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DIAGRAM OF FCETAL CIRCULATION.
W. Preyer del. 
?QUIZ-COMPENDS? No. 14.
COMPEN D
DISEASES  OF  CHILDREN.
ESPECIALLY ADAPTED FOR THE USE OF
       MEDICAL STUDENTS.
     MARCUS P. HATFIELD. A.M., M.D.,

PROFESSOR OF DISEASES OF CHILDREN, N. W. U. MEDICAL SCHOOL, PHYSICIAN TO
     WESLEY HOSPITAL, HOME FOR CRIPPLED CHILDREN, CHICAGO
            ORPHAN ASYLUM, ETC., ETC.
  SECOND EDITION, THOROUGHLY REVISED.

      WITH A COLORE^kt?,Hr:U[:S 0Ffr,CE

              |     NOV. -2Z--1901
         PHILADELPHIA :  ) ^ ($*]!) \<S>
P. BLAKISTO IC~S..ON-&-C-©,,-
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             1896.
1 
lfVrvr\€.ls
Copyright,  1895, by  P.  Blakistov, Son  & Co.
Press of Wm. F. Fell & Co.,
  1220-24 Sansom St.,
      philadelphia. 
                   TO





  PROFESSOR  EDWARD  HENOCH,



                  OF THE




           UNIVERSITY OF  BERLIN,






MY  BEST  AND MOST ENTHUSIASTIC TEACHER IN





                PEDIATRICS,





    THIS LITTLE COMPEND  IS GRATEFULLY





               DEDICATED BY





            ITS COMPILER. 
 
PREFACE  TO  SECOND  EDITION.
  This little book is founded upon Dr. Ernst Kormann's excellent
" Compendium der Kinderkrankheiten," translated many years
ago with the cooperation of Dr.  E. J. Doering, while  fellow stu-
dents at the University of Berlin.  This joint  translation in time
became the basis of an annual course of lectures delivered at the
Chicago Medical College, and these  lectures recondensed have
furnished the material for this Compend.  At this date  it would be
difficult, if not impossible, to state exactly how  much credit should
revert to Henoch,  Kormann, Bouchut,  Baginsky, Steiner  and
others, all of whom were drawn upon freely  in the preparation
of these  lectures, and in  a work of this  character, individual
acknowledgment has not been attempted except in case of direct
quotation.
  Unstinted assistance has been freely given by Dr. R.  Engleman,
and Dr. Eva McClanahan,  without whose aid the preparation of
this work would  have been  impossible, with  the other demands
of a professional life.
                                             M. P.  H.
vii 
TABLE  OF   CONTENTS.
                                                 PAGE
Section    I.—Anatomy and Physiology,.......    9
Section    II.—Physiological and Traumatic Accidents
               of Birth...............   16
Section   III.—Malformations  and Diseases of the
               Navel................   39
Section   IV.—Care of Newborn, and Diseases from
               Malnutrition,............   44
Section    V.—Acute Infectious Diseases,......   77
Section   VI.—Endemic Infectious Diseases, .....  108
Section  VII.—Diseases of the Nervous System, ...  115
     Brain and Membranes, Spinal Cord and Membranes,
      Neuroses of Motility.
             The Organs of Special Sense.—Smell—
               Hearing—Sight—Defects and Diseases of,  141
Section  VIII.—Diseases of the Respiratory System, .  143
Section   IX.—Diseases of the Digestive Apparatus, .  175
     Mouth and  Pharynx, Alimentary Canal,  Liver and
      Peritoneum.
Index,........................217 
                   A  COMPEND

                          OF THE


DISEASES   OF   CHILDREN.




                     SECTION  I.

          ANATOMY AND PHYSIOLOGY.
  i.  The Circulation of blood in the fetus is as follows : From
the placenta, through the umbilical vein,  which enters the body at
the umbilical ring and passes to the under side of the liver.  Here
the current divides, a part going through the ductus venosus (see
plate opposite) directly into the inferior vena cava (vena cava ascen-
dens) ;  the remainder enters the portal vein and, as in the circula-
tion of adult life, passes through the liver, before entering the vena
cava ascendens, and through it to the  right auricle.  Here the
currents of the descending and ascending vense  cavae join, but do
not coalesce, being separated by the Eustachian valve; conse-
quently the bulk of the blood which enters the right auricle through
the inferior vena cava does  not  follow  the course of the adult
circulation, but  flows directly into the  left auricle, through the
foramen ovale, and thence into the left ventricle and aorta, as in
the adult. The course  of the current entering the right auricle
from the  superior  vena  cava (descendens) is quite different, for
this blood, in the main, passes through the tricuspid valve into the
right ventricle, and thence into the pulmonary artery,  as in the
adult;  but, unlike the adult, the bulk of  this blood never reaches
     \                      9 
10
diseases of children.
the lungs, but passes directly into the aorta by the ductus arterio-
sus (Botalli), which passes from the pulmonary artery to the aorta,
entering below the origin of the great vessels.   A small portion of
blood flows past the ductus arteriosus into the lungs, via the pul-
monary arteries, just sufficient for the growth  and nourishment of
the lungs, then passes through them, and, as in  the adult, enters
the left auricle,  where it is mingled with the blood entering the
same cavity, via the foramen ovale, as described above, and fol-
lows subsequently the course of the adult circulation, until it at
last enters the umbilical arteries, which are given off by the hypo-
gastric arteries,  and which convey venous blood directly from the
fetus to the placenta.
  2. The changes in the fetal circulation which occur at birth
are as follows :—
  (a) Disuse of  the ductus  arteriosus, owing to the  expansion of
the lungs  bending  and thus obstructing  this duct and relieving
aortic  pressure,  with coincident closure of  the foramen ovale.
Neither the  foramen ovale nor the ductus arteriosus become com-
pletely impervious immediately after birth, for the first may remain
open for a month,  and the ductus often is not entirely closed until
the third month.
  {b) Obliteration of the arteria umbilicales, in which, immediately
after the detachment  of the placenta, thrombi  form, owing to the
lessening of arterial  pressure.  The umbilical arteries thus oc-
cluded  are  later transformed into the lateral ligaments  of the
bladder.
  (c) Thrombosis   of  the  umbilical vein  similarly follows the
detachment of the  placenta.  This thrombosis extends past the
umbilical ring to the bifurcation  of the umbilical vein  at  the  end
of the transverse fissure of the liver, and fills the ductus venosus
(Arantii) with a clot which eventually converts it into the ligamen-
tum teres of the liver.
  3. Pulse at birth 130-150 per minute, irregular and  very easily
disturbed by slight causes ; at end of first year, 100-120;  second
year, 100;  fifth year about 90.  Pulmonary blood pressure in the
child is greater than in the adult.
  4.  Respiration varies with age  and is easily disturbed; at
birth, 40 per minute ; from two months to two years, 25-35 '<  from 
anatomy and physiology.
11
two to twelve years, 18 when  sleeping and about 24 when awake.
A well child ought to breathe through its nose, keeping its lips closed.
Pulmonary excretion of carbon dioxid in the child is nearly double
that of the adult in comparison with the body weight.
  5.  The Stomach of the newborn  child is almost without a fun-
dus and lies nearly vertical.   At birth it holds less than 2 ozs. (40-
50 c.c), and serves, according to Traube, mainly as a place for the
coagulation of the milk, which passes through the pylorus other-
wise little changed.  Vaughan's experiments  seem to show that
the digestion of milk in the infant is accomplished almost entirely
in the small intestine by the  aid of the pancreatic fluids, whose
activity is well  developed in the newborn.  The proper  nourish-
ment of the  young  child  calls for relatively more  albuminoids
and  fats  than  the adult and  less carbohydrates.   See feeding,
where a fuller  discussion  of the  action of the digestive ferments
may be found.
  6.  The Feces, with an exclusively milk diet, should have a bright
mustard-yellow color, are  of  the  consistence of ointment,  feebly
acid,  and contain about  85 per cent, of water, white flecks of fat,
calcic lactates, traces  of bilirubin, intestinal epithelial cells, and
mucous bacteria.  These bacteria have not yet been fully studied
and differentiated, but the bacterium  lactis aerogenes,  and various
micrococci, seem to be fairly constant.   100 parts milk diet should
produce about  three parts of feces on an average.
  7. Meconium is the name giventhe dark-green feces first passed
by the newborn child, from their resemblance to inspissated poppy
juice.  Meconium is  viscid, odorless, feebly acid, and consists of
partially  digested  amniotic  fluid,  epidermal  cells,  fine  hairs,
cholesterin crystals, and  intestinal epithelial cells, but  contains  no
products of decomposition  nor bacteria when first voided.
  8.  Urine is secreted in utero, and is voided both before and often
during the act  of birth.  The kidneys are relatively large at birth,
and often show a peculiar  reddish discoloration of their papillae,
produced by a  deposit of uric acid crystals and urates, especially
well marked in those children whose  supply of oxygen has been
deficient at birth.  This is  the so-called uric acid infarct, and is of
little  pathological significance.  The quantity of urine  increases
rapidly for the first  five days, after that more slowly.  At first 
12                 diseases of children.
it averages from 12-13 ozs- (4f7 c-c0 >  after two years ll reaches
15 ozs. (500 c.c), rising to 18-19 ozs. (600 c.c) at four years.  The
specific gravity  of the urine increases up to the tenth day, after
that it  slightly diminishes.   Average specific gravity, 1005-1010.
The urine of early life is often turbid, dark, and acid ; later it be-
comes  clear straw yellow and generally neutral in  reaction.  The
excretion  of urea is relatively less in children than in adults, and
still less relatively are the phosphates.   The same is true of chlorid
of sodium.
  9.  Temperature at birth is 990 F. (37.70 C), falling in a  few
hours a degree  or  more Centigrade (377°-36.20), but  rising again
within  thirty-six  hours to about its initial height.   The tempera-
ture in a young child is best taken in the anus or vagina ; and it
should be remembered that comparatively trifling causes in  infants
may produce relatively great variations in temperature, especially
through depressing agents.   In  general, the temperature rises dur-
ing the forenoon, reaches its highest point in the afternoon,  begins
to sink about six, and reaches its minimum in  the early morning
hours,  shortly after midnight.   It should also be remembered that
in very young children the temperature may mark  high (105-1060)
without necessarily grave results, except in those  predisposed to
eclampsia.
  Aphorism I.—Lowered temperature is  found in anemia, pro-
fuse hemorrhage, collapse, death agony, and sclerema neonatorum,
hydrocephaloid, and in children prematurely born.   In early
infancy there is no absolute relation between organic lesions  and
the height of temperature observed, for high fever, great restless-
ness, and even convulsions may disappear quickly, and leave
absolutely no lesions behind.   (Bouchut.)
  Aphorism II.—A  temperature above  ioo° (37.8-380 C.)  during
the first four days of life  is pathological.  The same is true of rise
of temperature during sleep.
  Aphorism HI.—The morning and evening differences in tem-
perature in the fevers of children  are, as a rule,  greater than in
the adult.
  Aphoris?n IV.—High febrile heat with sudden  chilling of the
extremities is one of the frequent phenomena of fever in very
young children. 
anatomy and  physiology.
13
   10. The Skin of a newborn child is more or less covered with
 a smeary, white substance  (Vernix  caseosa), readily  soluble in
 lard or vaselin, before the first bath, after which  the  surface of
 the child's body, if healthy, appears reddened, delicate  in texture,
 and covered with fine hairs.   During the first week of life a quite
 extensive exfoliation of the epidermis takes place.  The hair with
 which the head  of the child was  covered at  birth gradually falls
 out and is succeeded by an after growth.
   u. The  Sudoriferous  Glands secrete  but little  during the
 first weeks of life.  The mammary glands of the newborn are not
 infrequently found in a state of congestion and  enlargement in
 both sexes,  often sufficient to produce in them a few drops of a
 milky secretion (" Hexenmilch," see Mastitis).
   12. Dentition commences usually at the  seventh month, but
 it may be deferred  till the twelfth to the eighteenth month, even
 to the second year, especially in  rickets.   When a child is born
 with  teeth,  they usually  fall  out early.   The  temporary teeth
 (twenty in  number)  are  generally cut in  pairs.   The following
 table indicates, in  months,  the usual time of their appearance,
 above and below, thus :—

