--Prodromal symptoms may be absent, or consist merely of slight fever and general indisposition for 24 hrs. preceding the erupt.ion. Young infants, however may vomit or have convulsions. Erupt ion. Small, red, widely scattered papules, usually on face, scalp or shoulder first,; it comes in crops, spreding slowly to over trunk and extremities, All stages my be present in different parts at the same time. Papules at first small; increase in size; surrounded by an areola, 1/4 to l/2 inch in width. Vesicles; most of the papules become vesicles; vesicles flat, superficial, unilocular ( small pox multilocular), slightly umbilicated. Crusts:-- Vesicles change to crusts; obese last 5-20 days; fall off leaving no scar as a rule. Temperature:—usually highest on 2nd or 3rd day; usually not above 101 or 102 and lasts but 2 days. Severe cases may have temperature of 104-105 and lasting 4- 5 day so Complications: Most serious is erysipelas which may develop about the pocks.. Adenitis occasionally seen. Scarlet fever may be present at same time., I&&S2&EL1s: 1. Eruption comes out slowly and in crops« 20 Yesi- clesunilocular, 3» Pocks on raucous membranes of mouth.. 40 History of exposure. Isolation should be enforced in schools and institu- tions,. At home quarantine usually unnecessary Locally,-carbolized vaseline to allay the itching if it is bad. Milk diet to avoid kidney complications, diphtheria. Predisposing causes:- chronic catarrhal inflammations of mu.cuus membrane of nose and throat, especially found in children with adenoids or enlarged tonsils. Cavities of carious teeth may harbor the bacilli* Age*- children under 10; greatest susceptibility between < and 5 years. Etiology:- The K1ebs-Loeff1er bac illus„ Incubat ion: - 2--5 days 0 Mode of transmission:- Direct infection; bacilli contained in great numbers in sputum, nasal discharge and saliva; not present in urine or faeces c * Direct infection may occur from persons har- ing the bacteria in their nose or throat without themselves having the diseaset Virulent bacilli usually found in throat two weeks or more after the membrane has disappeared. Indirect infeat ion, from bed, clothing, carpet, furniture., wall paper, toys or picture books, dishes, drinking cups, sppons tongue depressors, etc,, used by patient. Diphtheria may be car- ried by the physician or nurse. It has been often spread by milk. Pathology:- Essential lesions are not the production of a mem- brane, but changes produced by the toxines in different cells of the body:- epithelium of affected mucous membrane, heart muscle kidney, liver, peripheral nervous system, spleen and lymph-glands. Lesions produced by other organisms are often present, e.g, broncho-pneumonia and nephritis, due to streptococcus pyogenes and pneumo— coccus. There may also be a general streptococcus septi- caemia. Distribution of the bacillus of diphtheria:-on the affected mucous membrane and in the false membrane itself; very rarely in the bloodr and then only in small numbers. Diphtheria toxines:-Very widely diffused through blood; may of themselves, i.e, without the bacteria, when injected into ani- mals produce all the lesions except the false membrane, and all the essential symptoms, including paralysis; Catarrhal diphtheria:- The membrane is not always formed, but satarrhal inflammation of the mucous membranes may be the only result o f infec t ion. 1) ip h t h e r i tic me mb r an e; - Mo s t often on tonsils, soft pal a t e „ uvula, pharynx, nose, larynx, trachea and bronchi; less often on mouth, lips, oesaphagus, conjunctivas, middle ear. stomach and genital organs* Color:- Most frequently gray or mouse color; may be white, yellow,, green or almost black* Tonsils most often affected, and usually earliestc Membrane often extends to- uvula and pharynx. Membrane very adherent in these situations* Larynx membrane more superficial and may be 29 coughed, up in large pieces or as a cast* In young children there is a strong tendency ‘iio invade the lower air passages when once it gets into larynx„ Visceral lesions:- Due to (1) action of the diphtheria toxines; (2) invasion of the organs themselves by other organisms5 espec- ially the streptococcus , Cervical glands most frequently affected., Spleen is usually swollen.. Small hemorrhages under capsule of liver are common* Areas of necrotic cells in the liver itself„ Kidneys:- Nehritis may come on in severe cases late in the disease* Heart:- a toxic myocarditis is often present. In cases dying sud- denly in the early stage,, cardiac thrombi are often found; these have formed suddenly just before death* or slowly for several days in the weakened blood current,, Nerves: - Diphtheritic paralysis, though not so frequently seen as before the use of antitoxin, does occur fairly often; due to a peripheral neuritis, not central in origin* Degeneration of the pneumogastric may cause serious heart disturbance0 Lungs:- Broncho-pneumonia common in young children,;, particiliary in laryngeal cases. asea; - aa-With no membrane 0 be- Membrane limited to tonsils or nose* ■ oms; - d case;'?: ac-With no membrane., b„- Membrane limited to ton- sils or nose„ 2S Severe cases. a*-Marked evidences of constitutional poisoning from the diphtheria toxines. b«~Gases with laryngeal stenosis« 3„ Cases of mixed inflection, "septic cases". Cases without membrane:- Constitutional symptoms usually slight0 May be pharyngeal; sore throat9 swelling and tenderness of cervi-ga cal glands; or nasal., usually having a thin irritating nasal dis- charge; this may continue for weeks. Cases with a small amount of membrane. Exudation usually limited to the tonsils; more frequent in older children and adults than in infants and young children. Onset:- Sore throat: initial tem- perature 100-103; throat slightly red. folowed by a gray film* later by a gray or white deposit on tonsils,, Membrane adherent,, Constitutional symptoms slight:- diagnosis only made by bacteriol- o g ical examinat i on; Severe cases:- Onset sometimes gradual:- some malaise for a day or two, some soreness of throats Temperature bu t little elevated, of ton less than 100,. Symptoms increase steadily for 4-5 dayso In other- cases onset abrupt* with vomiting,, chilly sensa*- tions, anti temperature of 103-104, Abrupt onset seen more often in young children, Membrane not limited to tonsils: spreads to fauces sides of pharynx., uvula, rhi.no-pharynx and posterior naresc When fully developed* abundant discharge from nose and throat*ice* mouth,. Membrane at first gray* afterward darker, dirty olive- green color. Constitutional symptoms increase with spread of membrane; evi- dences of intense toxaemia by 2nd or 3rd day:- great prostration, pulse feeble and rapid* stupor or apathy; these are the very se- vere cases o More commonly symptoms increase more gradually* >?eaoh« ing height on 5th or 6th day0 Temperature irregular* no relation co the severity of the disease; usually from 101-103; in some of 30 worst cases nay never go above 1010 Urine;- by 2nd or 3rd day shows albumin; granular and hyaline casts, and occasionally blood in small amount is found. Laryngeal symptoms* when present occur in the first week* ally from 2nd to 5th day*- hoarseness, croupy cough and slight dyspnoea. These symptoms increase till all signs of laryngeal stenosis are present * - great hoarseness or complete aphonia,-, marked dyspnoea shown by dilation of alae nasi5 loud breathing., recession of supraclavicular regions., suprasternal fossa and epigastrium pulse is rapid and weak; face and finger tips show cyanosis Death most often occurs at height of local process in throat, usually bth to 10th day. Due to (1) progressive the result of the diphtheria tcxines*(2) heart failure, early or late; (3) broncho-pneumonia: (4) invasion of the larynx,, Note: death may occur after throat has completely cleared from a late pneu- monia.. or. nephritis,, and notably from heart paralysis „ Signs of a failing heart are: pulse weaker than usual, occasional irregular- ity: slight dyspnoea is seen and patient vomits or does net take food. we.DL: there is usually considerable pallor; extremities cold. Sometimes there are no premonitory symptoms£ probably due in these cases to toxic myocarditis. When prodromal symptoms are present, especially if there are vomiting, abdominal pain and distrubed respiration-, its probably due to a toxic degeneration of the pneumogas-tric or cardiac nerves,- a species of post diphtheritic paralysis0 Cases of septic diphtheria.- or mixed infection: — Symptoms severe from beginning0 Membrane extensive, may cover entire pharynx, extending to nose and middle ear. Tonsils and $.vula much swollen. Very offensive diphtheritie odor, Cervical glands much swollen. Nasal discharge abundant and offensive„ Constitutional symptoms severe:- Temperature high and widely fluc- tuating s 101-106, Pulse weak, rapid and compressible* Extremities cold; prostration extreme; often vomiting and diarrhoea.. Delirium or apathy and stupcr. Nephritis common and severe. In a large proper* ion of such cases under three years, broncho-pneumonia develops , Recovery is rare,. .Oonipl.ic.at ions and ->• 1. Broncho pneumonia most common in young infants and children0 Occurs especially in laryngeal cases and in septic cases* whether larynx is involved or not. Usually develops at the height of the disease- but may come late, even during convalescence^ 2„ Myocarditis not uncommon* though in only a small prpoption of cases do es it show di st inc t syrnptoms <> 3C Subcutaneous hemorrhages:- an evidence of a very high degree o-f toxaemia o 4-0 Otitis: not-very frequent; but usually severe when it occurs* 50 Albuminuria:-Present in almost every case of moderate severity. Severe nephritis seen in the worst septic cases; and less often a diffuse nephritis with all signs of uraemia,-dropsys scanty or suppre ss ed urihes vomit ing . Sequelae:- Anaemia; usually folows; severe and persists for weeks* Post diphtheritic paralysis* the most important sequelQ 31 Diagnosis:- 2 kinds. Clinical and Bacteriological. Clinical diagnosis 1. Patient and his surroundings. Diphtheria favored by:-age under 10, home in a tenement house or institution, presence of other diphtheria in the neighborhood. Iv'ode of onset and constitutional symptoms:- onset more often gradual and tsmper- aturs low than with other threat affections, basal discharge if abundant and thin, development of croup symptoms, rapid enlarge- ment of cervical glands, and early appearance of albumin in urine point strongly to diphtheria*, Local signs:—Membrane{, appearing first on tonsils as a gray film, becoming more dense and white; changes later to gray, greenish yellow, brown, sometimes black. Pact of its spread is important; "if it extends from the tonsils to the faucial pillars and the uvula, it is almost surely diphtheria"(Holt)o In pure diphtheria there is little oedema of faucial pillars and uvula. Differentiate scarlet fever;- onset very abrupt with vomiting* prostration and very high temperature;and xs very active inflam- mation in throat. Bacteriological diagnosis:— Culture should not be taken from centre of membrane but near junction of mucous membrane with edge of membrane, or underneath edge of membrane. In laryngeal cases, bacteriological examination usually fails. Prognosis.Difficult to foretell the outcome in the individual case; always treat the mildest case as if it were severea In major- ity of cases its impossible to tell how severs its going to be before the 3rd or 4th day. The prognosis is much more grave in the first two years of life, without antitoxin treatment it ranged from 30-60/6 in private pra’c- tics, and in hospitals from 60-80,1* Remember that the danger is