   Molars.      Canine.      Incisors.       Canine.      Molars.
   24-12         18        9-7-7-9         18        12-24

  The lower teeth usually are a little in advance of the upper. The
permanent (thirty-two in number) appear in years as follows:—

                      permanent teeth.
     23-13-6 (Molars)                      (Molars) 6-13-23
     Bicuspids.    Canine.    Incisors.    Canine.    Bicuspids.
       10-9         II       8-7-7-8       II        9-10

  13. Saliva.—The earliest saliva secreted by the infant is small
in quantity and deficient in ptyaline, the  starch-converting  power
of the infant up to the sixth or seventh month residing in the pan-
creatic diastase.  After the sixth  month the  infant's saliva has
properties similar to that of the adult, although not fully developed
until after dentition. 
i4
diseases of children.
  14. The Lacrymal Glands secrete  very  sparingly  during
the first few weeks of life ; the sebaceous glands often continue
their interuterine activity, especially those of the hairy scalp.  (See
Seborrheal)
  15. The Thymus Gland at birth  lies immediately posterior
to the manubrium in the anterior mediastinum,  and consists of a
long, flattened, lobulated body, to which are laterally attached two
unequal lobes, which closely resemble in structure the salivary
glands, but are subject to  extraordinary variations in size.   Its
uses are unknown, and it  normally diminishes in size from the
second year to puberty, when it should have disappeared. Morpho-
logically it consists of a long tube  to which the primary nodules
are attached, like knots on a rope.  Each lobule contains a cavity
communicating with a larger central cavity—the  reservoir of the
thymus—which contains a whitish fluid in which  float numerous
corpuscles similar to those found in the chyle.
  16. The Growth of the Child.—The average length of the
newborn child is 18 inches (50 cm. for boys and 49 cm. for girls),
and its  weight about one-thirtieth that of its adult weight (3300
grams).
  The increase in the length of the child's skeleton  is most rapid
during the earlier months of its life, decreasing with  each year up
to the fifth in  about the following ratio : first year, 16-20 cm. (5-7
inches);  second  year,  10 cm.; third year, 7.5  cm.; fourth year,
6.5  cm., and during the fifth year to the sixteenth or eighteenth
year there is a yearly increase of 5  cm. (1%. inches); after 18 this
growth decreases  to 3-4 cm. per annum until the full growth is
attained, between the twentieth and twenty-fourth  years.
  Growth is retarded by poor nourishment, impure air, and certain
diseases  of nutrition, such  as scrofula,  etc.  On the other hand,
certain exanthemata and other as  yet unknown conditions have
the  power at times of greatly accelerating growth, but such rapidly
growing children are apt to become feeble and  require especially
good food, much rest, and relief from their studies.
  The smaller Pontanelle closes immediately  after birth, but
the  anterior fontanelle remains normally open until  the middle or
the  end of the second year.  According to Elsasser the width of 
ANATOMY AND  PHYSIOLOGY.
15
the great fontanelle increases up to the ninth month of infancy, for
the reason that  the edges of the fontanelle can only increase in
like measure with the sutures forming the fontanelle, for otherwise
the borders of the fontanelle must grow more rapidly than the
sutures  and cranium in general.  The sutures  begin to coalesce
about the ninth month and after that the fontanelle lessens in size.
The reason of the late coalescence of the sutures is the enormous
development of the brain during the first months of life.  The
tension observed in the still open fontanelle often affords valuable
aid in diagnosis, e. g.:—
  Aphorism V.—Protuberance of the fontanelle  indicates hypere-
mia of the  brain, or exudation into the same, most marked, in
hydrocephalus.  Depression of  the fontanelle  implies cerebral
anemia, and is found in hydrocephaloid, general  atrophy, or the
collapse of cholera morbus and Asiatic cholera.
  Growth of the Head.—The average circumference of the
head at birth  is 13 inches (34 cm.), its long diameter 11.2.  The
increase in  the long diameter up to the third year is 4.5 cm., dur-
ing the next four  years 2.3 cm.  more, the full development of
the cranium being about completed by the end  of the seventh
year.
  17. Weight.—The weight of the fully developed child at birth
is about 3500 grams for boys, and 3200 for girls.  During the first
three or four days  there  is a loss  of about 200 grams (average
222, or 6.5 per cent,  to 6.9 per cent.), which  is regained by the
twelfth day, and usually trebled  during the first year.  Hahner's
observations show that the increase in a child's weight is not regu-
lar,  but irregular, though the  most  rapid gain  takes place, as a
rule, in the second month of life, though it may occur in the fourth.
According to  Russow, there is a marked difference in the growth
of children  who are nursed by  their mothers and those who are
bottle-fed, for  the children of the first double their weight in five
months and treble  it within twelve, while  children who are arti-
ficially fed  require two years to produce  a similar  increase in
weight.  The  advantages gained by children  that are nursed are
apparent as late as the eighth year, when, according to Russow,
children who have been  nursed  at  the  breast still show on  an
average a  gain  of  2000 grams over those artificially fed.  The 
16
DISEASES OF CHILDREN.
following table taken from Uffelman shows the relative increase n
weight for boys and girls, for each from i to 15 years:—

    Weight at birth,  .
    End of first year, .
    End of second year,
    End of third year,
    End of fourth year,
    End of fifth year, .
    End of sixth year,
    End of seventh year,
   . End of eighth year,
    End of ninth year,
    End of tenth year,
    End of eleventh year,
    End of twelfth year,
    End of thirteenth year
    End of fourteenth year,
    End of fifteenth year,  .

  Nervous  System.—Uffelman well describes the newborn
child  as  a reflex automaton  (Riickenmarkindividuum), for it
requires weeks and months to develop its higher nervous organism,
during which  period  its nervous system is in an easily disturbed
condition. Hence its uncertain equilibrium as shown in thetwitch-
ings of fever, the frequent chorea, and convulsions of childhood.
Grams.	Grams.		
boy, 3,500	3,200	for	girl
" 10,006	9,5°°	n	C<
" 12,000	11,500	"	(<
" 13,200	12,750	"	It
" 15,000	14,500	«	it
" 16,750	16,000	£<	H
" 18,200	17,600	"	it
" 20,000	19,150	"	it
" 21,750	20,800	((	a
" 23,200	22,300	"	"
" 25,000	24,200	U	n
" 27,600	26,600	(<	tt
" 31,000	30,600	((	a
" 35.3°°	33.8o°	(I	tt
" 39,000	36,700	"	it
" 45>o<x>	41,500	"	a
                       SECTION II.

   THE  PHYSIOLOGICAL AND  TRAUMATIC
               ACCIDENTS OF BIRTH.
  The physiological accidents of birth arise from any interference
with the physiological changes normally occurring in the  child's
organism at time of birth.  The more important of these changes 
PHYSIOLOGICAL ACCIDENTS OF BIRTH.
17
   First.  The  establishment  of pulmonary respiration forces a
 stronger current of blood into the pulmonary artery than formerly,
 hence the blood no longer passes into the aorta by the prenatal
 duct—ductus arteriosus Botalli.  This duct passes from the pul-
 monary artery, before it branches, to the arch of the aorta and is,
 therefore, the prenatal short cut for the blood, thus enabling it to
 escape the pulmonary circulation.  At the time of birth the expan-
 sion  of the  lungs  changes the  position of this  duct, which thus
 becomes bent  and obliterated in the course of a few weeks.
   Second.  The accumulation of carbon dioxid in the blood of the
 newborn stimulates the respiratory centers and  the expansion of
 the lungs.  This causes no inconsiderable pressure on the  heart
 and blood-vessels  of the  thorax, whereby more blood is forced
 into the pulmonary artery, relieving the  pressure existing in  the
 aortic system during the fetal life.  The most evident result of this
 diminished pressure is found  in the arteries of the umbilical  cord,
 which cease to pulsate.  These arteria umbilicales are the largest
 branches of the hypogastric arteries, being given off at the side of
 the bladder, and passing upward  and outward  of  the  umbilical
 ring into the cord and thence to the placenta.  After the placenta
 is detached from the uterus, thrombi form in the umbilical arteries
 nearly up to their origin in the hypogastrics.  These thrombi later
 become  organized,  and form,  with the  obliterated  arteries, the
 lateral ligaments of the bladder.
   Third. At the same time  that the  umbilical arteries become
 obliterated  by  the detachment of the  placenta the umbilical vein
 is also deprived of the supply of blood, which it previously carried
 through  the umbilical ring to the liver and through its anterior
 longitudinal fissure to the left  end of its transverse fossa, where the
 umbilical vein  divides into two branches.   By one of these it sends
 the greater part of its blood into the left branch of the portal vein,
 by the other, under the name of the ductus venosus, it carries the
 remainder of the blood into the inferior vena cava.  Both the duct
 and the umbilical vein are obliterated after their circulation is cut
off, the latter becoming  the ligamentum teres of the liver.   As a
result of the obliteration of the umbilical veins and the ductus ven-
osus, the ramifications of the portal  vein are filled with more blood
in the same measure as the rapid flow into the vena cava inferior 
IS
DISEASES OF CHILDREN.
is checked  through  its  former channels.  If the portal capillaries
have from any reason become weakened, they may give way, and
we  have hemorrhage into the intestines, or more rarely into the
stomach.  (See Melena neonatorum?)


                 APNEA NEONATORUM.
  Synonym.—Physiological apnea.
  Definition. — Physiological apnea is  tardiness  in beginning
respiration, placental  circulation  persisting  for some time after
birth, and the cord pulsating for an undue length of time, the child
dying from  heart failure.
  Etiology.—Failure of respiratory centers to promptly respond
to their usual stimuli of cold,  etc., hence the child continues in the
state of physiological apnea in which it was before birth.
  Prognosis.—Hopeless, if persistent.
  Treatment.—(See Asphyxia neonatorum.)


               ASPHYXIA NEONATORUM.
  Synonyms.—Asphyxia pallida neurosa,  asphyxie des nou-
veau-nes, apparent  death of the newborn.  Literally, a pulseless
condition of the newborn.
  Etiology.—Generally due to mechanical interference with the
circulation  of the oxygenated blood in the fetus, as may happen
from flooding, premature detachment of the placenta, pressure
upon the cord resulting in premature stimulation of the respiratory
centers from the accumulation of carbon dioxid in the fetal blood,
or from the inherent debility  of child from any prenatal cause.
  Pathological Anatomy.—Dark, liquid  blood, engorged in-
ternal organs, hemorrhage  into  serous  membranes,  intestinal
hemorrhage, presence of meconium,  mucus,  and amniotic fluid
or blood in the respiratory tubes.   The more frequent locations of
hemorrhage are the  meningeal surfaces, especially toward the pos-
terior lobes of the  cerebrum, around  the cerebellum, and in the
spinal dura mater.
  Symptoms depend upon the amount  and duration of the
pressure  upon the cord ; if slight, the  child is simply pale and 
PHYSIOLOGICAL ACCIDENTS OF BIRTH.
19
anemic, the limbs relaxed, and heart-sounds are feeble.   If prema-
ture  respiration  has occurred, we may find mechanical asphyxia
added, from the inspiration  of  foreign matters into  the  mouth,
pharynx, and  trachea.  Frequently divided into asphyxia livida
and asphyxia pallida, which may thus be differentiated :—
  In  asphyxia livida  we have cyanosis; injected conjunctivae;
protuberant eyes; strong cardiac action; slow, full pulse ; cutaneous
sensation ;  tense musculature; umbilical pulse; intermittent respi-
rations, with generally a favorable prognosis.
  In asphyxia pallida  we find  death-like paleness; relaxation;
minimum heart-beat; no  umbilical pulsation ;  diaphragmatic re-
spiration poorly established ; sphincter paralysis;  conjunctival
and cutaneous insensibility, also of the palate, which, when it fails
to respond  to tickling with a finger, is a bad symptom.
  Prognosis.—According to Bouchut, if careful auscultation for
five minutes fails to reveal any heart-sounds, the case is hopeless ;
otherwise persevere so long as any  action of the heart  can be
detected, though the duration and degree of the compression en-
dured determines  the  danger of the asphyxia.  It must  also be
remembered that even when life is preserved, there is subsequent
danger from pneumonia or cerebral compression, which may pro-
duce permanent paralysis or idiocy later in life.
  Prophylaxis, whenever possible, should be attempted, espe-
cially in breech presentations and prolapse of the cord, by methods
described in the  standard text-books on obstetrics.
  Therapy.—i. Where there has been premature inspiration, re-
move all foreign substances from the mouth and trachea, if neces-
sary, by inspiration through a flexible catheter thrust into the wind-
pipe.
  2.  Stimulate respiration by slapping the child's back and but-
tocks, or by sprinkling alternately with hot and cold water, or im-
mersing  in hot  and cold baths alternately.   The inhalation  of
brandy, ammonia, or Hoffmann's anodyne. Electrical stimulation,
if possible.
  3.  So long as any motion of the heart can be detected, artificial
respiration should be persisted  in by means of either Marshall
Hall's, Schultz's, or Bird's method, at the  rate of not more than
sixteen forced respirations a minute. 
20
DISEASES OF CHILDREN.
   The writer's preference  is for Bird's method, which consists in
 holding the child on the outspread palms, one under the buttocks,
 the other behind the head  and neck, which are supported between
 the thumb and second finger.  By everting the palms the child's
 chest is  expanded, and by bringing the hands toward each other
 the air is expelled from  the lungs, and the process repeated as
 often as is necessary to fully expand the lungs.


       ATELECTASIS PULMONUM  CONGENITUM.
   Synonyms.—Fetal lung, congenital atelectasis.
   Definition.—A partial persistence of the fetal condition of the
 lungs after birth.
   Etiology.—Any cause which interferes with the initial expan-
 sion of the fetal lung.  Chief  among  these  may be  mentioned
 asphyxia, accompanied as it frequently is  with  greater  or less
 paralysis of the respiratory centers.  Pressure on  the  brain may
 do the same, or premature birth, in consequence of the  inspiratory
 muscles being too feeble to elevate the thorax during inspiration.
  Pathological Anatomy.—Unexpanded portions, chiefly at
 posterior  and inferior borders of the lower lobes, and along  the
 free  margins of the lungs, which here  appear depressed below
 normal level;  reddish brown, bluish, or steel  blue.  These spots
 sink readily in water  and show a granular surface from which
 exudes a  bloody fluid without air bubbles.
  Symptoms  and  Course.—Such   children  have a weak,
 whimpering voice,  are often distinctly cyanotic, nurse with diffi-
 culty, sleep much, and are prone to die of collapse.  Breathing is
 rapid and superficial;  the  pupils are dilated and react feebly.
  Prognosis is generally  unfavorable,  death occurring after
 collapse in the course of a few  days.   Occasionally convulsions
 precede death.
  Treatment and  Prophylaxis.—Whenever atelectasis is
 feared the child should be encouraged to cry vigorously in order
to produce deep  inspiration.   The respiratory muscles  should be
stimulated by counterirritation, electricity, change of position, etc.
 Bodily warmth must  be preserved by  the use of warm baths,
flannels, hot bottles, etc. 
PHYSIOLOGICAL ACCIDENTS OF BIRTH.
21
                  CYANOSIS INFANTUM.
  Synonyms.—Morbus ceruleus, the Blue Disease.
  Definition.—Strictly  speaking,  not a disease  at  all,  but  an
almost invariable symptom of all diseases attended with defective
oxygenation of the blood.  Of especial importance in early life as
indicating cardiac malformation, though it should be remembered
that this may exist without cyanosis.  "White  cyanosis" is the
name given by Mouls to such cases.  Morbus Winckelii is the name
given to an  epidemic  form of cyanosis first fully described  by
Winckel in 1879, as observed by him in the Dresden  Hospital.
Sporadic cases had previously been reported by  Garrod, Bigelow,
and Baginsky.
  Pathology.—Once supposed  to be due to malevolent  spirits,
which are now known to be those of arrested development.  (See
Cardiac Malformations?)  In more than  half of the cases, exam-
ined after death, malformations have been found in the pulmonary
artery.  Others arise from the mixing of arterial and venous blood
in the heart,  from a patent  foramen  ovale or  other congenital
defects, and others, according to  J. Lewis Smith, to a congenital
failure of oxygenation of the blood without recognizable lesions.
No accurate chemical examination  of the blood of cyanotic chil-
dren has yet  been made, but it probably closely resembles ordi-
nary venous blood.  The liver is usually enlarged and congested ;
pericardial and pleuritic effusions are frequent occurrences.  More
frequent with males than females, and increases in frequency with
bulk of population.  Often hereditary in  families, but, even when
due to  congenital malformation, symptoms do not  necessarily
occur immediately after birth.
  Symptoms are chiefly those of blueness or lividity of the face,
lips, and tips of the fingers, intensified by exertion or fright, which
occasion paroxysms of  dyspnea.   Clubbing of  the finger-tips
found in all chronic cases.
  Prognosis.—Unfavorable  for recovery,  though not immedi-
ately so, for life may be  prolonged  for years; 80 per cent, die in
the first five years.  Very bad for Winckel's Disease.
  Treatment.—Rest, mental and physical, digitalis, quebracho,
and chlorate of potash and tonics. 
22
DISEASES OF  CHILDREN.
                 ICTERUS NEONATORUM.
   Definition.—Yellow discoloration of the skin of the newborn,
occurring from the third to seventh day.
   Etiology.—According to Goodhart may be either physiological
or morbid.  The first is due to an alteration in blood pressure,
caused by the act of birth.  This variety is frequent in premature
infants and does not stain the conjunctiva and urine yellow while
the feces retain their natural color.   More or less of this discolora-
tion of the skin is observed in all newborn children ; but staining
of the sclerotics is  due to reabsorption of the coloring matter of
the bile, due to either catarrhal or pernicious jaundice.
   Ordinary icterus neonatorum arises from mechanical rather than
hematogenic causes; because  if due to destruction of red cor-
puscles their number ought to  be relatively lessened, but careful
counting shows this is not the case.  (Phil. Med.  Times, Vol. xiv,
p. 124.)
   The reason why infantile jaundice does not invariably occur, is
that the amount of interference  by the umbilical ligature depends
upon the amount of  anastomosis of the  umbilical vein with  veins
of abdominal wall, and the relative vigor of cardiac contractions,
for the freer these anastomoses the less resorption of bile.
   Differentiation.—Catarrhal jaundice is due to a simple catarrh
of the ducts.  Pernicious jaundice arises from defective circulation
in the liver, such  as might be  caused  by congenital hepatitis or
malformations.  Such causes are hepatitis syphilitica, closure of
the ductus choledochus by gall stones, or phlebitis umbilicalis.  It
is also met with in pyemia from any cause, scarlatina, pneumonia,
atelectasis of the lungs on account of a damming up of the blood
in the liver from an imperfect emptying  of the heart, etc.
  Prognosis is generally good, unless mistaken for jaundice due
to prenatal disease (icterus embryonum)or syphilitic thickening of
the ducts, etc.   It  should also be  carefully  distinguished  from
septic jaundice (see  page 22), which is a symptom  of the  gravest
import especially if associated with purulent omphalitis.
  Treatment.—Icterus neonatorum is so trivial  a physiological
accident that it requires no treatment except warmth and rest.
  Catarrhal jaundice lasts  from one to two  weeks,  and has a 
PHYSIOLOGICAL ACCIDENTS OF BIRTH.
23
spontaneous cure, provided serious mistakes in diet are avoided.
Pernicious icterus is generally unsuccessfully treated,  ending fa-
tally, with rapid atrophy and the appearance of hemorrhagic pete-
chias and brain  complications, in about two weeks.  In umbilical
phlebitis  antiseptics are to be applied to the  navel, and quinin
and sulphate of magnesia tried.  Death in these cases results from
pyemia and gradual wasting; less frequently from umbilical hem-
orrhage.

         SEPTIC INFECTION OF THE NEWBORN.
  Etiology.—Septic infection may be either ante- or post-partum,
and like other septic poisoning may variously locate itself in  the
child's body, appearing either as erysipelas, metastatic abscesses,
joint disease, pneumonia,  endocarditis, or peritonitis.  These mor-
bid  processes being explained according to modern theories by
bacterial  invasion, or poisoning from  their  products,  usually
through the umbilical wound.
  Pathological Anatomy depends upon the part affected.  In
interuterine sepsis the child's  body may  show macerated skin,
bloody effusion into the cavities of the body, petechias in the lungs
pericardium  and pleura,  ecchymoses  on  the  peritoneum,  and
generally fatty degeneration of the internal organs.  Should  the
child be born alive it may die in a few days from  fatty degenera-
tion of the liver or interstitial pneumonia.  Very  often the septic
process begins in the subperitoneal connective tissue surrounding
the vessels of the navel, ending in thrombosis and peritonitis.  In
others, the mucous membrane is the first affected, with ulceration
of the mouth,   pharynx,  or  intestinal canal; again it  manifests
itself in localized gangrene of the  skin and subcutaneous tissues,
or affections of the joints, or hemorrhage into the brain, liver, or
kidneys, or as septic pneumonia, pleuritis, or meningitis.
  Symptoms  are those of the  complications  described  above.
Interuterine sepsis was well known to Underwood, who wrote a
hundred years  ago :  " Infants have not only come into the world
with several and inflammatory patches and ichorous blisters about
the belly, but with other spots actually in a condition of gangrene."
If such children  survive they suffer from  multiple abscesses and
sloughing of the subcutaneous tissue from extensive burrowing of 
24
DISEASES OF  CHILDREN.
pus.   Suppuration of the joints is by no means infrequent, resulting
in separation of the epiphyses and deformity, though not necessa-
rily so. Among other symptoms may appear various diseases of the
navel (which see), otitis, erysipelas, dermatitis exfoliata, and septic
croup.  The general condition of the child is poor.  It is emaciated
and has high fever ; anorexia, diarrhea, prostration and early death
from  exhaustion, pleurisy, or  pneumonia  may  be  confidently
expected.
  Differential  Diagnosis is not difficult,  although it is not
always easy to settle the  source of the septic infection, even after
the cutaneous affections, stomatitis, otitis, or joint affections clearly
indicate the nature of the disease.
  Prognosis.—In general  bad,  especially  so with bottle-fed
babies ; others  may  recover even after extensive arthritis.   The
mortality in epidemics is higher than in sporadic cases.
  Treatment.—Chiefly in the way of prophylaxis during  preg-
nancy and parturition, especially during epidemics of puerperal
fever, when the child should be removed from the breast.  (Bag-
insky.)
  Strict antisepsis should be observed  in dressing all septic wounds
or those liable to become  so.  Boracic or salicylic  acid, thymol,
or iodoform are preferable  to  carbolic acid for use  with children.
For treatment of  Erysipelas see page  25.


               ERYSIPELAS NEONATORUM.
   Synonyms.—St.  Anthony's fire ;  Rose ; Rothlauf.
   Definition.—Differs  in no  wise from that  seen in adults, and
like that due to  a local  invasion of the lymphatics and  skin by
a specific organism.
   Occurrence.—Comparatively  infrequent  since greater  care
and cleanliness  in lying-in asylums, etc.  Rarely seen in private
American families, unless  unfavorably located, as in room over
open sewer, noted in a case of the  author.
   Symptoms.—Those of ordinary erysipelas except  a  more
rapid course than with adults.  Attacks umbilicus,  genitals, neck,
nates, legs,  thigh,  arm, and face.  Migratory  often.  Peculiar
features found only in children under one year. 
PHYSIOLOGICAL ACCIDENTS OF  BIRTH.
25
  Etiology.—Still in dispute, but evidently a filth disease, asso-
ciated with puerperal fever, etc. ; probably due  to a micrococcus.
More strictly speaking, a specific dermatitis due to a specific organ-
ism, the streptococcus erysipelatis.  (Fehlman.)
  Symptoms and Course.—May  proceed to abscess, slough-
ing, gangrene, and death from pyemia or diarrhea.  Or there may
be tedious recovery, with cellular induration, or it may be compli-
cated with peritonitis, pleuritis,  pericarditis, or meningitis.
  Prognosis.—Discouraging, though all do not die.  Earlier age
more unfavorable, very fatal below three weeks.
  Prophylaxis.—Strict cleanliness,  antisepsis of the navel, espe-
cially in  suspected sepsis.   Kraske's  needle punctures  highly
recommended by Siebel.
  Treatment (Local).  Largely consists in exclusion of the air
by  means  of  corn starch,  cotton wool, white  paint, collodion,
ichthyol (five per  cent.).  Hydrogen  peroxid, theoretically, best;
tinct. benzoin favorably spoken of, also hot lead-water and opium,
or hyposulphite soda (Z) to Oj).