not over when the throat has cleared,. The most frequent cause of death after this time is heart failure; this danger exists in every severe case, and occasionally in the mild cases, those in which the early symptoms are of moderate severity„ Paralysis * of respiration, nephritis, or broncho-pneumonia are other dangers* Prophylaxis:- Public funerals of children dying of diphtheria should be prohibited, Schools closed wheii the epidemic prevails * Children in a family where the disease exists should be kept from school at least two weeks after the recovery of the last case, In cities all patients should bo removed to special hospitals for contagious diseases* Quarantine:- Every case and evry suspected case should be promptly quarantined* Quarantine to be continued til cultures show no bacilli in throat or nose* Suspected cases and children who have been exposed should at once receive an immunis- ing dose of antitoxin. Nurses should receive an immunising dose, and use an antiseptic gargle several times a day* Physicians should take the same pre- cautions as in scarlet fever. Sick—room:-Same precautions as in scarlet fever* All spoons, cups etc* used by patient should be sterilized 20 minutes by boil- ing. Disinfection of the room after an attack should be done as in scarlet fever* 32 Treatment*- Plenty of fresh air* Keep patient in bed during whole attack, even in mild cases; in severe cases this should be continued throughout convalescence, if there have been heart symptoms in the acute stage, Food should be milk, usually some- wl at diluted, and in young infants peptonized. Nursing infants must not be put to the breast„ Stimulants:- Alcohol is the best drug known to combat the effects of the disease upon the nervous system and heart. Indications:- harked prostration, feeble pulse., weak first sound of heart. One oz. of whiskey in 24 hrs. is enough to begin with in a child of 4, Dilute with at least G parts of water Strychnine also given for heart and respiration. Local treatment: cleanliness the essential. Irrigate the mouth and where there is much nasal discharge, the nose, with lukewarm salt solution, l/o, or boric acid solution, For- enlarged lymph glands and sore throat, the ice collar is best* Antitoxin treatment:- At the Boston City Hospital, 2000 units is the average dose given in children from 1-15 years, repeated every 4 hours if the case is moderately severe or severe, gill the characteristic effects arc seen upon the membrane,i>e. the membrane stops spreading, begins to soften and curl up at the edges * For severe cases in adults 3000 to 4000 units are given,. Laryngeal cases: If dyspnoea becomes marked, as shown by the retraction of supraclavicular, suprasternal and epigastric regions, and the dilation of the alae nasi, intubation is required. The antitoxin is used as before till the constitutional symptoms im- prove, viz., lowering of the temperature and pulse and improve- ment in the nervous condition. Antitoxin must be given early; for it cannot undo the effects of the diphtheria poison after it is once exerted on the tissues. The needle and syringe, as well as the skin at the point of in- jection. and the hands of the operator must be sterile, or antitox- in abscesses will result* Convalescence:- Keep patient in bed for at least a week after throat has cleared, and longer if there is any tendency to heart weakness0 An abnormally slow pulse, a rapid pulse, irregularity, intermission, dicrotism of pulse; weak first sound of heart or reduplication of 2nd sound:- look out for these. If present keep patient recumbent and absolutely quiet* For the anaemia give iron* Incubation: 3-4 days to a week. Etiology:- Usually occurs in infants with mother's sepsis. A streptococcus affection of lymphatics; may cause pneumonia by extension. 2 forms: (1) In new-born; (2) in older children. 2 types:- Pigrans, spreads peripherally from one spot0 (2) Am- bulans,- skips about to various parts; rare® In new-born:- Begins usually around navel or genitals, iec where skin is thin and abraded; may begin at side of noses when there is abrasion from forceps. Symptoms:- (1) Local:- Skin red and hot. Typical afflorescence comes and goes for first 24 hrs. Next day the same are is dark red and indurated.. Constitutional symptoms:- Temperature: high but zigzag, fluctuates between 102 and 106; vomiting; may be convul- sions. Child may be blue and colcU lldiooryls:•• Very bad in infantse In now-born almost always fatal rhon starting from umbilicus* In older children mortality iB high, biit not- qufoe so bad as in new-born. h/inuif is: according to the kind of efflorescence* ; - 1, Allay fever: ~ Cold sponging* Antipyretics may kill 2. Sustain strength and vitality:- rood and brandy, 20 Lo- cal treatment: (as given,by Holt)- Ointment, 10% ichthyol in lano- lin o, kept constantly applied,, NERVOUS DISEASES* OMTETRIOAL PARALYSJSo (Paralysis of the New-born) Pathology: Arm usually affected* Upper arm t yp e, "Erb 1 s Paraly- sis'1'. 5th and 6th cervical nerves affected, causing paralysis of deltoid, biceps* brachialis anticus, supinator longus, and some times supra- and infra-spinatus muscles„ 'Etiology: Trauma; usually in breech deliveries. .SYir^torns;- No constitutional symptoms„ Arm paralyzed* Character of peripheral paralysis:- flaccid* reflexes absent or diminishedInability to flex forearm; arm rotated inward. Rapid atrophy; this may not he noted in a fat baby,, Sensation impaired* Reaction of degeneration in severe cases ( in few days to a week)0 Difference in temperature in the two arms. Differentiate (1) Surgical injuries., e,g. fractures: (2) Poliomyelitis:- Almost never occurs in first weeks* No distur- bance of sensation. Tendon reflexes- unimpaired* " Varies with severity0 1« Mild cases: usually well i21 2 months... 2, Other cases we hi in 6 months, 3„ Severe cases with reach, ion of degeneration may not recover, i 0 e a paralysis may he permanent 0 Treatment; - Let alone for first 2-3 weeks except $ bandage to protect limb,- Then electricity after the first month, used regu- larly faradism if muscles respond, if not* galvanism. Also mas- sage., * Contractures may occur in normal muscles from lack of oppo- s it 3 oru CEREBRAL PARALYSIS OE CHILDREN„ 3 classes of cases:- 1* Prenatal, from cerebral defects« 2,, At- birth,~ result of trauma: prolonged labor* forceps, some- times These are really due to hemorrhage, 3, Acquired,- during 1st 3 years,-, hay be associated with hydrocephalus. Causes:- ?/3 c a. s a a due t. c he mo rrhag e of one k ind o r ano t he r, e * g = •- T r aurna tic; infectious:- typhoid, pneumonia* scarlet fever; Thrombosis* from cacheula or local disease; Embolism from endocarditis; Pertussis* Nature of paralysis: Paraplegia or Diplegia in the prenatal and congenital forms * Hemiplegia common in acquired form* 34 Hemorrhages most common at bass of brain,, especially in posterior half, ove cerebellum and occipital lobcs„ Severe at onset, as a mile„ At birth:- Temperature; unconsciousness,- baby refuses to nurse, i; Tall and apathetic; frequent convulsions„ These cases usually die uishin the first 4 days',, primary respirations may be poor. In older children:- A0 Constitutional:- Fever, vomiting, convul- sionso Ee Paralysis:- Hemiplegia; Spastic, followed by*rapid con- tractures. Flexors overcome extensors. Sensation not disturbed* Reflexes- exaggerated. Bladder and rectum not involved. No trophic symptoms. After effects:- l/s cases have epilepsy, chorea or athetoid movements develop later, 4-0-50;t have mental impairment* Contrac- tures likely to develop 2-3 yrsc after. iiiasnosis,:- Increased reflexes5 contractures; History; move- ments '30 differentiate from epilepsy); loss of power in affected limbs o [ minor symptoms) Pupils are decreased.; eyes osci3.ate* f ont an dies bul y e „ ZilQ£21Qsi_s: - For life; Bad in prenatal and congenital cases. Grave for acquired cases„ (2) For paralysis: Not vcy good: im- provement cones soon if ever. (3) For mind: Poor. (4) Post#paral- yt ic mov ement s 1 ik ely, Imat.rnent: Nothing in early stage„ Operation useless. luassagGj elec uricity; orthopedic apparatus to prevent contractures,. Orthopedic surgery laterft In acquired cases during stage of onset: Absolute rest* Ice to head. Bromides. INFANTILE SPINAL PARALYSIS, (Acute Poliomyelitis) - Symptoms suggest infection by a micro-organism; but no proof of this yet. Age:- 80/ in first 5 years* Greatest number in 2nci year, c.eason: much more prevalent in warm months„ -Acute inflammation of gray matter of anterior horns of spinal cord* In long standing cases part of cord affected is small o-r than re si. Ganglion cells few in number or wholly disap- pGai ccie Anterior nerve roots of affected side smaller than normal, and degenerated to the muscle.. Condition of cord one of sclerosis. Affected muscles smaller than normal; muscle atrophied, limb short- er, bones smaller man on sound side0 Lumbar region of cord most ofien affected; but there may be other foci* Both horns may bo involved.. : - (1) Onset sudden; general symptoms:- Fever., vomiting, convulsions; sometimes coma*. Some cases have no constitutional disturbances, (2) Paralysis;- Kotor; flaccid, reflexes dimin- ished or absent* Peculiarity: more involved early than late in disease* (3) Atrophy: rapid, shows in 2-3 days* (4) Sensation not disturbed (diff6 Obstetrical paralysis) Holt states that there may be pains and xsoms&s£kjs&hyperaesthesia* (5) Bladder and rectum not involved* (6) If lesions are severe, there may be failure of development and trophic disturbances * Affected part may 35 be mottled and coal, (7) Late symptom: Contractures in normal mus- cles. (£) Reaction of degeneration if at all severe. Cerebral paralysis . Ant a Poliomyelit is. Pathol, Hemorrhage, embolus, throm- Inflam, of ant, horn of bosis. Sclerosis,Atrophy, cord, porencephalia* Age0 Under 3 years. Under 3 yrs. Onset„ Acute febrile. Acute febrile Motor dis- Hemiplegia (commonest) Monoplegia most common, turbancos. Spastic rigirity. Flaccid. All muscles of limb. Groups of muscles; exten- sors most commonly, Contiac- All muscles, specially Flexors in calf, ture s, f13xo rs & adductors. Spasmodic Athetosis.Post- Absent, Convulsions may movements, paral, chorea. occur at onset, Fpileptiform convulsions. Sensation. Unaffected. Unaffected, Nutrition, Arrest of growth. Tendency «o extreme atro- phy, coming early inparal- yzad limb. Elec-. Reac- Normal. Reaction of degeneration,, t ion. Tendon re- Exaggerated on paral- Unimpaired, flexes. ysed side. Speech. Liable to impairment. No impairment. Intelligence. Often impaired. Normal. Hlcimo.sis: Hotch gives the following differential diagnosis:- Prognosis:- For life,- good. For improvement:- Mild cases show great improvement in a few months. Don't expect complete recovery in severe cases. You may hope for partial recovery, in 6-9 months. Treatment: - Nothin'- for first few weeks, except perfect rest; later on, same as in obstot. paralysis,i.e. electricity - mild current3-s massage. Apparatus to prevent contractures. SYPHILIS. 2 fsrsrms in early life: 1.Hereditary. 2. Acquired; (pretty rare). Hereditary £orm: a. In new-born; b. In older children*, i,e„ new-born are equivalent to the secondary lesions of acquired syphilis,- eruption on skin, coryza, fissures and mucous patches, especially about lips and anus; slight fever; sometimes much tenderness at epiphyses of long bones, shoulders elbows, wrists and ankles* Lesions of retarded syphilis are those of tertiary in the ac- quired form: Gummata in the solid viscera,; affections of the teeth; bones,- an osteo-periostit is of shaft of long bones and of cranium. Symptoms of Syphilis of new born:—Not present at birth in most cases, if -child is born alive. Still-born and macerated foetuses are commons "Where symptoms are present at birtn the cnild does 36 not often live more than a few days. On skin are pusutles, papules, or bullae (syphilitic pemphigus). Body is wasted* skin wrinkled* temperature sub-normal• Ohild sucks feebly if at all and soon dies from inanition. In nos: cases: Child appears healthy a: birth. Earliest symptoms usually from 2nd - Gth week. If 3 months pass without oveidneo of syphilis, child is probably safe. First symptom usually coryza, “snuffles *. whieh persists. Hoarse cry; Eruption soon follows: usually macular,most abundant on face, neck, anterior surface of arms and leas, and on hands- and feet. Color; bright at first, soon coppery, duration 5-8 weeks. Fissures and mucous patches: lips and anti Sc Resist local treatment, bleed easily. Hemorrhages; bleed ing from nose and lips not uncommon. Hails:-narrow, pinched, claw- shap e d c Late hereditary form:- Synro ..oms come on at any time up to pu- berty* Teeth: Liable to early decay, i.c, those of first sot* 2nd set • Hutchinson tooth:-Upper central incisors have a single crescentic notch on the lover edge, hay be rounded and peg-like, 3screw-driver11 teeth* (These arc lacking in one half the eases). Bonos: sec above* Lymph glands:-Post-cervical and epitrochlear often moderately ?v;ollcn„ Eyes: Interstitial keratitis often present, especially associated with notched teeth* Syphilitic ulcers of skin not rare in untreated cases* Nose and palate:- Ulceration of mucous membrane, necrosis of turbinates, ethmoid or vomer sometimes seen* Such children arc often undersized and anaemic, and may have impaired mental power* Diagnosis: The characteristic symptoms• In tho young infant snuffles, efflorescence, and fissures. Prognosis:- Varies with severity of case, with treatment of parents before birth of child, and with treatment of the baby0 Of the mild cases, not one half recover,. Prognosis better the long- er after birth the first symptoms ap_ ear. Wait some time before g iv i ng any pro gnosis. Prophylaxis:- No person should be Allowed to marry till at least 2 years have passed after the initial sore (Wood and Fizz say four) steady treatment continued meanwhile; nor if there are any avtive symptoms o The mother should be treated during her pregnancy (1) if syphilitic; (2) if father is syphilitic; (3) if she has had prev- ious signs of syphilis, even though she has shown no recent signs * Treatment,: Feeding of syphilitic child:- breast fed, iL£ mother is -also syphilitic. Don't have a wet nurse, as child will infect her. Drugs: Mercury by inunction; if skin becomes sore give by mouth or in a wash. Hypodermics likely to cause slouhing. Oleates likely to turn rancid and so take skin off. Signs of too much ITg„, are first, diarrhoea (child too young to have saliva- tion) . 10 gra of the ointment with equal part of vaseline for a young infant, rubbed in to pal-ms, soles, axillae, or inner surface of thighs, alternaing each day. By mouth gray powder. Hydrargyrum cum creta, gr.j, t,i.d.-4.i.d.; or corrosive sublimate, gr,l/l00. Treatment of fissures:- dus« on some preparation of Ilg. For snuf- fles, ointment to nose. Keep up treatment for years, 3/4 time for 1st yr., 2/5 time for 2nd, etc. But don't give continuously. 37 Tor late syphilis give the iodides and mercury0 KI should always bo given well diluted,, EYEING IT IS /3 » Tubercular* II, Non-tubercular: a, Acute purulent bv. Serous (Whitney)* c* Epidemic Gerebro-spinal.. Serous (Wentworth thinks its existence doubtful as b, separate form) 0 Etiology; No organism found; follows infectious diseases, es~ pecia11y m e as J. o s0 Fat iology: Doubtful„ Symptoms: described by some writers as(1) Sudden onset:-Vomit- ing, temperature; Recovery common* or (2) Onset slow*(like tuber- cular form) Acute Purulent. Meningitise Infect ion varies with the cause of olio primary disease. Secondary to:- Acute Exanthemata; Pneumonia; Empyema,, especially the encapsulated form; Influenza; Typhoid fever; malignant endo- carditis; sometimes acute nephritis; Cerebral abscess; otitis; Inf lamina tions of the eye; Mastoiditis; Infections of cord in babies Pathology; Staphylococcus, Streptococcus, Pneumococcus*- vary- ing with nature of primary infection. 2 forms:- a* A mass of pus covering the brain.- obscuring the out- lines. be Follows course of blood vessels in streaks. Both forms may be caused by the identical organism. Symiptpms: (1) Pub to mechanical pressure. (2) Intoxication. 1. Pressure symptoms:-Headache,- usually frontal but sometimes general and accompanied with vertigo. Pains in back of neck, along spins: tenderness along spine* Neck retracted and rigid. May be opisthotonos. If case is protracted there is likely to be local paralysis, one side, or one extremityc Eyes: pupils generally contracted at first, then irregular, later widely dilated: external- strabismus common. Bulging of fontanelle com- mon in infants. 2Toxic symptoms:Onset generally with convulsions. Stupor comes on with slow pulse and irregular respiration* Temperature hugest at onset in many casesn Often the symptoms are very obscure. Note that it always begins after something. In pneumonia, for instance in which it supervenes, the only s-ign may be a certain amount of stupor 36-48 hours be- fore deathj Piayprvysis.: -Very difficult. Lumbar puncture furnishes only reliable m e an s,, Prognosis: - Very bad. Great majority of cases die in 3-4 days. 'Treatment; Always have a consultation; insist on it; you thus protect yourself from undeserved blame„ Treatment, chiefly valua- ble to satisfy the family that everything possible is being done. Arrange treatment so that something is being done at frequent intervals. Instruct nurse to be always on the watch to do some- thing for the child, even though its unconscious,- e.g. arranging pillows, etc. Feeding: Small quantities and often, every 2 hrs. Brandy may bo given to sustain strength. Move bowels with salines 38 or calomel0 Ice bag to head* To stop convulsions give a small amount of ether* Bromides and chloral act too slowly** They may be given several times a day as a preventive of convulsions* Be on the watch for bed-sores and retention of urine; both these are rasfehor common0 Epidemic Gerebro-spinal Mening.itis„ JLWpJLSSJK:-Biplococcus meningitidis intracellularis of Weichsel- baum. -Exudat e,, usually more fibrinous than purulent, fol- lowing course of vessels: more marked over anterior half of brain and at base- Cerebro-spinal fluid increased; ventricles somewhat distended. Cord: Exudate along posterior surface in its whole length, Sdhl¥it^pmjs.:- Cerebral (common to all forms): Paresis or paraly- sis of ocular muscles. temporary; Dizziness; Pupils unequal, don’t react, to light; Vomiting; Headace; Retraction;pain and tenderness in median line; Convulsions; Exx Hyperesthesia; Mental disturb- ances* varying degrees, from apathy to unconsciousness. Note: any or all of these symptoms may be present. Cerebral symptoms also occur in children, especially the very young, without meningitis: acute ear may cause unconsciousness, cyanosis, rigidity and pupils without reaction*, Don’t make a diagnosis on any one symptom. Associated symptoms in meningitis are: Rapid emaciation, Retracted abdomen; Incontinence of urine and faeceso Magrnsis:-Easier than in secondary meningitis,, Note history of sudden onset with no previous disease. In first 24-36 hours:- Headache. Vomiting (almost invariable in children); Temperature moderate to high elevation,-102-105, Mental symptoms, in first 24 hours, apathy, sleepiness etc. Pain in neck,-usually in first day. Less constant symptoms,- inside of 5-6 days:- Hyperaesthesia,- pains in spine and general pains, (may be absent); Herpes,- face and lips; Conjunctivae injected; Pupils dilated and unequal. Symptoms vary much from one time to another; child may be coma- tose at one time and clear headed later in same day. Pulse;- rela- tively rapid in children,- may not be in adults. Lumbar puncture the only absolute means of diagnosis. Complications of epidemic form. Eye:-- Optic neuritis, may cause blindness. Ear: Internal ear, may cause permanent deafness. Joints: inflamed. Paralysis: usually temporary. • .Varieties of epidemic form, lo Acute cases: 10-14 days; end in recovery, chronic ity or death. 2. Intermittent cases: With one or more acute exacerbations0 3, Chronic cases; Duration 4 or 5 weeks to 4 months. Death, or recoveryv possible at any time. 4. Abortive cases: Begin like acute cases, hut stop after few days. 5, Mild cases: Like other acute cases, only milder. VE2enpsjL§.: Uncertain; may die any day with no apparent change in syrnp toms,; ixEiVaidJOiit: Same as for Acute Purulent form. Tuberculous Meningitis» Etiology: Predisposing causes: Tuberculosis elsewhere; Measless Influenza., Pneumonia; Rickets ( and other chronic diseases); Chronic Diarrhoea; Any disease attacking respiratory tract; any disease causing anaemia* Pathology* Miliary tubercles along vessels of pia mater; when few,, only at the base, along Sylvian fissure, and in the inter- peduncular space. When numerous, scattered over convexity in small groups,, but most abundant at base. Amount of lymph and pus usually small. Lateral ventricles distended with clear fluid; fontanel often bulges. Three stages. • 1st stage,, two varieties: A. Like acute indigestion: Vomiting, headache, moderate temperature and pulse; dizzinessy constipation. Diagnosis at this time impossible. May occur without history of errors in diet, B. Onset, more gradual: Change of disposition. Irritability- Drowsiness; Loss of appetite, vomiting; Headache, chiefly frontal. Screaming without waking (of. night cries of Pott's and Hip disease) . Temperature not high, 99-101* Stupor., 2nd stage; Symptoms increase slowlyc 1st and 2nd stage together take a week or more; 2nd stage lasts 3-10 days. Pulse., slow, irregular, intermittent. Emaciation rapid, especially of neck and body. Abdomen retracted. Neck retracted and rigid; may be opisthotonos* Stupor increase. Rarely tubercles are seen on ret in a,. 3rd stage: Pressure symptoms begin to appear:-Coma, stupor; no vomiting, Cheyne-Stokes respiration. Pulse and temperature rise just before death. Pupils dilated, may be unequal; don’t react to light. Duration of stage of coma is 2 days to a week or more, A rapidly rising temperature or convulsions in this stage indicate approach- ing death* Duration of the disease is from 2-3 -weeks in young children to 6-8 weeks in older children. No sharp distinction between the 1st, 2nd and 3rd stages, 1st, vomiting etc„; 2nd, increase of these; 3rd, mental symptoms predominate. Ends with high temp, and pulse, suddenly. May be contractures; patient usu- ally dies unconscious. Tuberculous meningitis most common in children from 2 or 3 to 8 or 10 years. The younger the child and the more rapid the onsett the more severe the diseasea P.DPPid’irri.