                              (21)
      r&.  Acid, carbolici,.........gr. xij
          Oleic acid,...........^ij.
      To be applied with the finger.  (Atkinson.)
  Internal.  Free use of alcohol and  tincture of chlorid  of iron,
gtt. j-v in glycerin, good food, and strict cleanliness.
  Differential Diagnosis.—Sclerema might  be mistaken  for
cellular induration of erysipelas, but  former shows skin from first
white and  cold, with diminished sensibility.  Mixed infection of
diphtheria and erysipelas sometimes met with.  (J. L. Smith.)


                TETANUS NEONATORUM.
  Synonym.—Trismus neonatorum  ; lockjaw;  " nine days'fits."
  Etiology.—Infantile tetanus is so  largely influenced by locality
that it is now generally believed to be due both to a local and to an
exciting cause.   The  latter is  some open wound, generally about
the navel,  and  the local cause is a widely distributed  bacillus
found in garden mold, especially that formed by decaying fish.
      c 
2fi
DISEASES OF CHILDREN.
Hence the disease is endemic in Iceland, certain portions of Long
Island, and frightfully common in the negro huts of the South.
  Symptoms.—Premonitory.  For one or two days there may
be noticed  uneasiness, sudden starting during sleep, and fever
(4-14 days); next follows, as the first pathognomonic sign, inabil-
ity to hold the nipple, then difficulty in  swallowing, and  quickly
thereafter rigidity of the  lower jaw (trismus) and stiffness of the
neck (tetanus).  At  the  same  time or  somewhat  later the facial
nerve and the muscles connected with it are implicated, and hence
result wrinkling  of the skin, closing of the eyes, and pursing of
the mouth.  Generally this condition quickly extends  over the
whole body, so  that the  back and extremities  become stiff and
wooden, and the abdominal walls hard and tense.  The pulse and
respiration  are frequent and the temperature of the skin is mark-
edly increased (105-ui0 F.), and this may even increase after
death, because the rigidity of the muscles also persists for a while,
and every contraction of the  same produces  a certain  degree  of
heat.
  Course.—Is not uniform, occasional hopeful remissions taking
place, but as a rule the tonic spasms recur with greater frequency
and intensity.  Sometimes these paroxysms diminish in frequency
just before death, which  takes place on the fifth to ninth day of
the disease,  from exhaustion or asphyxia due to a spasmodic clo-
sure of the glottis.   Very rarely the temperature falls after a brief
elevation, and when it remains so there is hope of recovery.
  Autopsies have revealed the umbilical fossa lined with sup-
purating membrane and vessels still patent.   Peritoneum inflamed
and cellular tissue saturated with  yellowish fluid.  Billard reports
meningeal  apoplexy  and  thick  follicular  exudation  on  spinal
arachnoid.   Existence of pathognomonic bacillus claimed.
  Prognosis.—Bad. The older the child, the lower the tempera-
ture, and the  longer  the duration of the disease, the  better the
prognosis.   The later the onset, the more hopeful  the prognosis.
  Treatment.—Furlong advises laudanum, others chloroform,
for spasms.  Best results obtained by stimulation and good nour-
ishment, milk, egg  enemata,  etc.  Hypodermics of woorara, or
extract of Calabar bean,  are highly recommended.  Think favor-
ably of chloral hydrate, which, like chloroform, will relieve spasms, 
PHYSIOLOGICAL ACCIDENTS OF BIRTH.
27
but will not cure.  Merriweather applies blister to umbilicus. Tur-
pentine has a high reputation in the Southern States as a local ap-
plication.   Antitetanus toxin isolated and hopeful results reported.
  Prophylaxis.—Pregnant women must not be" delivered where
disease  is endemic, nor child return home until navel is entirely
healed under antiseptic dressings, best of which is iodoform. The
temperature of the bathing water ought not to be over 34°-35° C.
(ioo° F.).


        SCLEREMA  NEONATORUM  CONGENITUM.
  Definition.—Consists of a hardening  of the skin and subcu-
taneous cellular tissue, accompanied with subnormal temperature.
  Etiology.—This constitutional disease—sometimes congenital
—attacks  premature and atrophic children who are compelled to
live in  the bad  air of overcrowded foundling  asylums in  large
cities. The sinking of the temperature of the body (in consequence
of its imperfect calorification) is probably primary, and the stiffen-
ing of subcutaneous adipose tissue and the  other symptoms are
secondary, and due to solidification of animal fats.
  Symptoms.—After an indefinite period of premonitory symp-
toms—somnolence, apathy, difficulty in nursing—acute edema of
the skin begins  in the most exposed parts, i. <?., the  face and
lower extremities, generally in the calves, when the disease spreads
upward or downward.   The skin attacked becomes pale, hard, and
generally swells considerably from secondary edema (myxcedema),
while the skin which remains healthy appears cyanotic.  Gradually
the whole body  becomes affected, and such  children lie in bed,
cold, stiff, yellow as beeswax, and with countenances so swollen as
not to be  recognizable. The temperature  may fall i8° F. (io° C),
and not even intercurrent pneumonia, which frequently compli-
cates, can bring  it to a fever heat (870—Porteous).   Respiration is
always laborious and superficial.
  Progress.—The disease generally ends  fatally  within one to
four days; very seldom is a cure effected.  Recovery begins with
respiration becoming freer, nursing easier, and the temperature
rising.  Then the swelling of the parts affected diminishes reversely
as they are affected;  but  the skin remains cyanotic for a long 
28
DISEASES OF CHILDREN.
while.  Intercurrent pneumonia may also interfere with the efforts
toward a cure, and death result in two to three weeks.
  Autopsies demonstrate an abundant bloody edema of the sub-
cutaneous cellular tissue, which is  often changed into gelatinous
masses; moreover, serous effusions into the pleura are possible.
  Prognosis.—Nearly always  fatal.
  Treatment.—Supply warmth by means of warm bottles, sand-
bags, massage, strong wine, camphor, musk, etc.
  Good nourishment, as  wet nurse, whose milk must be injected
at first, or nourishing enemas.


                  EDEMA  NEONATORUM.
  Synonym.—Dropsy of the newborn.
  Etiology.—Due to interuterine fetal cardiac or renal disease.
Also claimed to arise from maternal disease affecting the placenta.
  Pathology and Symptoms are the same  as those  in the
adult.  Here mentioned  chiefly for sake of  differentiation from
sclerema neonatorum, previously described.


              OPHTHALMIA NEONATORUM.
  Synonyms.—Infective conjunctivitis of the newborn.  Augen-
tripper der neugebornen.  Infective blenorrhagia.
  Etiology.—Specific infection from  the vaginal discharge of the
mother at the time of birth,  or like infection from carelessness on
the part of the nurse.  The vernix caseosa serves to guard against
this  accident, but the premature opening of the infant's eyes may
introduce into them irritating matters.
  Pathology.—First Stage (twelve to twenty-four hours)  : char-
acterized by a prodromal red line transversely marked on the lids,
as if penciled with carmine ink ; purulent injection of the conjunc-
tivae which are slightly edematous and very  photophobic. This
stage, untreated, passes rapidly  into the second stage.
  Second Stage:  that of general  edema of the conjunctivas and
lids, accompanied by a thin, purulent secretion, very profuse and
irritating in character.  If unchecked the natural course of this is
to the destructive 
PHYSIOLOGICAL ACCIDENTS OF  BIRTH.
29
   Third Stage : marked by prodigious swelling of the lids, macera-
tion  and  destruction of the conjunctivas  by the profuse muco-
purulent, septic discharge.   The cornea is the part most frequently
ulcerated, and the process is attended with  fever and pain ; or the
pathological processes may not reach this final point, but stop any-
where  in the above  description, reaching a subacute  condition,
which  may persist for months, and result in general hypertrophy
of the  papillae of  the lids, forming cockscomb-like bands in  the
vicinity of the canthi, with thickening of the lids.
  Course and Symptoms are very variable, for the disease
may proceed  to gangrene in a few hours, or persist for months as
a subacute inflammation.  The complications most frequently met
with are ectropion, ulceration and abscess of the cornea, conical
cornea, hernia of the iris, rupture of the cornea, capsular cataract,
staphyloma, leucoma, or total loss of the eye in the worst cases, and
even in the more favorable corneal opacities are very frequent.
  Differentiation between  this  and simple catarrhal ophthal-
mia is  made chiefly upon the virulence and rapid course of the first.
  Prognosis is good only so long as the cornea remains intact.
The earlier the cornea is involved the worse is the prognosis, be-
cause the sequelae of  inflammation of the cornea (white  cicatrices,
etc.) persist  for life, and are the most frequent  cause of infantile
blindness.  According to  statistics (in 1876) thirty-three per cent.
of all the children  admitted into  the blind asylums of Austria and
Germany had become  blind  from this  affection.  Nevertheless,
the prospects  of recovery are generally favorable,  jf unremitting
care is given the child, either by the doctor or a competent nurse.
  Treatment.—The most essential part of  any efficient method
of treating this disease is frequent and thorough cleansing of the
eye with  some weak antiseptic  solution, carefully protecting the
other eye from infection.  Some advise the use of ice bags during
the intervals of cleansing, but frequent antiseptic cleansing is more
important than the choice of the germicide  or antiphlogistic.
   Corrosive Sublimate  (gr. j-Jviij).   Highly  recommended by
Smith.
  Nitrate of Silver (gr. ss.-v-^j).  Largely  used by some, after
previously thoroughly cleansing  the eye with a two per cent, solu-
tion of boracic acid. 
30
DISEASES OF CHILDREN.
  Alum  (gr. v-^j) is  preferred by  others, while  zinc  sulphate
(gr. ij-§j) is always used—Jones.
  Zinc chlorid (gr. j-Oj) has given excellent results in the writer's
hands when used hourly, or oftener, if necessary.
  Solution  of yellow pyoktanin  (i : ioo)  is very  efficient, but
frightfully stains the child, its clothing, and the hands of the one
using it.
  Prophylaxis.—Credit has obtained most remarkable results
by the  use of a two per cent, solution of nitrate of silver, applied to
the eyes with a glass rod immediately after birth, by which-means
this disease has disappeared from the Leipzig hospitals, and nearly
so in all the Austrian hospitals. Gaunt advises zinc chlorid.  In
every suspicious case the vagina and external parts of the mother
should be scrupulously cleansed before and during her confine-
ments with a bichlorid  (1-5000) or carbolic acid solution.
  Moreover, if one eye becomes infected, the other  must be pro-
tected from  contagion  by borated cotton laid over it and held in
position by  adhesive plaster.  The  utmost care should be taken
in handling infected instruments, towels,  cotton, etc., for it should
be remembered that nurses have more than once lost their eyesight
from lack of care.  Hence the State of Rhode Island requires that
the monthly nurse shall report every case of ophthalmia neona-
torum  within seven days under penalty of $100 fine, or sixty days'
imprisonment, or both.


                 MASTITIS  NEONATORUM.
   Synonym.—Hexenmilch.
   Definition.—An  inflammation of the mammary glands occur-
ring in either sex from  an ignorant attempt to empty the breasts by
squeezing them.
   Etiology.—Compression or bruising of the glands already dis-
tended by the milk, for it must be remembered that the mammary
glands of boys, as well as girls, often secrete, during the first two
weeks, a milky fluid which closely  resembles  colostrum,  except
that it is without its sweet taste, and sufficient in one of the author's
cases (male Jew) to trickle out by expression.
   Progress.—The  swelling and redness of the mammary gland 
PHYSIOLOGICAL ACCIDENTS OF  BIRTH.          3l
ought to  disappear  in a  few days if let alone; if not, in three or
four days fluctuation will be felt until the abscess breaks and the
skin heals, some time  after.  Erysipelas, with deep  sloughing of
the cellular tissues and generally with a fatal result, occurs only in
marasmic infants.
  Prognosis.—Generally good ; unfavorable only with cachectic
children.  The worst sequelae for  girls  is the  destruction  of a
portion of the  mammary gland  and cicatrization of the abscess
wound, very frequently  resulting in a retracted or funnel-shaped
nipple.
  Treatment.—The best is  to absolutely let them alone, but if
the mischief has already been done, then resolution of the inflam-
mation must be sought by means of lead wash,  iodid  of  lead
ointment, or oil cataplasms.   If these fail and the case passes on
to suppuration, incise early, with  the  incision  radiating from the
nipple to minimize deformity,  and treat abscess antiseptically.


                HEMORRHAGIA INFANTUM.
   Etiology.—Occupies  an  intermediate position  between the
physiological and the traumatic accidents of birth, since it may be
either.   Doubtless  the  larger proportion  of cases are traumatic,
but there are others whose origin lies in the faulty development of
the fetal blood-vessels.   Hemorrhage from this cause is one of the
more frequent causes of death within the first  forty-eight  hours of
infant life, especially in syphilitic children.  Any of the acute in-
fectious  diseases, contracted  by the mother  during  pregnancy,
 predisposes the child to this hemorrhagic condition, which may
 manifest itself in the  brain,  stomach, intestinal canal, vagina, or
 any of  the mucous surfaces of the newborn  child.   For cerebral
 hemorrhage, see Apoplexy, page 35.
   Autopsies made upon newborn infants show almost invariably a
 congested condition passing to punctate ecchymoses of all the
 abdominal organs. When this gives rise to actual hemorrhage
 the condition is called Melena Neonatorum, whose symptoms are
 vomiting and  purging of blood, progressive weakness, and  death
 from collapse  if the hemorrhage remains unchecked.  It may be
 difficult to distinguish a passage containing coagulated blood from 
32
DISEASES OF CHILDREN.
the meconium passed during the first days of life, unless it be re-
membered that  meconium stains water in which it is placed an
olive  green, while bloody passages color it bright  red.  Course,
one to five days, and prognosis is not  necessarily unfavorable.
  Treatment.—Cracked ice, ergot, or the extract hamamelis.


           TRAUMATIC ACCIDENTS OF BIRTH.
  Congenital Fractures and Dislocations include not only those
due to direct  violence to the child by means of the hands or the
instruments of the obstetrician, but also those due  to precipitate
birth  and dislocations in utero, especially  those of the  hip  and
shoulder.   Cranial fractures are not at all  infrequent, as are  also
those  of  the  clavicle, humerus, and femur.   Cranial fractures
are either funnel-shaped, grooved, or  " spoon bowl."  The  first
form  are  fissures extending from the periphery of a  bone to  a
point  of ossification, and being wider at the periphery than at the
center of the bone, are not inappropriately compared to a funnel.
The second form is  usually found in the  parietals, while  the
spoon bowl, so named from their  size and appearance, may be
found anywhere on the  cranial bones, wherever long-continued
pressure of the promontory of the sacrum has produced a perma-
nent  depression  by the  force  of the labor pains.  Or a similar
condition  may be produced by forcible use of  the forceps in  a
narrow pelvis.  Fractures of the clavicle or  humerus are usually
produced  by forcible extraction in breech-presentations, especially
if the  arm lies  in the neck.
  Prognosis.—Simple fissures and the gutter-like depressions of
the cranial bones  generally have no bad  consequences, but the
spoon-like depressions generally end fatally in a short time,  and
even when the life of the child is preserved, brain or nervous  dis-
eases  remain as sequela,  more to be dreaded than death.
  The fractures of the bones of the skull,  from  precipitate birth
while  the mother is standing, are often without evil results.  Frac-
tures  of  the clavicle  and humerus are  always  without  danger
(though there  may be apparent paralysis of the limb concerned).
  Treatment.—In fractures of the skull, treatment for pressure
of the brain is indicated.  Fractures of the  femur or humerus are 
TRAUMATIC ACCIDENTS OF  BIRTH.
33
to be kept replaced by  means of pasteboard  splints  and light
sticking plasters, or silicate  dressings.   Union without deformity
in eight to ten days.  Fractures of the clavicle heal spontaneously
if arm is kept extended upon a pillow for a few days.


                 CAPUT SUCCEDANEUM.
  Definition.—An edematous swelling of the skin and subcuta-
neous tissue, caused by uneven pressure upon the presenting parts
during labor.
  Occurrence.—So common an  accident  of all  tedious labors
that it may almost be considered physiological in such cases.  Its
usual location is over the upper and posterior portion of a parietal,
less frequently over the  occipital, still less frequently over  the
frontal, and in breech presentations over  the  buttocks.  These
swellings  are  purely mechanical,  being  due to an inequality of
pressure upon the the presenting parts, hence at the point of least
resistance a localized edema is produced.
   Pathological Anatomy.—A  round,  oval,  or  sometimes
elongated  swelling, usually  one to three  inches  in  its longest
diameter,  but at times large  enough to greatly disfigure the head.
Pits but does not fluctuate on  pressure ; often purplish, and may
even become dotted with gangrenous spots, but usually disappears
spontaneously in twenty-four to thirty-six hours.
  Differentiation may be made by  the disappearance of the
caput succedaneum in twenty-four to thirty-six hours ; other tumors
found upon the head are persistent, e.g., kephalhematoma.   See
next section.
  Hernia  cerebri, or encephalocele : in line of sutures and pul-
sates.
  Hydromeningocele: grows tense  with respiration  or crying.
  Kephalhematocele: communicates with sutures, and is  dimin-
ished by cutting off blood therefrom.
  Angiomata, or erectile tumors : change color on pressure.
  Hydrocephalus : entire shape of  head is altered.
   Wens, or enlarged sebaceous cysts, are solid,  and do not pit.
  Hydatid and simple cysts : like all  cysts, fluctuate.  Hydatids
diagnosed by microscope. 
34
DISEASES OF CHILDREN.
  Prognosis.—Always favorable.   Usually  disappear in  a few
hours, even  the largest  only persisting for two or three days.  In
rare cases of breech presentation sloughing has been known to
follow.  (Parvin.)
  Treatment.—The majority of cases need no treatment other
than a little vaselin or cold cream.   If the skin be broken dust
with subnitrate of bismuth or impalpable boracic acid.  If the
swelling is very great the child may require feeding with a spoon
for  several days (face presentation), while the reduction of the
swelling may be hastened by the application  of cloths dipped in
alcohol and  water, or a solution of muriate of ammonia.


                   KEPHALHEMATOMA.
  Definition.—A hemispherical, elastic, fluctuating tumor of the
hairy scalp, increasing in size after  birth,  and thus distinguished
from the caput succedaneum.
  Etiology.—Accordingto Naegele, often occurs before birth and
is due to a hemorrhage into the cellular tissue and periosteum of the
cranial bones, especially on  the  right side.  As a rule, however,
happens  during birth.  Occasionally, if a larger vessel has been
injured, the effusion does not remain small, but assumes after birth
larger dimensions, growing in  a  few days to a tumefaction which
we  designate as a true  kephalhematoma (c. verum seu subperi-
cranium), situated  between the bone and the pericranium.  More
rarely a true hemorrhage occurs between the aponeurosis of the
occipito-frontalis  and the  pericranium,  or laterally  under the
muscles, especially the temporal.   Still more rarely, hemorrhage
takes place  between  the bones  and the dura mater on the inner
surface of the cranium (c. meningeum  s. dura matris) which may
produce the symptoms of pressure on the brain.  From what has
been said it  follows that any part of the cranium which has been
subjected during  labor to great compression, even if of short
duration, can be the  seat of a kephalhematoma,  provided there
exists at the same time  a predisposition to fragility of the blood-
vessels of the periosteum.  Consequently it need not be situated,
like the caput  succedaneum,  on   the  presenting  part of the
cranium. 
TRAUMATIC ACCIDENTS OF BIRTH.
35
  The frequency of kephalhematoma is  about  one case in  five
hundred or a thousand of confinements.
  Course and Symptoms.—Afterbirth the caput succedaneum
often hides the deeper-seated kephalhematoma.  After the disap-
pearance of the caput succedaneum (occurring, as a rule, in from
ten to sixty hours) the kephalhematoma increases and appears as
a flat elevation  permanent and even enlarging, located most
frequently on one of  the parietal bones.   This tumor increases in
size for from four to six days, but, however large it  grows, it never
overlaps the sutures, because it lies between the bones and the
pericranium, which latter is strongly adherent to the edges of the
sutures.  If, at the same time, there  are present the symptoms of
pressure on the brain which do not disappear during the first day,
there  is very probably also kephalhematoma  meningeum, or a
large and free extravasation of blood into the cavity of the cranium
itself.  (See Apoplexy?)
  Prognosis.—Left to itself, true kephalhematoma is not serious,
for absorption begins simultaneously with  the formation of new
bone, which is  felt  as  a bony ring  at  the rim  of  the tumor.
The tumor becomes more consistent  and smaller because the fluid
parts of the blood are absorbed,  and in the  more favorable cases
disappears in from one to five months, leaving only a slight  ele-
vation of bone, which is covered with movable scalp.  More rarely
it proceeds to suppuration, with  or  without  the separation of se-
questra from the skull, with which  purulent meningitis may be
associated.  Kephalhematoma meningeum generally ends fatally
by pressure on the brain, convulsions, etc.
  Treatment.—Every  source  of irritation is  to be  removed.
Lanolin inunctions used  daily, or, after the hair has been shaved,
a coating of collodion may be applied.  Antiseptic incision indi-
cated  only when  suppuration is feared  Aspiration  is preferred by
Pinckney French.


               APOPLEXIA NEONATORUM.
  Synonym.—Asphyxia rubra  seu apoplectica.
  Pathology.—Hyperemia of the  entire head, passing into true 
36
DISEASES OF CHILDREN.
capillary hemorrhage, or larger effusions, even to a rupture of the
cerebral sinuses with profuse hemorrhage.
  Symptoms and Course.—Child usually well nourished, but
born highly cyanosed; the eyeballs often  projecting and  ecchy-
mosed, tongue protruded  and swollen, and the head showing a
caput succedaneum.  The heart's action is weak and irregular.
If the effusion is great and  located at the base of the brain, the
child dies from gradual cessation of the heart's action, with irregu-
lar respiration.  Or if the effusion is smaller in amount, the child,
which at first breathed only at long intervals, may  begin more
frequent respirations and  gradually recover, especially if the effu-
sion has taken place on the convexity of the brain, or if there has
been only a high degree of hyperemia without actual rupture.
  On the other hand, convulsions, spasm of the facial muscles or
of the extremities  (see Spastic Hemiplegia), are  among possible
complications or sequelae.
  Prognosis depends upon the amount and location of the effu-
sion, and whether it increases or begins to be absorbed after birth,
but the outlook is rarely entirely favorable, even when apparent
recovery takes place, for the child is very liable  to  be  left with
some defect of speech or mind.
  Treatment.—i. If the child is born cyanosed, cut cord at once,
and allow one or two teaspoonfuls of blood to escape, or until the
face begins to pale.
  2.  Endeavor to excite reflexly the medulla by stimulation of the
skin, or sprinkling the face and breast with cold water.
  3.  Counteract the morbid condition of the brain as far as possi-
ble by artificial respirations,  by any method given previously.
  Prophylaxis.—See Obstetric text-books.