-''‘Absolutely bad: no case has ever been known to re- cover in which the diagnosis was sure, Trecgtment:. Same as that of acute purulent maningitis* Although the disease is hopeless in spit of treatment., remember there is always the possibility that the case is simple and not tuberculous. Lumbar puncture as a moans o& diagnosis: the only relaiable test: Puncture has no therapeutical value except a temporary re- lief of pressure. It is not dangerous with surgical asepsis; the on ly recorded cases of death were those which would have died anyway, 2-3 -Co. enough for diagnosis. Needle should be O.l-fl-1.5 mm„ diam- eter.:, Length varies, 2 1/2 - 3 inches for children; 4—5 for adults. Diagnostic value is greater in children* on account of the greater prevalence of cerebral symptoms. Character of fluid withdrawn. Macroscopic appearances. Normal fluid clear as distilled water* No cell elements. Fibrin never forms no matter how long it stands. Abnormal fluid: Cloudy3 from admixture of cells* If very slight examine sub- microscopicallFc Dust in test-tube might make normal f1u id 1o ck c1oudy„ Tubercular meningitis:- Fluid only slightly cloudy* almost clear; often must be examined under the microscope. Cells:- chief- ly small, mononuclear, not pus cells; few polymorphonuclear neu- trophil es* Serum shows no culture growth* The tubercle bacilli are sometimes in fibrin meshwork; few and hard to find; therefore inoculate a guinea pig. Purulent meningitis;-(1) Growth on blood serum, (2) Exudate chiefly po1y morphonuc1ear neutrophilesc Epidemic corebro-spinal meningitis:- (1) Growth on serum if taken while symptoms arc acute. Chronic cases usually do not have this growth. (2) Organisms seen on cover glass preparations* iMHOREA o (St* Vitus's Dance) J&io.Xo&y>Io definite cause known. Follows:- Rheumatism; Endo- carditis; Scarlet Fever;Typhoid fever; Chronic malarial poisoning. Occurs in nerotic children; twice as often in girls as boys. Age: Seldom before 3 years. Y/ent worth gives greatest number of cases between 3 and 10 years; Holt says 7-14. Season: Spring and autumn* Overpressure in school an important factor. Fright often the immediate cause. Reflex causes: Ocular defects impor&ant; phimosis and worms are causes. More often these cause a symptomatic chorea, not a true chorea, but a habit neurosis. Palhplqgyy - Unknown * fvRtPikims: Onset usually gradual; child'is thought to be simply "nervousM Child laughs and cries in same breath; drops things easily; legs may affected, causing a stumbling gait. Child is irritable. Sleep may be restless, or good. Muscular contract ions; rapid, irregular, involuntary; affect as a rule certain groups of muscles; movements usually increased by effort to stop them; in- creased by excitement& embarassmsnt or fatigue. Usually diminish or staop during sleep. Tongue often affected, giving impeded speech though mental condition remains bright. Heart murmurs frequent; systolic, mitral; heart dilated. Patients always anaemic„ OflMiarcl charajtiori: Usually tend to get well in 6-lo weeks. May last 3-4 months. A few cases become chronic and last indefin- itely. Marked tendency to relapses and second attacks. Diagnosis*.The characteristic symptoms* Differentiate: Symptomatic chorea. (2) Post-hemiplegic Chorea:- History of hemiplegia; increased reflexes: Contractures bf paral- yzed side. (3) Hysteria:- Appearance; actions exaggerated; move- ments slower and at longer intervals; more purposive. PiTDJLQP.si.g.:As to life; good; occasional deaths have occurred from exhaustion. As to full recovery: Good in the majority of cases; but warn parents of the tendency to recur. As to heart disease: Fairly good; many cases recover; better give a guarded prognosis. Treatment: (1) Rest: take child from school. In severe cases put to bed. Warm baths or cold sponging daily, according to the case. (2) Piet: Simple and nutritious, but non--stimulating. Pro- hibit absolutely tea and coffee. (3) Drugs: Arsenic; Fowler * s sol, 5-6 m. t.i.d. Don’t give too large doses; examine urine for evidences of over dosing. Increase by 1 m. every day or two till limit is reached; then stop for a few days and resume. Bromides alone or with arsenic may be needed in acute cases (4) If there i s any o cula r defect, t reat that. Aetiology; Hereditary precTisposition. Immediate causes: Fright; worry, overstrain; trauma; Digestive disturbances. Eniptional ex- c i t oment« Close at mo sphc r e s e ... g. in theatre. church etc. Influ- ence of syphilis or alcohol doubtful, Pathology: 3To known brain lesion.. Symptoms: I, jhqand ml: (1) Aura: Colors before eyes, tinni- tus auriu'Tt. tingling of a it extremity,; aura of short duration* (2) Tonic stage of convulsions: Initial cry; sudden loss of con- sciousness; tonic convulsions; pupils contracted; eyes rolled up. (3) Clonic stage of convulsions: Unconsciousness continues ( 2 min- utes to half an hour); clonic convulsions; frothing at mouthabit- ing tongue); pupils dilated; sleep follows, usually lasting an hour or two; headache frequent after sleet). EPILEPSY. Nocturn?1 epilepsy: Signs of an attack during night, discov- ered when patient wakes in morning: After headache and prostration; lacerated tongue,- blood on pillow; involuntary passage of urine and feceso II. Petit mal: Sudden and- momentary loss of consciousness; con- vulsions usually not present. fairing and after an epileptiform seizure temperature may be high. Are of epilepsy:Most oases begin before 20; great majority of these begin about puberty. It may possibly begin with infantile convulsions; Gower and Sachs think it begins later and is uncon- nected with infantile convulsions. Tliacnosis: The symptoms given above. Differentiate: (1) Hysteria: Aura longer..; Onset slower; Consciousness partial or complete. Pupils normal. Exaggerated movements, rigidity, etc. No passage of urine and feces. Tongue not bittsn,patlent doesn’t hurt h iniB e 1 f in f a.l. 1 ing „ No af t e r s tup o r (2) Organic brain disease f. Rarely develops before 25 yrs. Usually unilateral at first . There may not be loss of consciousness (Jack- sonian, EpIlopsy}„ (3) Brain tumors: Headache, vomiting and dizziness« Optic neuritis. (4) Fainting: Gradual loss of consciousness (sudden in epilepsy); pulse rapid and feeble; pallorc Petit rnal: attacks may occur 30--40 times a day a Any sudden loss of consciousness with quick recovery is suspicious; may be due to heart disease., but usually to petit mal, 42 riff wrent late Spnstic Paralysis in children: Los?, of power in some extremity: increased reflexes follow* (!’) Remove the cause if you can find out what it is* Phimosis, adenoids,. and other sources of reflex irritation should be sought fo-r and remedied, (2) Piet; Above all things prevent constipation.. Give meat but once a day* ana in moderate amount. Prohibit absolutely tea. coffee, and alcohol in. every form* If much intestinal putrefaction exists* give intestinal antiseptics* saXol? or benzoate of sodium, or salicylate of sodium, after meals© (3) General hygiene: Simple, regular out-of-door 'life, free from exciremsnt* (4) Drugst Bromides* sodium or sodium and ammonium bromide combined; always dilute largely with'water; Seguin0s method is to give largo dosot for 24 hrs« previous to the expected lime of the seizure, with smaller doses between. ' Qo uvulaions (Not epileptic) „ Etiol.o gy: I:rrif an c y (a t1 a c k s relat. iv e 1 y rare af t e r ag e o f r e v on), Rickets; the most important predisposing cause,(where convulsions occur in infancy without evident cause, rickets should always be looked for). Hereditary nervous temperament„ Exciting causes: (1) Digestive disturbances, undigested food in the stomach or intestines*, probably toxicc Other toxic causes are the onset of acute infectious diseases, particualrly pneumonia, scarlet fever and malaria* In pertussis, which is more often than any other infectious disease accompanied by convulsions,the cause may be asphyxia, due to a severe paroxysm, or cerebral congestion or hemorrhage resulting from it., (2) Reflex irr it at ion:-renal or intestinal colic,, retention of urine, foreign body in the ear etc0 (3) Direct irritation of the cortex of the brain:- Meningitis, meningeal or cerebral hemorrhage5 tumor* abscess, hydrocephalus, etc» gyppo toms: Onset, usually sudden: face pale* eyes fixed and rolled up, twitchings of the muscles of eye or face, rapidly spreading to other pares of body* Convulsions usually gel-oralHay be some frothing at mouth * Loss of consciousness * Respiration feeble and shallow* Pulse weak, often Irregulavv, pace becomes cyanotic about lip Sc. Convulsions consist of alternate rhythmic extension and flex- ion; last from a few minu-f.es to half an hoursusually cease grad- ually., One attack may be followed by another*. The symptoms * Differentiate (1) Epilepsy" likeHy to be a history of preceding attacks* a dis- tinct aura xrcs ceding the attack& biting of the tongue* tonic spasm before the clonics full recovery in a few hours,. Rarely any marked rise of temperature u (2; Prognosis: Pep ends largely on the reason for the consulsionc Idiopathic or reflex convulsions rarely endanger life except in very young or rachitic infants« Convulsions in the onset, of acute infectious diseases seldom fatal. Convulsions of pertussis* and asphyxia are especially fatal* Nephritic convulsions bad but not necessarily fatal.-, Bad signs are,- prolonged or frequently recur- ring at backs' very great prostration.; feobre pulse with cyanosis or deep stupor* Where convulsions recur often* an epilepsy is somewhat likely to dev slop 3.at err 43 ihfhtjuent(i-) The attack:- Remember the underlying pathological condition, a tendency to congestion of all the internal organs* especially cerebral hyperamia, pulmonary congestion and an overtaxed right heart* Therefore (a)Keep child perfectly quiet; fb) Apply ice cap to- head; (5) Dry heat and counter irritation to surface of bodies and extremities, mustard pack and mustard foot bath while child lies in crib; the old time mustard bath demands too much movement of the child* (d) To control the convul- sionbc inhalations 01 chloroform.; at the same time give rectal injection of chloral hydrate,dose nt 6 months, 4 grQ; at 1 year, 6 gr„; at 2 years 8 gr,, dissolved in one or., of warn milk* Repeat this in an hour if necessary. If this fails to stop convulsions,-or enema has been expelled,, Holt advises morphine,, sub-mu.. l/48 gr. for a child o..i 6 mon«>hs<, .<./2a gr, at 1 year; l/l6 grD at two years in well grown children. (2) To prevent recurrence, keep patient for two or three days Uno. er ini laence ol end or at with sodium bromideIn. infants irri- gate the colon with warm water to remove any possible source of intestinal irritation- one of the reflex causes of c onvu1s ions 0 (3) Improve general condition: fresh air? iron, eg, Syr* Terri lodidis cod liver oil and phosphorus, tho last two being especially valuable if rickets is L-he underlying cause of the convulsions* Rickets (Rac h it is)0 A chronic disease of* nutrition^ Sad diet the essential cquse; attifidial foods, espec- ially those with excess of carbohydrates and deficiency of fat and proteids; proprietary foods and sweetendd condensed milk are the most common of such foods„ Although not usually found in breast- fed children, it may be found in those nursed exclusively for a long t irne ? e 0 g 0 f ift een of e ight een months * (2) Bad hygiene: Rickets essentially a disease of cities; dark damp roomso (3) Nationality: Negroes and Italians most commonly affectedo (4) Age: Usually begins at 6 months to 2 years« (1) Bones: Increased production of cartilage at the epiphysis, and excessive cell growth beneath the periosteum; ossi« fication slow. Bones become unnaturally flexiblea Long bones have enlarged epiphyses; flat bones have local thickenings or bosses* soft and spongy 0 o *Bpiphyseal change s result in arrest ed growth and the bones affected become shorter than normal* (2) Viscera.l lesions? Not an essential part of 6 he disease* but often found* Lungs:- Broncho-pneumonia* or acute and chronic bronchitis very common; Castro-intestinal tract--, a mild chronic inflammation of the stomach and intestines, Spleen,- enlarged in moso cases during the acute at age: Lymph at 1. s glands more often enlarged in rachitic children than in others * Sxiriptciiis: Early symptoms: Sweating of head; Restlessness at night; Const ip at ion; Beading of ribs, “rachitic rosary”; Granio- tabes, soft spots over the occipital bone or posterior portions of parietals ( not a frequent symptom) Later symptoms:- Enlargement of epiphyses of long bones, most marked in radius and tibia; Curvatures of legs(bow-legs) and arras; 44 Lax re head, shape rather square, fontanel closes latese„g« 21/2 to 3 years; Harrow chest, ribs beaded; Abdomen prominent ; Anaemia in almost all cases, lib, may be as low as 30-40.2; Dentition is let:.