           INFANTILE  SPASTIC  HEMIPLEGIA.
  Definition.—Unilateral  paralysis  with contractions,  due  to
cerebral hemorrhage at time of birth.
  Occurrence.—Comparatively infrequent, because usually one
of the untoward sequelae of  a breech presentation.
  Etiology.—Results from localized atrophy of the cortex, due 
TRAUMATIC ACCIDENTS OF  BIRTH.
37
to the pressure of a blood clot at that point.  Dr. McNutt's post-
mortems demonstrate that hemorrhage on the convexity of the
brain gives rise to paralysis without convulsions;  but that vertex
presentations are more liable to produce hemorrhage at base of
the brain, causing convulsions, without paralysis, and ordinarily a
shorter duration of life.
  Pathological Anatomy.—Clot, or its remnants with hema-
toidal crystals, can  usually be found in fissure of  Rolando, para-
central lobe, or upper part of frontal convolutions.  (McNutt.)
  Symptoms.—Often  initial fever,  followed by paralysis with
flexion,  pronation, etc., with  wasting of the affected side.  Such
children are apt to be passionate and  ill-tempered, though some-
times they are dull, aphasic,  or stammering in  the speech.  Some-
times choreic or showing athetoid movements.
  Prognosis.—Not necessarily hopeless.  Life is often prolonged
for years in these spastically paralyzed children.
  Treatment.—Passive exercise and massage to prevent wasting
of muscles, galvanization, cold douches, with the  internal use of
potass,  iodid and ergot.  Deformity apparatus and tenotomy if
required.

                APOPLEXY OF THE LUNGS.
  Occurrence.—One  of the  rarest accidents  at  the time of
birth, but such cases have been reported by  Loomis, Jacobi, and
Walsh.
  Symptoms.—Nothing abnormal for some hours after birth,
then  groaning and  short spasmodic respiration, with  capillary
congestion of the extremities, lips dusky, and death from collapse.
   Pathological Anatomy.—Effusion  of  blood into  pleural
cavity,  associated with general pulmonary congestion and inter-
lobular  hemorrhage, due probably to fatty degeneration of  the
vessels.
  Differentiation.—Probably not possible during life.   Should
not be confounded at autopsy with the punctate ecchymoses of the
pleura observed in almost all children dying shortly after a difficult
labor.
  Treatment.—Heat to extremities, hypodermatics of ergotin.
  Prognosis.—Most gloomy. 
3s
DISEASES OF CHILDREN.
             HEMATOCELE TRAUMATICA.
  Definition.—Effusion of blood into the tunica vaginalis testis,
produced  by the long-continued pressure of a tedious labor, usu-
ally breech.
  Differentiation.—A soft, doughy tumor located in the scrotum,
not translucent to light, as is  hydrocele, and not reducible,  as is
hernia.  Does not pit on pressure, like edema of the scrotum.
  Varieties.—According  to  Konig (Kk. p  242)  there is a cir-
cumscribed hematocele funiculi spermatici, and a diffuse form
which forms a tumor for the entire length of the extra-abdominal
spermatic  cord, and may even  pass into the  abdominal cavity.
  Course.—Differs from  ordinary edema of the scrotum, in that
only ihe cutis shrinks, and the  testicles remain large and sensitive
to touch, and secondary  swelling of the skin follows, with fever
and deep fluctuation if the formation of pus takes place.
  Treatment.—Such  effusions are always slowly absorbed, and
should be  treated mainly expectantly, but  may be  opened,  with
antiseptic precautions, and the  blood clot evacuated, if absorption
cannot be  obtained.  The tunica should always be  incised where
there  is any evidence  of the formation  of  pus within it, and the
cavity treated antiseptically.

      PARALYSIS NERVI FACIALIS TRAUMATICA.
  Etiology.—As its name implies, is due  to the pressure of the
forceps on  the stylo-mastoid foramen in birth.  It is always con-
fined to one side, and usually cures  itself in a few days.  Wilson
says always seen on right side, and may be permanent.  For the
symptoms of other  paralyses of the facial  nerve see Peripheral
Diseases of the Nervous System.
  Treatment.—None advised for a week;  if persistent, then try
faradaic or galvanic currents.

INFLAMMATORY  PARALYSIS   OF  A  STERNO-CLEIDO-
                         MASTOID.
  Symptoms.—Affects  only  one side, and is sometimes found
after breech presentations on the side of the child which was near- 
        MALFORMATIONS AND DISEASES OF THE NAVEL.     39

est the mother's sacrum while passing through the pelvis.  This
side was subjected to a high degree of extension, which was shared
by the sterno cleido mastoid, whereby perhaps some of its fibers
were torn.  After birth the head inclines a little to the affected
side, and the muscle is sensitive, perhaps inflamed, and appears
thickened and rope like.  The same condition is said to have been
noticed after both difficult and normal head presentations.  It dis-
appears spontaneously after a few weeks.
  Treatment.—Iodin salve; rest.

          WOUNDS  OF  THE FACE AND  SCALP
Are not infrequently produced by the blades of the forceps.  Such
wounds are usually superficial, and  heal rapidly under dusting
with antiseptic  powders (as bismuth and  iodoform)  or  lotions.
Punctured wounds have been made by an obstetrician  attempting
to puncture a caput succedaneum for tough membranes, and the
eyelids  and eyes themselves have been known to be injured by
like brilliant operators.  Even ablation of a limb has been reported,
and  the  author knows of a midwife  who succeeded in breaking
the child's neck and leaving its head behind in utero.
                    SECTION III.

MALFORMATIONS AND  DISEASES  OF  THE
                     NAVEL,  Etc.
                      EXOMPHALUS.
  Synonyms.—Hernia funiculi umbilicalis congenita.  Amnion
navel.
  Pathological Anatomy.  Instead of normal cuticle surround-
ing the umbilicus, we find a thin membrane covering the end of
the umbilical cord, and within this loops of the small intestines,
and sometimes also the liver, are found.  After the sloughing off
of the cord, the contents of this hernial sack are exposed. 
40
DISEASES OF  CHILDREN.
  Etiology.—This condition arises from imperfect development
of the abdominal plates, resulting in an unclosed central abdomi-
nal slit at the time of the separation of the intestinal and umbilical
portions of the amnion.  In consequence, the loop of ileum, which
at first lies  within  the umbilical cord, is  not withdrawn, but is
developed, either alone or in connection with the liver, enclosed
within  the amniotic covering of the cord.  This amniotic sac is
often ruptured during or prior to birth, such children being  born
dead or expiring very shortly after birth.   If this is not the  case,
the  coverings soon become  gangrenous  and fall  off,  and the
exposed  loops of  intestine early share the same fate and prove
rapidly  fatal through secondary  peritonitis.  Very rarely, when
the liver is contained  within the sac, a spontaneous cure becomes
possible by means of  the formation of granulations by the perito-
neal covering of the liver.  Still more rarely does this take place
with the intestine, thus closing the abdominal gap by the contrac-
tion of the cicatrix and the retraction of the protruding intestine
into the abdominal cavity.
  Treatment.—i. Good nourishment by breast milk.  2.  Local
application of carbolated salve or other antiseptic dressings.
  Successful cases of operation and recovery by granulation under
iodoform dressings are reported in recent literature.


               THE CARE  OF THE  NAVEL.
  The normal desiccation of  the umbilical cord is a physiological
process closely resembling surgical  torsion of the  arteries, for if
the child dies at  birth, clots do not  form within  the umbilical
vessels, which remain patulous and  may be injected.  Ordinarily
these clots form a line of  demarcation about the  fifth day  from
which the horny-like cord should drop away without assistance
and leave a  moist, puckered  cicatrix behind.  The size and  con-
dition of this scar depends  largely upon the amount of the Whar-
tonian  jelly  in the  cord, and  the care that has been given  it for
the first few  days after birth.   The exact length that it should be
cut is of small importance compared with its being securely tied
with aseptic silk, and, preferably, doubled  upon itself if it is  large
and gelatinous, and held in place with  a rubber band slipped over 
         MALFORMATIONS  AND  DISEASES OF THE NAVEL.      41

 the doubled cord.  The stump  should then be freely dusted with
 impalpable boracic acid and wrapped in aseptic  cotton as one
 would a cut finger.  This dressing should be removed  sufficiently
 often to keep the desiccating cord in an  aseptic condition, and
 leave the umbilicus without inflammation at the time of the  spon-
 taneous separation of the cord.   This should never be artificially
 hastened, even if the separation should be delayed as  late as the
 ninth to tenth day, as sometimes happens with large and gelatin-
 ous cords.   Some of the  older writers speak of what they call
 " persistence of vitality in the cord "  remaining for months after
 birth.   These cases,  in all probability, were unrecognized  cases
 of persistence of the vitelline duct,  or
   Congenital umbilical polypi, which not unfrequently are found
 after the separation of  the cord implanted on the umbilical cica-
 trix, as a smooth, deep-reddish polypoid growth, one or more cen-
 timeters in  length,  and  usually pedunculated.   They  closely
 resemble in appearance rectal polypi and secrete upon their sur-
 face a viscid fluid, acid in reaction, and,  according to Tillmann,
 containing pepsin. They persist for years without any appreciable
 effect upon the general health, and often are difficult to differenti-
 ate from umbilical granulations or angioma, except by a micro-
 scopic examination after removal, which should  be done as  early
 as practicable.


            INFLAMMATION OF  THE NAVEL.
  Synonyms.—Omphalitis,  ulceration of the navel.
  Etiology, etc.—When from uncleanliness, or septic infection,
 the normal  cicatrization of the navel is interfered  with, there
 results excoriation and ulceration of the umbilical folds, often at-
 tended with inflammation and great pain.  Not infrequently gran-
 ulations  spring from these  umbilical  ulcerations, constituting the
 so-called fungus umbilicalis.
  Course.—The  omphalitis may  assume a diphtheritic  or  gan-
grenous  form, with all  the dangers  connected therewith, or the
ulceration may proceed to  actual  perforation of the abdominal
cavity with death from septic peritonitis.  Or, as  more frequently
      D 
42
DISEASES OF  CHILDREN.
happens, if the strength of the child is preserved, tedious recovery
takes place by means of cicatrization.
  Prophylaxis is more important than  subsequent treatment,
and is best accomplished by mummification of the cord by means
of impalpable  boracic  acid  or lycopodium  on  cotton.   Later,
careful examination of the navel after the separation  of the cord
and  the  cauterization, if necessary,  of any unhealthy ulcerating
spots  as they appear, with nitrate of silver, should never be for-
gotten.  Should the  stump  assume  a diphtheritic or gangrenous
appearance, the promptest possible recourse should be had to local
antisepsis and general  constitutional  treatment, as elsewhere
directed for these diseases.
  Treatment.—With the first  appearance of inflammation about
the navel,  the surrounding parts should  be scrupulously cleaned
with some mild antiseptic and  the umbilical  cicatrix packed with
aristol, or bismuth and iodoform.  Granulations should be snipped
off with  sharp scissors  or brushed with a solution of nitrate of
silver (gr. x-fgj).  The surrounding cellulitis should be held  in
check by compressors soaked in  a saturated solution of boracic
acid or a weak leadwash.  Diphtheritic cases require the generous
use of coffee, wine, and quinin inunctions with the  local use  of
peroxid of hydrogen.


               GANGRENE OF THE  NAVEL.
  Definition.—Omphalitis terminating in gangrene, which mani-
fests itself as a sloughing gray mass with a carrion-like odor.
  Etiology.—Always preceded  by ulceration or phlebitis,  and
especially frequent in  the atrophic  children  of infected lying-in
establishments.
  Course.—Occasionally a  line  of demarcation  forms, and the
enclosed part sloughs away,  leaving healthy  granulations below,
when the ulcer may heal by  cicatrization.   Generally death occurs
in seven to fourteen days, accompanied with pernicious icterus.
  Complications.—If the urachus is patulous, instead of having
been converted into the  middle vesical ligament, gangrene may
attack it and a urinary fistula result.   Or peritonitis may supervene,
with or without suppuration, and in the former case it is possible 
         MALFORMATIONS AND DISEASES OF THE NAVEL.      43

 to have the establishment of a fecal fistula, through which feces
 may pass later via the umbilicus.
   Treatment.—Prompt removal  from the infected spot; wine,
 coffee, and wet-nurse, if possible.   Strictest cleanliness by means
 of washing, and  the  local use of disinfectants, as a  solution of
 carbolic  acid or permanganate of potassa (3ss-Oj), hydrogen per-
 oxid spray, or iodoform powder dusted in the sloughing tissues.


         PHLEBITIS  ET ARTERITIS  UMBILICALIS.
  Definition.—Inflammation of the arteries and  vein of the
 umbilical stump, generally conjoined with omphalitis.
  Etiology.—Originates from suppuration of the coagula which
 fill up that portion of the umbilical vessels within the abdominal
 parietes.  Arteries often alone affected.
  Symptoms.—Often  escapes  the  attention even  of a trained
 physician, but may be suspected when there is prolonged umbilical
 suppuration, and when pressure  over the  track of the umbilical
 vessels crowd out a  drop or two  of pus. Generally  there is  also
 high fever and great restlessness, except of the abdominal muscles,
 which are moved as little as possible.  Sometimes also jaundice.
  Complications.—Reabsorption of pus  may be productive of
 pyemia and peritonitis, or pleurisy and abscess of the liver occur,
or death  may occur from erysipelas.
  Prognosis.—Death usually before the end  of the third week,
unless  the pus lessens and repair by coagulation begins  under
proper treatment, but even then these cases are very prone to
 relapse, some of them persisting to puberty.
  Treatment.—Great cleanliness and copious  syringing  with
 carbolized water,  to  be followed  by the  application  of hydrogen
 peroxid.   Good nourishment,  and wet-nurse if necessary.


           HERNIA UMBILICALIS ACQUISITA.
  Definition.—As the name implies, it is an acquired protrusion
of the omentum, etc., through the navel ring.
  Etiology.—Occurs quite  frequently, being  due  to either an
incomplete closure of the navel ring, from failure to cicatrize, or 
44
DISEASES OF CHILDREN.
complete closure  which has been dilated by great meteorismus,
impacted feces, continuous crying of atrophic  children, or any
other cause which produces sufficient abdominal pressure to crowd
a loop of the small intestine and  omentum against the umbilical
ring until it dilates.
  Symptoms.—The true navel,  expanding less than  the integu-
ment, is generally found crowded over to one side of the abdomi-
nal tumor, which  may be of the size of a cherry pit  to a pigeon's
egg.  This  may  be reduced with a gurgling sound,  while  at the
same time the edges of the hernial opening may be  felt beneath
the fingers.
  Prognosis.—Usually  recovery with  increase of the adipose
tissue of the child.  Occasionally it  persists  until adult life, and
still more rarely in these cases does it result in incarceration of the
intestine.  Chiefly of importance  as  a  possible complication in
later pregnancy.
  Treatment.—Reduce hernia, and apply over it a piece of flat
cork, a little larger than the navel, kept  in place by  a strip of ad-
hesive plaster, with binder over all.   Kormann advises the use of
a long  strip  of adhesive plaster, passed  around  the  back  of the
child, its ends crossing over the skin laid in a fold over the navel.
To avoid the unpleasant abrasion of the skin from the irritation of
the plaster,  the child ought to be bathed, and the adhesive plaster
renewed daily, for from three to six months.
                      SECTION  IV.

CARE  OF  THE  NEWBORN  AND   DISEASES
      ARISING FROM  MALNUTRITION  OF
                     THE  INFANT.

  Clothing.—The ideal dress for a newborn child is a loosely
knit woolen band, socks, diaper, containing oakum to receive the
first meconial  discharges, and a loose, short, flannel wrapper;
only these and nothing more in the way of pinning blankets, 
DISEASES OF  INNUTRITION.                45
bands, skirts, shirts, et al. so dear to the heart of the young mother.
The days of swaddling and salting the  navel  (Ezekiel xvi:  4)
have passed for all except Italians and Russians, but the American
child  is still in bondage to  its  grandmother in  the matter of its
dress  during infancy.   Recognizing fully,  as I do, the slight influ-
ence  of the physician upon fashions, good  or  bad, the  writer,
nevertheless, sincerely entreats the reader, so far as in him lies, to
protect the newborn in its inalienable rights to comfortable cloth-
ing, pure  air,  and suitable  food.  Comfortable  clothing for the
infant implies  that it shall be kept warm, and it should be remem-
bered  that radiation  is more rapid in the newborn than later in
life, and hence it should be washed and changed in a temperature
that may  be uncomfortable  to the adult.  Premature children re-
quire  a couvreuse, or when this is impossible it is far better to wrap
the child in cotton wool and substitute oiling for  the bath usually
given immediately after birth.
  Bathing.—The first bath should be given in the nurse's lap,
using  preferably a bit  of soft flannel instead of a sponge to remove
the smegma, the  name given to the cheesy-like substance found
on the skin of the newborn child.  The  over-zealous efforts of an
ignorant monthly nurse to scrub away all of this smegma irritates
the tender skin of the babe, to which  not even castile soap, but
the white of an egg,  purified vaselin, or unsalted lard may  be
used  for the first  cleansing,  which should  never  be too  vigorous.
It does no possible harm to  leave bits of this smegma until it rolls
up  and comes away of its own accord, and  in some of the best
lying-in hospitals the newborn child is not washed at all, except
the eyes, for the first twenty-four hours, but simply wrapped in soft
flannel and allowed to sleep.  In one of the modern German hos-
pitals the  infant, if at all puny, is packed in  warm, sterilized bran
up  to  its  neck, reminding one of the customs of the  Cheyenne
Indians, who use for  this purpose  dried horse manure, or  the
South Africans, who plant their babies in dry sand.  The Italians,
like the North American Indians, bandage their babies on a board,
with appropriate  arrangements for drainage, and consider that a
bath during childhood is almost murder, and after that little short
of suicide. Well-to-do  American infants  usually  are  given two
warm  (95-1000 F.) baths daily for  the  first  year, and  after that 
4rt
DISEASES OF CHILDREN.
once a day for the second year.  If the child is vigorous the tem-
perature of the bath may be safely reduced to 86°, if care be taken
that  chilling  does not follow.  Very weak children should  be
sponged instead of given an entire bath, which should never  be
persisted in if the child leaves it blue, cold, or frightened.
  Sleep.—The newborn infant should  sleep about  twenty-two
hours out of a possible twenty-four;  gradually  diminishing this
until at two years the child ought to sleep at least twelve hours of
the day, and at three not  less than  eleven.  Sleep is largely a
matter of habit with young children and they cannot be too early
inducted into correct habits in this matter, for the American child is
too often left to its own sweet will in the matter.  The ideal infant,
though there are very few of them left, should sleep consecutively
from 11 p. M. to 5 a. m. whether nursing or not.  It should also have
a morning nap from 12 to 2 p M., for which purpose the child should
be undressed and put to bed with unchanging regularity, if possible
in a room set apart for that purpose, with temperature 640 to 700.
  Ventilation.—Bad air  is perhaps the most frequent injustice
inflicted  upon the  well-born American infant.  Steam-heated
apartments, slovenly help, and the exigencies of the modern  dwell-
ing have  much to do with our enormous infant mortality in  all
large cities.  No child, nor adult either, for that matter, can remain
well and breathe the vitiated air of a single room.   Such poisoned
air makes the mother nervous,  neurasthenic, and  nagging, and
works  even more injury upon a tender infant.  From 240  to 300
cubic feet of space should be the minimum permissible for each
person  in  a  living  or  sleeping room, and some arrangement
should be made  by which  at  least 600 cubic  feet  of vitiated  air
per person shall be drawn from such rooms every hour. This can
be most easily accomplished by an open fireplace, which whenever
possible should  determine  the choice of the nursery ; heating, of
course, usually being done by other methods than the open grate,
which should be insisted upon solely for the purpose of ventilation,
easily accomplished by placing a lighted candle  or lamp in the
grate to establish ventilation through the chimney upward  when-
ever necessary.   Failing this, a narrow board or slat four inches
wide and cut  the exact width of the lower sash may be placed
beneath it, and will in this way leave an opening between the upper 
                  DISEASES OF  INNUTRITION.                47

and lower  sashes through which can be secured good ventilation
without direct drafts upon the occupants of the room.   The usual
antipathy against night air is thoroughly unreasonable, as it is by
far the best  that we have in our large cities.  Babies  may be
carried out-doors as early as six weeks if the weather is favorable;
but at this tender age should be carried in the arms of the nurse
and not jolted in  a baby carriage, where  too often the child is
allowed to grow wet and cold by a careless nurse girl.
   Anuria, or retention of the  urine, in the newborn not unfre-
quently unduly alarms the mother or nurse.   Frequently urine is
voided during birth, and the fact escapes the attention of the nurse,
and on  the  other hand there  may  be suppression for twelve,
twenty-four,  or even  forty-eight hours without any  subsequent
injury to the child.  In these latter cases, where no malformation
can be detected, the existence of uric acid infarcts in the kidneys
may be suspected  (see page  n).   Even these rarely give rise to
calculi, though  it  is possible that they may, unless they  are early
dissolved away by the free use of warm  sugar water, which is the
only  thing that should be used, except an  occasional  hip bath,
in the place of the gin, sweet  spirits of niter,  marshmallow, or
parsley  tea  so often  administered to  these  unfortunate infants.
All such drugging invariably gives rise to indigestion  and
   Flatulency, one of the young child's most frequent ailments.
The evacuation of wind, or the passage upward of sour-smelling
 eructations, generally affords temporary relief.  Such children are
 very irritable, from  the pains being repeated at every meal, and
 especially annoying at night, when the child is apt to be feverish
 and seized with fits  of screaming.  At such times the  feet are cold,
 though  the  bowels, hands, and cheeks  are  hot.  The  appetite,
 generally, is  ravenous, the child  eating everything that is offered
 it, but nevertheless continues to  waste and  suffer from various
 intercurrent  ailments, such as nettle-rash,  strophulus—red  and
 white gum—thrush, " inward fits," diarrhea, aphthae, bronchitis,
 etc.
   Treatment of  Infantile Flatulency and Colic consists,
 first, in the  immediate relief  of its agonizing pain, and, secondly,
 in the removal of its  cause, which  usually must be sought for 
48
DISEASES OF CHILDREN.
either in indigestion or malaria.  For immediate relief, any of the
following will be found useful:—

                               (22)
      R.  Spt. junip. compound,.......10 c.c.
           Glycerinse,...........5 cc-
           Aquse anisi,...........45 c-c-       M-
      Sig.—Teaspoonful in hot water, as required.—(H.)

                               (23)
      &.  Sodii bicarb.,..........gr. xvj
           Syrupi simplicis,.........^ ss
           Aquse menth. pip.,  .  t......5lss-        M-
      Sig.—Teaspoonful p. r. n. for a child a month old.—(Starr.)

                               (24)
      R.  Pot.  bromidi,..........gr. xvj
           Chloral hydrat.,.........gr. viij
           Syrupi aur. cort.,.........^ss
           Aquse menth. pip.,.......  . f. iss.        M.
      Sig.— 3J pro dosi at one-half hour intervals.

                               (25)
      IJ.  Liq. am. anisat.,.........4 c.c.
           Spt. chloroformi,.........I  c.c.
           Elixir lactopeptin.,........55 c.c.       M.
      Sig.—One-half teaspoonful  to a teaspoonful every fifteen minutes.