- nd difficult (Mote, however, that the nn': are of good quality; in hereditary syphilis obey arc very prone to decay).-, Course and termination of rickets: Active symptoms usually last 5-15 monthso Sweating of head, restlessness at night, delayed denti-..ion, enlarged fontanel, enlarged epiphyses, rosary* differentiate (1) Acute anterior poliomyelitis: Reaction of degeneration* (2) Cerebral birth paralysis: Cerebral symptoms, increased knee- jerks, rigidity of legs* (5) Syphilis: Early le- sions: boggy infiltrations over the bones, not actual swelling of the bones, as in rickets.. Later lesions (a) Usually in shaft of bone ( at epliysis in rickets); (b) If near Joint usually at one side only; (c) necrosis; bone never breaks down in rickets, (4) Scurvy: Hypcraesthesia, ecchymoscs, bleeding of gums, relief b y a nth-sco r b ut i c e i et, Promnosis: never fatal of itself, but the cachexia predisposes to acute disease; rickets is the commonest causal factor of con-’ vuls ions. Remove the cause, i, e. improve the diet and hygiene, Piet: Reduce carbohydrates to the miniarm. Give milk, cream, eggs, red meat and fresh fruit; if an inf nt under a year reduce the preport ion of sugar* Hygiene: Plenty of fresh air during the day and night, insist upon this; cold sponge baths in the morning; plenty of sunshineu -rugs: Cod-liver oil; arsenic and iron for the anaemia, Treatment of the deformities: Orthopedic. ruj.s: Variefcties,- Catarrhal form; Ulcerative; Aphthous* (Fcrpctic); Thrush; Gangrsnous * Catarrhal Stomatitis: Etiology:- lie chani cqI s - Trauma; heat a Chemical: ■■■Fermentation, from sour milk, unclean nippless HFPtyupysp Mucous membrane injected and rod. Some swelling of m.,m.. In young infants mout is dry; in older children wet from increased salivation* Pain, shown by fretfulness; tenderness,.--baby won’t nurse0 The symptoms. PfPh;nQ.s.is: Good if cause is remedied* Keep mouth clean, without using any roughness,, DonH rub, but clean every hour with distilled water or 1% boracic acid solution* Feeding: make the child feed; spoon or medicine dropper* Aphthous Form (Herpetic)* Etiology,: Cause unknown* Catarrhal form may coexist* Holt says "Herpetic stomatitis is always associated with more or less cataxv. rhal inf 1 ammat ionw * Appearances of the mouth: Mouth constantly wetc The primary vesicles have nearly always broken by the time the physician sees .Dis.ee;go.s of zho I'outha or grayish the can leaving a white depression in a red mucous membrane 0 T here are usually 6-12* surrounded by a red halo, at first dis- crete but may coales00, if numerous* Situation: on, under, and at edge of the tongue9 inside the cheek, on gums and at junction of gums with lipSo Size, from pin’s head to head of a pea or larger. .SymuiQris,• Same as catarrhal, only more severe* The lesions de- scribed; salivation; pain, very severe; may be some fever. Good, sometimes healing spontaneously. Treatment: Wash, but don*t irritate0 Touch lightly with silver nitrate, or finely powdered burnt alum. Ulcerative stomatitis. Etiojlogj:: Sequel of acute infectious diseases among poorer pa- tients 3 e,g0 pneumonia, typhoidc Scurvy in infants* Lack of clean- liness of mouth, Mineral poisoning (Hg,, Pb,5 and Phosphorus), but rare in children. Gums swollen, spongy, blied at slightest touch; line of ulcers about the teeth, most marked along the dneisors* Lymph- atic glands beneath jaw swollen, pinful and tender, but do not suppurate o Symptoms:The appearances of the mouth; Profuse salivation; very offensive breath. Pain, but not so severe as in aphthous form. Often there is anaemia and cachexia due to the preceding disease* Temperature more or less elevated, uiprgrio.s.jis.: The condition of the gums about the teeth* Prognosis.: Dependent on the underlying condition. These cases may deve].op seps is , Trpult.ment: Cleanliness; permanganate of potassium, l/2-lX» or myrrh mouth wash* (2) Remove the cause if possible; if due to scorbutus. treat that; if to fevers, i.o. infectious diseases, treat the local condition, (3) Chlorate of potash internally, half a teaspoonful of the saturated solution, largely diluted* (4) Treat the general condition: Tonics, plenty of fresh fruit and vegetables, as in scurvy. Thrush* Etiojorcc: A fungus? the exact nature unknown® Thrush is most common in first 2-3 months of life, especially in protracted., exhaustive-diseases of early 1 if e ® Xj6]3innj?.: White spots looking like curdled milk ( but leaves bleeding points when scraped off), usually situated on the tongue, inside of cheeks and hard palate. Fungus begins on the surface of the mucous membrane, but tends to work down between the cells® Microscopical characteristics: Parallel sided, long, narrow* highly refractive, glistening threads. Oval spores about the size of a red blood corpuscle® Usually a catarrhal stomatitis is present at the same time® Symptoms:As thrush is associated with some underlying disease, there are no special symptoms except the small white flakes on the mu c o u s me mb r an e ® prp/xnp^si„s.: Depends on the general condition,. With proper treat- ment* most cases involving only the mouth are easily cured® Tre^menc: Prevent it by cleanliness of child5s mouth, nipples bottles etc® For the attack use an alkaline mouth wash* sodium bicarbonate or borate (Thrush grows in an acid solution, therefore mouth wash should be alkaline,J Sop on every hr, without rubbing* Pericarditis, Etiolofty: Almost invariably secondary to an infectious disease, acute or chronic0 The micro-organism causing it varies with the nature of the primary disease; may be streptococcus, staphylo- coccus, pneumococcus or tubercle bacillus0 h may follow rheuma- tism or occur with it;pneumonia, scarlet fever or measles; may accompany acute endocarditis; may come by extension from medias- tinal glands (g «g o tubercular); is found at times with pyaemia, especially in the new born, with chronic nephritis; and rarely it is the result of trauma. Pathology: The exudate may be sero-fibrinous, fibrinous, puru- lent or hemorrhagic. Serous exudates are usually absorbed, fol- lowed by adhesions; the pericardial sac may be obliterated. Result is often a weakenin'; of the heart action, the muscle nay be degen- erated. heart hypertrophies and dilates, with failing compensa- tion as a result in sons cases, A purulent effusion Is rarely ab- sorbed „ Symptoms: -i- H- C% bis, and not useful for diagnosis; masked by the symptoms of the disease to which the pericarditis is secondary. There may be localised pain and tenderness; if much effusion, there is some' dyspnoea, precordial distress, palpitation and some irregularity*. ’Diagnosis: Rests upon the physical si-ms. Acute dry pericarditis. Friction rub to-and-fro, syn- chronous nith heart’s action. But Sound3 prac t ic a11y equa1. Begins at base,- spreads from day to dayQ Sounds not transmitted. Heart dulness not increased. Acute dilated heart„ fulness not triangular in shape, nor in 5eh interspace to right of sternum Saner si a huix Cy ano sis dy sp- noea. feeble and rapid pulse (might exist in effusion also). Double valvular lesion. Two murmurs differs in length and quality. Transmitted. Dulne33 increased. Later. &igns of failing compen- t ion© Pericarditis with off us ion,. Triangular dulness. Increase to right of sternum in 5th space Intercostal spaces may be flatter than normal. General bulging if effusion is large. Chronic dilatation„ Evidences of failure of compensation. Enlargement down and to left. Stasis; 2nd sound accentuated. As c it 0 3 c, o edema* albuminuria. Obliterated Peri card iuxn „ Systolic contraction of precordial area, or in back (Broad- sign)o Prognosis of pericarditis: Grave in any case, from the compli- 47 eating pneumonia, scarlet fever, etc. Adhesions may form enough to interfere with the heart * s action. A large effusion prevents proper dilatation of heart. Purulent effusion nearly always fatal. .Treatment: 2ry Absolute rest in bed; cold applications to praecord ram; Digitalis, with caution; if pain is intense Holt uses morphine; Careful feeding; regulate the bowels. (2) Treatment of S££3is_ipn: If effusion is slight, counter-irritation over heart may help its absorption. When large, aspirate under strict asepsis; Rotch advises the 4th or 5th interspace on the right, Holt and many other writers advocate the same interspace on the left. The rest of the treatment is the same as for the dry form. CpjhLfiniial Iieart disease A&t io.lp,gXi» (1) Malformed ions: a. Open foramen ovale, the com- monest and mildest form. b. Perforate septum. c. Open ductus ar- teriosus. d. Transposition of the aorta and pulmonary artery. (2) Inflammations in utero: Hay cause an endocarditis, chiefly of the right side of the heart, tricuspid or pulmonary. Sy.iiM.tpJiis: Usually appear at birth or shortlv afterward, fl) Cyanosis, "blue baby"; a common and early symptom; may persist from birth or only occur on exertion, such as crying; in some cases appears only after some months. (2) Murmurs: may be present, or not; usually systolic, and loudest near base,- under or to right of sternum. Occasionally a double murmur is present. (3) Hyper- trophy of right ventricle,- heart dulness increased to right. With the hypertrophy are precordial pulsation; increased action,- a pe— culiar heave to the impulse (important); bulging of the prccordia. (4) Inpaired nutrition signs: Pingers often clubbed; extremities cool. Growth is stunted if the child lives long enough to make this noticeable. (0) Signs of dilatation: Attacks of dyspnoea, cyanosis, cough. May be convulsions, following crying attacks,-- rigidity, blueness, possibly loss of consciousness. Remember that all these symptoms may be present, or only one or two. prognosis: Depends on the severity of the lesions. Usual cases die before puberty; such children are more susceptible to inter- current diseases. Open foramen ovale is as a rule most favorable. Narrowing of the pulmonary artery, as a rule, is most unfavorable. (1) Frequent feeding; small quantities,, easily di- gested food. (2) Keep up the bodily heat (very important); warm clothing, particualrly of the extremities; hot water bottles during the day; have the baths much warmer and less frequent than for normal children; sponge baths only. (3) Protect child from wind and dust. Later treatment:(If baby lives)Plenty of rest (most impor- tant); keep theses children in bed a certain number of days in each month. Avoid exertion that is too severe. Use drugs only for an acute attack of lack of compensation. Give tonics and f,resh air for the appetite. 48 Etiology: Rheumatism; Scarlet fever; Diphtheria; Measles; of these* rheumatism is by far the most common cause. J/P.sJ-ons: Mitral valve in 90/ of the cases; chiefly vegetative,- roughening and thickening, but less fibrous deposit whan in adults. Ulcerative from rather rare. Acute heart: Symptoms: No diagnostic symptoms; make diagnosis on the physi- cal examination. There may be: Some rise in temperature, rapid pulse, palpitation sometimes, quickened respiration. Physical examination: About 3rd or 4th day, or later, is heard characteristic soft, blotring, systolic murmur at apex; usually transmitted to left; may be a thrill. Diagnosis: Differentiate: (1) Pericarditis: Friction sound to-and fro-; increased by pressure vrith stethoscope; more diffuse; not transmitted to left,. (2) Functional murmurs: Usually at base rather than apex; likely to me irregular in time, transmission and constancy. Progne sis: Usually good as to life* TThen death occurs, its us- ually from the disease- to which the -endocarditis is a complication. There is always danger of recurrence * Treatment: Keep in bed for at least a month, and then allow a very limited amount of motion for many weeks. Protect from future attacks of rheumatism. During the- attack give anti-rhsumatic remedies if the heart be a symptom of rheumatism or chorea. Chronic heart: Symptoms: (1) Stage of compensation: may last a lifetime. Shortness of breatr the only diagnostic symptom. Occasionally there are Precordial pain, palpitation, headache, epistaxis, anae- mia and cough. (2) Failing compensation: Dyspnoea, cough, cya- nosis (clubbing of fingers). Dropsy; Pulse soft, rapid and irregu- lar o Prognosis: Not likely to die before puberty. Then the disease may become serious. Few children with serious heart lesions before 8 years of age live to adult life in good condition. Treatment:Keep child under constant medical supervision,- exam- ine at least 3-4 times a year. Don’t allow over taxation of the heart. At first sign of overtaxation put child to bed* Propect from fresh attacks of rheumatism.* For failing compensation: (1) Prolonged rest in bed., (2) If dropsy, give digitalis or stro- phanthus, provided the pulse is weak and arterial tension low. Diuretics or saline purgatives to unload the venous congestion. Iron, strychnine, cod-liver oil for the tonic treatment. For sudden heart failure, strychnine hypodermically. Acquired Heart Disease. Etiology; (1) Primary cases: Bacteria,-pneumococcus alone* or with streptococcus (mixed infection). (2) Secondary cases: (1) Streptococcus* most important. (2) Staphylococcus0 (3) Pneumo- coccus n (4) Priedlander 5s bacillus <> Age: 955 under 4 yrs„ Seasons: All seasonss but. 705 in cold months0 Predisposing causes: Poor hygiene, especially "institution" life AcirLe. J^L^cJio^-jD^uinDBias 49 Bronchitis; hassles; Pertussis; Diphtheria; less commonly scarlet fever, ileo-colitis, influenza, varicella, erysipelas.. Pathology: Thickening of walls of bronchi and infiltration of surrounding tissue,-zones of pneumonia.. Seat: Both lungs in 82/£; lower lobes "posteriorly, posterior part of upper lobesy and lowere 3 types of the disease: (1) Acute congestive form. (2)Mottled red and gray form* (3) Gray pneumonia, persistent broncho pneumonia* Terminations: (1) heath at any stage0 (2) Resolution: before any recognizable consolidation; after consolidation has bead complete (3) Chronic interstitial pneumonia. (4) Tuberculosis* Complications: Pleurisy, in almost all cases of more than four days duration and over large areas„ (2) Abscesses of the lungs more common in prolonged cases, those unusually severe, and in very delicate pat lents« Symptoms: (1) Acute congestive type. Often unrecognized. Symptoms few and irregular. High temperature* 104-107., prostration* rapid respiration, and cyanosis. Respiration 00-30, (2) Capillary bronchitis. Respirations very rapid.80-1000 Temp- erature not high, 100-102. Great dyspnoea, Gough, Physical signs: Sibilant, followed by sub-crepitant rales over entire chest. Ho evidences of consolidation. Respiratory murmur feeble. Exaggerated resonance on percussion,~ due to emphysema0 Two terminations: a. Fatal, Symptoms increase till 3rd or 4th day, death occurring from heart failure and disturbance of respiration* b. ' Non-fatal. Great improvement in symptoms usually by 3rd or 4th day* Complete recovery may take place by the end cf a week. (3) Ordinary ttoe of broncho-pneumonia. T.iien primary begims suddenly, somewhat like lobar pneumonia; but symptoms are more distinctly pulmonary,. Temperature high,, ■with daily fluctuations often of 4-5 degrees6 Fever lasts one to three reeks; ends by lysis. Respiration: 60-80 per minute, some- times 100 or even 120. Signs of great dyspnoea: alas nasi move, supra- end infra-clavicular and sternal spaces retract on inspi- ration. Cough:- Very severe and almost constant. Strong cough is a good symptom. Cyanosis: when present is a danger-signal Ox respirator y j.aix ur e , s t ro - ent eric s ymp t a ms: imp o rt ant and frequent in infancy. Greenish diarrhoea* vomiting, distension of stomach or intestines from gas may be present. physical 3igns: (1) Ther£ may bo no signs of consolidation during the whole course of the disease * Feeble breathing o ver the affected area, coarse and fine rales * followed by moist rales usu- ally in one of lower lobes behind. Respiratory murmur in affected area feeble and higher pitched. )2) Partial consolidation. Small areas; percussion usually normal# Fine moist rales appearing high-pitched and close to stethoscope Respiration feeble and broncho-vesicuaar over these areasa Vocal fremitus not changed3 Vocal resonance exaggerated. (3) Areas of more complete consolidation: There may be very slight dulnesc (consolidated portion of lung is superficial)„ Slight •increase in vocal fremitusc Coarse and fine rales over whole jehest sometimes9 but more commonly only behind. Bronchial breath- ing Ejudxxxiiss over centre of consolidated areas . But note: there is no definitely limited area demonstrable* as in lobar pneumonia. 50 (4) Persistent broncho-pneumonia. Like an ordinary case for two or three weeks* but the fever continues, though a little lower and irregularc Areas of consolidation increase till there is marked dulness, sometimes almost flatness; exaggerated bronchial breath- ing „ Acute onset with continuous high fever, rapid respi- rations and cough*- suspect pneumonia0 For differentiation from lobar pneumonia see Lobar pneumonia. Severe bron.cih.itis:High temperature usually of short duration, 24-48 hrs, Prostration less than in pneumonia; • all synqptoms, except possibly cough * are less severe* Malaria: Temperature intermittent (that of pneumonia though often remittent* is seldom intermittent)0 Affected by qui- nine,, Lock for enlargement of spleen and the in blood* Prognosis: Depends on the age, surroundings and previous con- dition of the patient, 10-30/b in private practice, much higher in hospitals. Packets increases danger. Very high or unusually low temperature is unfavorable, the first as showing the virulence of the disease, she latter because generally seen in infants with feeble vitality,. Treatment: As in- adults, little can be done for the disease* much for the patient. Many of the mild cases need no other treat- ment than careful nursing: i.e .Large, well ventilated room,, prefer- ably one with an open fire; change position frequently, never allow a child to lie for hours on the back. Careful feeding. In severe cases: Early stage, two dangers,- (1) Intensity of the general infection; give alcohol and strychnia. (2)Embarassment of heart and respiration, from inflammation, and congestion of lungs; give Counter-irritation to chest, and heat to extremities. Later stage: Principal danger from exhaustion. For temperature of 105 or over, cold bath for infants or cold pack for older chil- dren ■ For nervous symptoms: cold bath or phenacetine gr,j every 2 hrs, in a child of 6 months. Stimulation: whiskey or brandy 1/2 to 2 ozf. daily for a child of 1 yr. Indications*,- weak., rapid, compressible and irregular pulse. Strychnine sulphate, gra l/500 for a child of 1 year* repeated if necessary every 3 hrs. In protracted cases-* and those with delayed resolution-, change of air the best remedy. Age: any age, but greatest susceptibility in childhood is from the 2nd to 6th years0 Season: Spring months have most cases* Specific organism: Micrococcus lanceolatus (pneumooocous) &9.bar Pneumonia. Patho logy: Lungs affected most frequently in the following order: (1) Left base; (2) right apex; (3) right base; (4) left apex. Four stages in the disease: Congestion* from a few hours to several days; Red Hepatization, 2 days to 2-5 weeks; consolida*-* tion chiefly made up of fibrin, with some leucocytes, red blood c cells, and epithelium. Gray Hepatization, shorter than the red stage. Resolution, begins usually when the temperature falls to normal. Lesions in other organs: (1) Pleurisy« (2) Pericarditis* (5) Acute meningitis (rare)« Sy kip tong * 'I yp i c al c o ur se„ Onset sudden: Vomiting and chill or convulsions, followed by rapid rise in temperature, to 104 or higher. Headache, great prostration* Pain*- in side (lower chest) or may be referred to loin- epigastrium or even right iliac region., suggesting appendi- citis- Pulse full and strong, at first,- 120-130; later may be weak. compressible and irregular* Respirations: 40-50, Gough* Course and termination: Temperature and respiration remain high till 6th or 7th day, then comes the crisis. Temperature drops rapidly and pulse comes down to 90-100, Respirations drop to 25-30. Appetite improves,, and convalescence is rapid* Child may be out of bed in a week; and out of doors in a month from the beginning of the illness. It is another month, however, before recovery is complete* Two thirds the cases follow this course. Variations in type: (1) Prolonged course: the pneumonic process lasts 10. 12. or 15 days; one part of the lung involved after another. A prolonged course is always suggestive of pleurisy0 (2) Cerebral pneumonia ( so-called): Cerebral symptoms predomi- nate. Onset begins with convulsions; may be repeated several $imes in first 24 hrs, Followed by drowsiness and stupor or active deli- rium* May be almost all the symptoms of meningitis: opisthotonus, dilated or contracted pupils, irregular pulse* retracted abdomen* Physical signs: 1st stage: Diminished resonance or slight dul- ness over affected area; resonace over the rest of the lung, and th opposite lung is exaggerated. Auscultation:-Respiratory murmur feeble and high pitched. Crepitant rales present but easy to miss. 2nd stage:- Marked dulness. Vocal fremitus increased. Vocal reso- nance increased; bronchial breathing over the affected area* ■ 3rd stage;- Gradual disappearance of signs of consolidation* Moist rales of all kinds are heard. Sometimes dry friction sounds* Diagnosis: Holt makes the following differential® diagnosis: Broncho -pneumonia a Mora often secondary« Ifoder- Z\ chiefly under 2 yrs. Delicate and debilitated chil- dren mo st f r equently* Bacteria: pneumococcus in pri- mary c SoOS J mixed infect ion in secondary: chiefly streptoe* Onset: often gradual0 Pevar lasts 5-4 weeks., '©r-isis rare„ No typical course. Both lungs usually* Consolidation later* 4-7th day* May be none. Less well defined* Resolution slow* 1 wk,-2 months. Hospital mortality 50-65X. Sequelae: Empyema., chronic inter- stitial pn*, sometimes tuberculosis. Lobar pneumonia* AImo s t a lwa y s p r irnar y „ Most common from 3-8 yrs0 In those previously healthy. Pneumococcus„ Sudden with well marked sympt0 Typical, Crisis from 5th-8th day usually* One lobe or part of one, left base oftenest? rt, apex next* Consolidation 2-3rd day, com- plete; well defined* Rapid, within a wk. usually* Mortality 4,€ of all cases. Empyema only sequela* 52 Note: v-:0n account of its frequency in children, pneumonia should always be excluded before accepting any other explanation of a continuously high tempenature", Differentiate: (1) Scarlet fever: Sore throat and eruption on the 2nd dayc (2) Tonsillitis: the local symptoms, fo) Gastro-enteritis: Temperature and prostration not so high as in pneumonia,, (4) Gerebro-spinal meningitis: temperature usually not so high as in pneurnonaa; pulse slow and intermittent„ Stupor greater0 May be localized paralyses» Steady increase in severity of symptoms for three or four days; in pneumonia the nervous symptoms are usually most marked in first 24-4S hours, (5) Malaria: see broncho-pneumonia diagnosis* Mortality about four percent• Bad signs are : con- vulsions coming late in the disease; a continuous temperature above 105; failure of resolution to begin with the drop of tempera- ture to norma1, Treatment:Keep in bed; plenty of fresh air in room all the time, pood at regular intervals, usually once in four hours* Por the nervous symptoms,- cold bath or pack. Same for hyperpyrexia* Per pain, counter-irritation* If this doesnot help, give morphine* Stimulants: Indications are weak, compressible and rapid pulse, face pa.les and extremities cold* l^eurjis^o Etiology: In almost every case it is secondary to a disease of the lungs; most commonly follows pneumonia, especially in in- fants, May also occur as a complication or sequel of tuberculosis of the lung; the infectious diseases, particularly scarlet and typhoid fevers, measles and influenza. Age: may occur at all ages, even in utero. Varieties: Dry. Serous with effusion. Purulent (Empyema). Dry Pleurisy, Lesions.:Pleura injected dull and roughened, from exudate of fibrin. Some pus cells and connective cells miked in. Exudate gray, grayish-yellow, or yellowish-green in proportion to the num- ber of pus cells. Dry pleurisy usually localized, but the two opposing surfaces are affected. In nearly all cases, some bands of adhesion are left after the disease„ Svnpjtpnis: (As and independent disease, it does not occur in infancy or early childhood. Holt) Pain* sharp, localized, increased by full inspiration; located in affected chest, or may be referred to the abdomen. Short cough* Physical examination:- Pleuritic friction sound; moist and crack- ling* on both inspiration and expiration; superficial and not changed by coughing as are the rales of a bronchitis. Course of the disease a few days to a week, without constitu- tional symptoms, as a rule. Treatjyejit: Counter-irritation by mustard plaster, tincture of iodine; morphine if the pain is too severe to be controlled by external measures* Limit the movement of the affected side by strapping with adhesive plaster,. Pleurisy with serous effusion* Not common in children, and very rare under 3 yearsa May be a complication of pneumonia, nephritis, acute rheumatism* or the infectious diseases0 Same as in dry pleurisy with addition of an exudate, serous or serc-fibrinous* Adhesions usually left behind to some extent„ • If the effusion be small there may be no symptoms0 If larger, acute febrile symptoms and pain at the beginning follow ed by shortness of breath, cyanosis (if the increase in fluid is rapid), weak pulse; general weakness and some anaemia are usually seen, heath may occur in syncope from embarassment of heart action. Exudate may be absorbed spontaneously or remain for months,, with slight fever, pallor and weakness. £hE^iLQaX_g_igns: Diminished movement of affected side. Apex beat displaced if effusion is large and on left side. Marked dullness or flatness on percussion, over lower part of chest, with hyper- resonance over upper part if effusion be small; over whole lung in large effusion. Line of flatness may change with position. Auscultation: Note carefully,- Bronchial voice and breathing often heard over affected area, instead of diminished voice and respira- tion as in adults. Displacement of heart.- flatness, absence of rales or friction sounds, and (usually distant; bronchial breathing. - Higher temperature, greater prostration* general symptoms more severe. Physical signs. £XP-SJiOs_ls.: For life, good. Remember that tuberculosis often develops later, and be watch for it where onset of pleurisy is insidious* IxeMiaeal: (1) Mild cases, i.e* with small exudate. Treatment symptomatic. Keep in bed. Relieve pain:- counter-irritation, - poultices, or in severe pain,, morphine. After fever has gone, patient may sit up, but avoid all sudden or undue exertion; many a death has been caused by neglecting this. In convalescence, keep patient in open air as much as possible* Tonic treatment0 Counter-irritation and diuretics sometimes hasten absorption of fluid* (2) Cases with large effusion:- Fluid should be removed by aspiration* Indications for aspiration:-Rapid accumulation of fluid during the acute .stage,, When there is no tendency to absorp- tion after two or three weeks of constitutional treatment* pany pneumonia* * May cpmlicate any of the infectious diseases: occurs with pyemia from any cause, appendicitis or other suppura- tion in the abdomen* osteomyelitis* necrosis of a rib. etc. Bac t or- ia: - Pn sumo coco us mo s t c omaicn „ Bt rep to o o a crus p yog one s & staph- ylococcus and sometimes the tubercle bacillus are found. EtlplQffy:9/10 cases in children under five yrs* follow or aocom- Pus collects at first in small pockets formed by adhesions; these break down a (4) Swellings and ecchymoses about joints. Symptoms: - (13 Hyperaesthesia bout knees and legs; pain ino-reasA Infantile Scorbutus (Scurvy)« 57 by motion and pres sure 0 (2) Disability or disinclination to move legs: due to pain or epiphyseal separation* (3) Swelling and eo* chymeses about knees and ankles *40Bleeding gums (hemorrhagi© gin- givitis) . $) Hemorrhages from mouthy nose, stomach, ’bowels, and- sometimes from kidneys0 (6) Cachexia and anaemia. (7) History of bad feeding5~ proprietary foodse (8) Symptoms at once improved by antiscorbutic foods0 • Variations in type, L0 Severe type with all above symptoms * 20 Mild type,, without swellings or mouth symptoms, i0e0 with ecchymoses about joint; pain,tenderness, and disability,, Diagnosis: The symptoms; especially improvement on antiscorbu- tic diet, Distinguish rheumatism. Paralysis, Rickets (no pain or stomati11 s) ? Ostitis,, Purpuraa Prognosis: Good if case is recognized early0 Complete recovery usual under proper diet in 2-3 weeks. Treatment! Stop all proprietary foods and condensed milk® Give fresh cows milk, beef juice,, orange juice, (potato if child is over 1 yr0)s Por the tenderness:*- keep child absolutiey quietj Per cachexia*:- protect from exposure and cold* Anaemia requires mild Pe preparations, the oxide or carbonate« The essential thing is change in the diet0 infantile Atrophy (Marasmus)» La Poor food* 2<, Poor surroundings:- large cities,- tenements; infant institutions (over-crowding and consequent lack of fresh air) a Summer3* Heredity*- e,g* illegitimate children of young girls of 16~18n Pathology: Nothing definite0 Hay have a large lively- fatty . degenerationc May be of heart*brain, kidneys and spleen* Symptoms: 10 Progressive lo-ss of weight; abdomen prominent while legs are like drum-sticks 0 20- Anaemia; heart murmurs often* 3* Subnormal (or normal) temperaturee 40 Stools:- often contain undigested food* 5* Vomiting,- easily induced* 6a General oede- ma (ocasionally)9 a bad signQ Complications: Thrush, erythema of buttocks, bed-sores, occa® sionally opisthotonus. Course of the disease: steadily downward* 'Diagnosis: Hard to differentiate tbc Signs of consolidation in lungs in front means tb* Dulness behind may be due to tb* or to the hypostatic congestion present in marasmus* Tuberculoma children are usually delicate from birth; in marasmus there is -often a history of good health till after weaning* Frognosis; Age:- Under 4 months very bad, especially if in an institution infant* Over 8 months, better; improved with possib11 i- ty of good nursing, fresh air, etc* Weight: - If under 40/£ normal • weight*, prognosis is very bad* Treatment: Prophylaxis most important0 good food and plenty of fresh air; pure cow;s milk properly fed; wet-nurses for babies under 4 months; or modified milk with low fat and proteids and rel- a lively high sugar,v Keep warm* Sponge baths, not tub„ Por very 58 young infanta with temperature habitually subnormaly the incubator should be used; or rub with oilg roll in and surround with hot water bags or bottles® Etiologjr: Plasmodium malarias* • Three varieties3 Mode of en- trance unknown. 10 Disc shaped hyaline bodies* occupying a small part of the corpuscle? at one side* 2* Increase in size to almost full corpuscleo Produce reddish brown pigment s - from the Hb0 of the corpuscle* Amoeboid movements. Pigment at first at edge of corpuscle-* but inside organism* Pigment then has oscillatory movement So Toward segmentation, pigment gathers toward the centre* Segmentation:- synchronous with paroxysm; segments vary in number with the species„• Segments are set free and enter other corpuscles as hyal ins bodies,, Thrtra- .cellular .form* About the size of a red cell; contain pigment: not confined in a corpusc1e; changes;~ become flagel- late,- - flagella, are cast off and move about, in blood; may help reinfection„ Tertian form: Mature in 48 hrs* Pigment granules smaller, finer, red-brown, more-numerous * Segment s number 12-20 * Quartan form;- Not so common* Mature in 64—72 hrs* Pigment coarser, redder, few in numbext Segments more symmetrical, pearw shaped; number of segments 6-12,, Aest iyo-autumnal tjypje: Not much known about it „ Matures in 24.-48 hrs * Smaller, highly refractive* Corpuscles containing* it often smaller and distorted-. Pigment granules few and coarse* Cre- scentic form a later development, - after a week or more in untreat- ed eases; larger than a red. corpuscle which seems to be in the concavity of the organism. Pigment in the crescentic form* Double infection possible in malaria, sc that 2 tertians give daily paroxysms; or there may be a triple infection of the quartan. In examining for plasmodia take fresh blood* rSymptom% of malaria: Regular type;. A, In older children;- May be like adult type, beginning with chill,, sudden high tempera- ture,, headache., and prostration; symptoms last several hours;, then they suddenly cease, and patient feels well* After the disease has lasted several days, they don't feel quite so well in the in- terval., Attack may begin with vomiting* In all cases there is pallor and hyperplasia of spleen; but spleen may not be palpable on account of tense abdomen, usually it, is felt in 2-5 days* Attacks may occur at night., causing the disease to be unsuspec- ted; the day temperature shows no elevation: but patient gets paler- weak, sick and miserable during day; spleen enlarges,« look for it *- Bu In babies: The younger the infant the more prominent the cerebral symptoms,. Attacks may begin gradually with malaise* fussiness, indigestion* and not much temperature* Symptoms may last 3-4 days* If disease is untreated and child remains in a malarial neighborhood, paroxysms occur consisting of: Cold extremities and cyanosis: Prostration; Stupor (child hard to rouse); Convulsions, not rarely; Temperature may nbt be high* These cases are likely to deceive you* Spleen enlarged* but not always palpable* 59 After a week or ten days the baby looks sick; attacks may occur every dayc Note carefully:- At some time of day the child is worse than at other times; this is the only evidence of periodicity0 iiTi’PJIlllar type: No clinical diagnosis beyond a certain periods icity in symptoms0 Nervous symptoms: Dizziness, syncope, neural- gias, headache; apparent asthmatic attacks; diarrhoea,- not yield- ing to food, cathartics or anything else0 These symptoms do not all appear in same pat lent * Diagnosis, of malaria (in general): L0 Thlnlr of, it,: rule it out if you can* 2» Blood examinat ion0 History,- other cases in family or neighborhood, 4, Periodicity of symptoms * 50 Enlargement of spleen; may be due in childhood to anaemia0 6, Effects of quinine„ 70 Leucocytes likely to be diminished in number0 Prognosis: Good, if discovered; - in most casesP * 1. Removal from place where infection took place, 20 -Quinine,~ Children with malaria take relatively large doses, eogo at one year or less, graj-ij t0iode Bisulphate more soluble than sulphateo Give by mouth as tablet triturate or chocolate lozenges; or as a suppository,- give more in this case, 3„ Give Arsenic in the rare cases where quinine doesn’t work* 40 After treatment:- Tonics, Ee„; fresh air; nutritious and easily digested food„ Rheumat ismQ Etiology: Probably infectious origin, but bacteria unknown0 Predisposing causes: Age:- Rare under 5 yrs. as acute articular form. Heredity:- important; family history in 2/3 cases (Holt)* Surroundings;- Damp dwellings; exposure to cold and wet. Insuffi- cient food,-. Season: Spring months most frequently,, JSypjptj^s; Onset; Not very acute. Temperature slightly raised, 100-101,5, Swelling and pain moderate0 Often no redness0 Number of joints involved small. Duration, 1-3 weeks* Joints;- stiff- ness; pain and soreness of muscles and tendons; Muscular spasm0 - CornpXications,; 1, Cardiac;- Endocarditis in majority of cases0 There may be no arthritis, i.e, endocarditis only sign of rheuma- tisnu High fever, and constitutional symptoms. Pericarditis less frequent0 Occurs most commonly in children -over 70 Dry and fibrous; tends to obliteration of pericardial sac0 2* Torticollis; Sudden in development; continuous spasm, muscular soreness; moderate pain; usually disappears spontaneously in a few days a 30 Chorea: May be first symptom of rheumatic diathesis., 40 Tonsillitis; Often ushers in an attack of rheumatic arthritis or endocarditis; -especiallyUquinsy2 Other symptoms* Holt lays considerable stress on the occurrence of subcutaneous tendinous nodules; like boiled sago grains; these are Xigf.jgxiHxkkxsxjsja'KHfexisx rare in this country, Di.agno.sis:- 1. Eamily history, 2. Previous history, 3. Physical examination: Heart, Temperature, tenderness in muscles or tender- ness and swelling over joints; tendinous nodules, when present0 riff©rentlate: Tuberculosis of bones: (1) Single joint affected* (2) Sloner onsetc Scurvy:- Mostly in infants* Confined to legs (usually)* No fevera Prognosiss Danger of heart comp lieationsu Recurrence frequent0 .TreatAc Prophylaxis: 1, Diet: Should be nitrogenous; milk freely* 2ft Planned underclothinga 36 Avoid exposure to dampness and cold; therefore a warm climate best; choose an indoor occu- pation for a boy with rheumatic tendency., The attack: Confine to the house in a warm room. If any fever* keep in bedc Drugs: Sodium salicylate, or other salicylates; Potassium acetate or citrqte in all cases0 General tonics impor- tant* iron and cod-liver oil. Give bettween the attacks0 t 3,895o lr An .irfnnt four weeks old b&e diarrhoea and vcmit*- ing# depending on an abnormal condition of the breast • milk0 Wkat would you expect chemical analyst of the mi,.71; to show? 20 In what waay can breast milk be modified? 3o Write prescription for modified miJ.k for a healthy infant9 five days old* two months old* six months old.. 4a When should you wean ?m infant? What are some of the indi~ cat ion>j and c ont ra indic at ;Lons ? 50 State proper diet and number of feedings in 24 hrsa tmy infant 14 months old? 6* 'Describe the efflorescence and its distri- bution in scarlet fever., measles, and varicella© 7« What are the most common compile at ions of scarlet fever and measles4? 8a How often during the first two madteksrxscgxyJs»x±±€s weeks of its life would you feed an infant prematura at the 7th month? 9nState the causes of dactylitis., 10* Give some of the causes of infan- til, e co nvulbions« A&L*?: Diagnosis* prognosis and treatment In fallowing c$se:— Boy, 6 yr«t, old* xjreviously healthy* had attack of measles Nov., 15., 18953 Attack was follower by a broncho~p neumonia * which kept him in bed till! Janv:, 15, On Feb . 1, had still a slight cough was moderately omac:Lateds showed considerable muscular weakness, pulse 90 v temperature 98, respirations 240 Harsh respiration and a few moist rales found in limited areas corresponding to parts of lower lobes cf lungs behind Had been decidedly constipated fox* 2 weeksc Psb0 2, suddenly attacked at 7 a.,ma with abdominal pain, cheifly located on left side; he vomited 2 om 3 times.. Pain soon followed by frequent discharges from the bowels, at first faecal in character: but- they were soon found to consist only of blood and mucus4 When seen at 10 a,mc pulse was 60, temperature 99* and respirations 30, Abdomen slightly distended and tympan.ltio, ex- cepting ever an area about 3 inches in diameter, where there was dulnesEo Dulnsss situated u little to left cf median line,, and on a level with umbilicus. Resonance between this dull area ana lower border of ribs,-. Palpation over area of dul.noss showed slight ten- derness and an ill-defined tumor., Deep rectal examination negative,, 2* Diagnosis and treatment of infantile scorbutus? 3o How would you treat an infant prematurely born at 7th month? 40 Diagnosis and treatment of congenital heart-diseasec 50 Diagnosis of congenital syphilis in first 2 months of life? Bo Differential diagnosis between thrush* stomatitis herpetica (aphthosa)and stoma tills ulcerosa,. 2JJ97* 1o Differential diagnosis, prognosis and treatment of following case:-- Boy 8 yrsw old, has been ill 5-6 days* Symptoms have been headaches languor,, some elevation of temperature, and a tendency to drowsiness r. There are five other children in family, one of whom has caries of spine * A mis tor of patient died at 3 yrsQ of tubercular meningitis*. The boy has* never been very strong, but no his troy of d is vase in past 5 yys, except suppurating gland on right side cl‘ neck.- removed 6 months previously. Phys* exam: —' p0y rother undeveloped* Pace flushed; mind clear0 No efflorescence* roderate enlargement of cervical glands on both sides and a cica- trix on right side of neck below ear* Lungs and heart showed noth** inn abnormal. Splenic dulness began at 9th rib in left axillary n hie, and dulness of liver at Gth rib in rught mammary line* Abdo« Fien not distended or tender f. Abdominal muscles tense, and palp a- • 15on unsatisfactory. Temperature in moutj 104 P0 Pulse 120, respi- rations 30» Urine acid*, sp« gr» 1022; no albumin* luring next week marked increase in severity of disease. Stupor developed; boy could only be roused when handled; at these times he was* very irritable. Pupils moderately dilated and reacted slow- ly to light* Tongue dry, and heavily coated, lips covered with bloody crusts; some tremor of handsc At time delirious* Lungs showed nothing abnormal: but soft systolic murmur heard over pre- cordial area. Abdomen not distended or tender.. Abdominal muscles remained tense and palpation was unsatisfactory* Bowels constipated No efflorescence. Temperature varied from -103,5.-105; pulse 120-130, respirations 30-35= Emaciation noticeable,. Urine diminished in amt, and passes involuntarily; contained 1/ 8g> of albumin, a few- hyaline casts, and desquamated renal cellsc 2, Symptoms* prognosis, and treatment of Acute Poliomyelitis Anterior of early life, 3* Symptoms, prognosis and treatment of Cerebral paralysis of early life, 4C Biffenentia3. diagnosis of Lobar Pneumonia* 50 Symptoms and prognosis of Congenital Cardiac disease, and its differential diagnosis from the acquired form* 6, Etiology, symptoms and prognosis of Rhachitis* 189.8* 1. Discuss following case as to diagnosis, prognosis* and treatment: — Eoy, 7 yrs« old* was exposed to a contagious disease* Pour days later seized with nausea, vomiting and sore threat* Throat much reddened; temperature 104j pulse 120; respira- tions natural, 36 hrs„ later, punctate erythema appeared on neck and chest. Urine at this time somewhat decreased in amt.,* darker than normal, contained si* trace of albumin; showed nothing else abnormal * In following week temp* gradually fell by lysis to normal; urine by end of week normal except now increased in amt0 In following week lamellar desquamation* A week later, ixd temp, began to rise; he then had dyspnoea, puffiness of eyelids and oedema of feet and anklese Exam, of chest showed nothing abnormal except a few fine moist rales at base of both lungs behind. Urine now decidedly de- creased in amt *, darker than N*, Sp„ Grs 1020, ale. 4/l0/h, consid- erable blood* Later a3.1 symptoms increased in severity* { There were also numerous casts in urine, some with blood and 0pi.theJ.1um adherent)* Dyspnoea became orMiopnoea; oedema spread to face armsj legs and abdomen; some cyanosis, extensive ascites ann. fine mo i s t r a 1 e s thro ugh all parts of b o t h lung s, but r e s o n an. < • e c n percussion. Area of heart dulness under lower 2/3 of sternum, and 1 in* to left of left mammary line as low as 6th interspace. Loud systolic murmur over region of cardiac impulse transmitted to every part of thorax. Za Give ruler, for care of premature infants, of Vrite a prescript ion for feeding v/ith modified milk, and in- fant cf average weighty 4 months old, 4. Describe a case of hereditary syphilis in the first four weeks of life, 5* Causes and treatment of convulsions in infancy? 60 Diagnosis, symptoms, prognosis nad treatment of Scorbutus in infancy. 1199: Differential diagnosis and prognosis of following case:-- Girl, 9 yrs. old, has had tuberculosis of right hip-joint for 3 yrs. For past IS months there have been several sinuses con- necting with tuberculous bone, which discharge pus. Operation a year ago only partly successful; recently surgical condition worse* Present condition: Emaciated and pale; respirations rapid and rather labored. Slight if any cyanosis; position semi-recumbent, in order to breathe more comfortably. No oedema. Abdomen distended. Tension and volume of radial pulse somewhat increased. Abnormally strong cardiac impulse felt in Gth interspace 2 cm, outside left mammary line; impulse abnormally strong throughout entire prefer- dial region, and can be felt in epigastrium. Cardiac area of abso- lut dulness extends from the 2nd left interspace downwards to 6th interspace 2 cm. outside mammary line, and obliquely downwards to the right under the lower 2/3 of sternum, and to within lea, of rte border of sternum. There is a systolic murmur heard all over precordial area, most marked at apex, and transmitted to axilla and back. 2nd pulmonic sound acccntuat-ed. Lungs, with exception of si. roughened breathing, are normal. Spleen palpable about 2 in,, below edge of ribs in left axillary line, and percussion shows it to be enlarged upwards. Edge of liver palpable about. 3 in., belc border of ribs in right mammary line. Surface of liver is smooth* Percussion of abdomen shows dulness below level of umbilicus and extending across entire abdomen. There is a distinct wave of flu.>< tnation. Veins on surface of abdomen somewhat distended. Repeat- ed examinations of urine have failed to detect any albumin, or any evidence of disease of the kidneys. During a period of six weeks the pulse has varied from 130-160? respirations 40-60; temperature 100-103 F. General condition during this time has been critical*. 2. State; (1) Number of t eeth in first dentition, giving avarage time and order of their appearance. (2) At what age should anter- ior fontanelle close? (3) Average capacity cf the stomach at birth. 5* Symptoms and differential diagnosis of- (1} acute fibrinous pericarditis; (2) pericarditis with effusion.. 4* 'Symptoms, prognosis, and treatment of phrenic duodenal indi- gestion in a child 4- yrs. old. 5,, Diff. diagnosis between a case of diphtheria and one of scar- let fever with marked lesions in the throat, before any efflores- cence or glandular enlargement have appeared. 6* Symptoms, prognosis and treatment of erysipelas of the new born.