  In obstinate cases hot fomentations or enemata  will be  found
useful, and if relief can be found in no other way, resort to opiates
is justifiable,  of  which the pulv. cretas  aromat. cum opii (¥\j part
opium) can be used carefully, with satisfactory results.
  Constipation is one of the minor and more frequent ailments
even of very  young infants.  It arises both from errors in feeding
and from the  relatively pouch-like condition of the colon in chil-
dren under two years of age.  This is often aggravated by a mild
degree of gastric or  intestinal catarrh, which  coats  the feces with
mucus and thus interferes with peristalsis.  Constipation is  never 
DISEASES OF  INNUTRITION.
49
to be neglected in the hope that nature will bring matters around
all right  after a time, but, on the contrary, every effort should be
made to  encourage, and, if necessary, mechanically assist a daily
motion from the bowels until the child is two years of age, after
which time the anatomical cause of the child's constipation recti-
fies itself.
  Treatment.—In very young children nothing is better than a
daily warm oil, or soapy water enema, or a small glycerin supposi-
tory.  Milk of magnesia may be added  to the nursing bottle, p. r.
n., and for older children Starr recommends :—

                             (26)
      R. Res. podophyll.,........   gr. ss
          Alcohol,.......q. s. ad sol.
           Syrupi,..........ad .  . giij.       M.
      Sig.— 3J once or twice daily.

which can be recommended as efficient, but is often obstinately re-
fused even on sugar by Chicago children.
  In such cases cascara cordial or syrup  of figs may  be substi-
tuted with good  results, remembering that if persevered in even-
tually a  proper habit is established.   In fact, the child soon be-
comes a  bundle of habits, good  or bad,  even in as trivial a matter
as the time of day in which the bowel movement occurs.
  Aphorism VI.—Under no circumstances, except by the positive
order of  a physician, should a young child be allowed  to remain
constipated over thirty-six hours.
  Atrophia infantum is simply another name for gradual  star-
vation produced from  any cause whatever.  It  is also  known as
marasmus, asthenia, atrepsia, general wasting, etc. It has already
been noted that there is a physiological loss of weight immediately
after birth  (see  page 15) which should  cease within  three days.
Persistence  of  this  loss of weight after that period constitutes
atrophia  infantum, which may vary from simple failure to increase
in weight to the most painful emaciation.  Any degree of  wasting
ought to  be a source of  anxiety both to the parents and physician,
since  starvation  is  the most  frequent  cause of death  in young
children.  Hirst says most truly :  " Comparatively few children die 
50
DISEASES OF  CHILDREN.
from diseases interfering directly with the functions of the heart or
lungs sufficiently to produce death, while multitudes die from fail-
ure to maintain the nutrition of the body sufficiently for the vital
processes."   Such children die from slow starvation, or marasmus,
as we more tenderly name it.  This occurs whenever food for any
considerable length of time is  insufficiently assimilated to repair
tissue waste.  This may  be learned with  absolute accuracy by
daily weighing, and may  always be suspected whenever we find
emaciation, febrile exacerbations, depressed temperature, wakeful-
ness, delirium, and other nervous symptoms not otherwise to be
explained.  These  nervous evidences  of malnutrition  have re-
cently been carefully studied byRachford.  Among these psycho-
neuroses he places, in addition to those already mentioned, chorea,
pavor nocturnus, and the  hyperesthesia  of  scurvy.  Christopher
goes  even further, claiming that general convulsions, except as
the result of direct brain disease, are  proof of  impaired nutrition
in the child. (See Rickets and Eclampsia.)
   Simple atrophy arises from  an insufficiency of food otherwise
good.  In such  cases the infant gradually loses its plumpness, the
fat slowly disappearing and the muscles growing very flaccid and
soft.  The face is pale and the lips thin.  The child does not thrive
and is peevish.   It takes the  breast ravenously, and not infre-
quently,  if the milk is scanty, the child  suddenly stops and cries
passionately, as  if from vexation.  Its skin is moist, and perspires
readily and copiously, as does  the rickety child.   The fontanel is
level or depressed.  If the child is generally sleepless and irritable
at night, but sleeps at the breast, it is a sure sign that the milk is
thin and serous, and lacks satisfying qualities.
   During the day the child is very quiet and drowsy, or holds the
thumbs in the mouth  and sucks them until the skin  about the nails
becomes raw and abraded.  The bowels  are usually constipated,
and the motions solid and well colored.
   More frequently atrophy is preceded or attended with attacks of
acute indigestion,  attended  with pain, vomiting,  and a  sudden
high rise of temperature.  Such attacks closely simulate the onset
of scarlet fever or other of the zymotic diseases, but a brisk purga-
tive clears up rapidly the otherwise  doubtful  diagnosis.   These
attacks leave behind  them more or less  gastroduodenal catarrh, 
DISEASES OF  INNUTRITION.
51
whose symptoms, therefore, are added to those already detailed.
Such children, after the acute pain has passed, are dull and drowsy,
and show depression of the fontanel.   Not infrequently there is
slight jaundicing of the skin, and the bowels irregular, constipa-
tion alternating with  diarrhea.  The stools are ordinarily hard,
whitish, and lumpy, consisting  largely of undigested milk  curds,
coated with  stringy mucus; or  there may be three or four loose,
slimy, greenish passages a day instead.
  Treatment often taxes to the utmost the skill of the physician,
whose success  depends not upon the amount and times at which
food is administered, but  upon the  amount of the food  that the
marasmic infant can assimilate.  Trouble often begins with the
stupidity of  the monthly  nurse, who, in the language of Meigs,
directly "flies into the  face of  Providence  by filling the newborn
infant's stomach with saccharine mixtures, gruel, or the milk of
quadrupeds."  But this error seems to be world-wide, for all sorts of
substances are used to appease the newborn child until the coming
of its mother's milk.  The Chinese  fill the child with an infusion
of umbilical cord; the Kalmucks give it raw mutton to suck  for
the first few days; in Southern India it is fed upon boiled  honey
until the third day ; in the Transvaal upon soft mush ; in America,
cracker-water and castor oil seem to be the favorites of the monthly
nurse.  All  these are  unnecessary and  hurtful, as Nature has
provided  for the interval before the coming of the milk  by the
mother's colostrum, and if this is drawn early from the breasts,
to which the child should be applied so soon as the mother has
sufficiently rallied to allow it, nursing aids in uterine contraction,
and the few drops of colostrum thus obtained  act as a  gentle
laxative.  Colostrum  differs physically from ordinary breast milk
mainly in color, which is pale yellow, due to the presence, in addi-
tion to the ordinary milk  globules, of other granular, pale yellow
corpuscles, to which this milk undoubtedly owes its laxative proper-
ties.
  As young  mothers often find it difficult to nurse their first babe,
they should  be shown that this can be most easily done by  laying
the child  on the mother's arm, and having her bend her body
slightly forward until the nipple falls easily into the child's mouth. 
52
DISEASES OF CHILDREN.
At first she  should  steady the nipple between  two fingers,  thus
holding it in its proper place and regulating in a measure the flow
of milk.   Normal nursing ought to  occupy about fifteen minutes,
and the child should be alternately nursed from each breast, which
ought to  contain enough to  satisfy  the  child at that nursing,
during which, if sufficient, the babe  usually drops asleep with the
nipple in its  mouth.   During  the first six months the infant  may
be nursed every one-and-a-half to two hours if awake; after thati
for the next  few weeks, it ought to be  nursed  regularly every two
hours, from  5 A. M. to 11  p. M., when it may be laid in its own bed
or cradle, and ought to sleep  until 5 A. M.  If it will not, it may be
given a little warm, sweetened water from a bottle and  nothing
else until  morning,  for here,  as everywhere  else, the young child
soon  falls into  an established habit.  At  four months the infant
needs to be  nursed only six times in the  day, or  every three hours,
provided  it  is  satisfied at each nursing; and, after six  months,
usually five  nursings a day are sufficient.  Such  is the ideal course
to be  adopted with the normal babe and perfect mother, but, as a
matter of  fact, too often we are obliged to resort to—
  Mixed feeding whenever the mother's breasts are not  able to
furnish the child more than one or  two  nursings a day.  In such
cases we  must separate the nursings  as far as  possible and give
any of the following substitutes in the interval every 2-4 hours, but
do not starve the child on cracker water, oatmeal gruel, or too
greatly diluted condensed  milk. And it should be remembered that
condensed milk is  only to be used  as a  temporary succedaneum,
in which  way  it often serves us a good turn for a  few weeks or
days.  Condensed  milk  requires  four parts of water  to  bring it
back  to ordinary milk, hence it may be prepared for the youngest
infants by adding  one teaspoonful of  the milk to four  of lime
water and ten of hot, sterilized water.   For older children it may
be prepared with equal parts of barley water alkalinized, but owing
to the large  amount of sugar which is added  to condensed milk to
preserve  it, its use should be only temporary.  Hence where it is
absolutely necessary  to  supplement or  substitute  something  for
mother's  milk,  any of the following can be recommended  for
continued use as better than condensed  milk :— 
DISEASES OF  INNUTRITION.                  53
                          Substitute No. I.
  2 tablespoonfuls of lime-water.
  2      "          cream.
  I      "          good milk.
  3      "          milk-sugar   water  prepared  by dissolving 17^
  __                drams of milk-sugar in a pint of hot water.  This
  8      «          mixture should be kept well corked in a cool place,
                    and renewed as often as it grows turbid.
                                                   (C. V. Meigs.)

  The eight tablespoonfuls are amply sufficient for  one feeding,
which should be given blood warm,  every two hours, if infant is
awake.
                                II.
                        1 tablespoonful cream.
                        2       "      of whey.
                        2       "      hot water.

   The whey, of course, to be strained and the mixture given from
a bottle, or one-third lime-water  may be substituted for the whey,
from six weeks to three months.

                                III.
   Keating's Barley Blanc Mange.— 3 ij- 3 iv Robinson's prepared barley
     flour to Oj  boiling milk; stir for twenty minutes at a boil, sweeten,
     allow to cool and solidify.  %  iv  of this is heated and given in a bottle.

                                IV.
   M. P. facobi's.—i tablespoonfuls pearl barley to Ojss water ; boil off one-
     third and dilute aa with good  milk, using upper third of milk.  N. B.
     If made fresh each time, use 3 j barley to g iv water.

                                 V.
   /. F. Meigs'.— 9J Russian isinglass or 2 square inches of ordinary gel-
     atin in  yi pint cold water by boiling, then add to this 3J arrowroot
     rubbed to paste with ^-% as much of  good milk (p. r. n.); boil and
     add 2 tablespoonfuls of cream to  the Oj.  (Meigs and Pepper.)
   Or, equal parts of thin arrowroot, water, lime-water, milk, and  cream. 
54
DISEASES OF CHILDREN.
                              VI.
    J. L. Smith's Peptonized Milk.—
  I gill ( ^ iss) unskimmed milk.
  I "    "   water.
  2 tablespoonfuls cream.
  200 grains milk-sugar.
  l% grains ext- pancreatin.  (Fairchild's.)
  4 grains bicarbonate soda; put all in  bottle, in water as  hot as your
    hands can bear for twenty minutes, warm, and feed.
  Oliver leaves out soda and keeps on milk till warmed (6 minutes).

  In regard to the multitude of patent and proprietary infant foods
upon the market, it need only be said that they are all for sale for
the benefit of their manufacturers, and the intelligent physician
who  is  willing to study his cases ought to  be able to  combine a
more appropriate food for each case than that made for the whole-
sale trade.
  N. B.—Rigid cleanliness in  all articles used in the preparation of
artificial foods must be absolutely insisted upon, and only simple
black nipples, such as can be turned and scrubbed daily, used. At
least two of these and two bottles should be used daily, being kept
alternately in weak saleratus water.  After each feeding the child's
mouth should be washed out with a bit of soft rag dipped in fresh
water containing a pinch of borax, for in this way the  occurrence
of thrush may be prevented.  In every case of bottle indigestion,
the physician ought to inspect and smell the  bottle, to convince
himself as to its sourness, or otherwise.
  Finally, it  must be remembered that the crucial test of an  artifi-
cial food is not that it shall be  scientifically combined, but that  it
shall be readily digested and nourish the child.  If this be not so,
then it will surely suffer from
  Acute Indigestion, which  may produce the most alarming
symptoms met with in early infancy, closely resembling the  onset
of the zymotic diseases, due probably to autogenetic poisons from
improper foods,  especially if at the same time the child has been
exposed to cold.  During such  an attack, the skin becomes hot,
the face flushed, and there is violent retching and vomiting of sour-
smelling food and mucus mixed with more or less bile—yellow or 
DISEASES OF  INNUTRITION.
DO
green.  The bowels are loose, often extremely so;  motions dark-
green or putty-like, passed with much straining and  griping, some-
times so extreme that the child screams, pulls up the legs, and rolls
from side to side.  The tongue is coated, the belly full and hard,
and the child refuses food, but drinks greedily, and vomits  soon
after  swallowing.   Convulsions  may also occur, sometimes fre-
quent and fatal, but usually the vomiting ceases after the first day,
or becomes very  infrequent; but  the  diarrhea is  apt to  persist,
with watery, loose, and usually offensive stools.
  Course, if neglected, is toward a frequent repetition of these
attacks of  acute indigestion, each  one leaving the child  a  little
more debilitated, until at last it  passes into a condition of maras-
mus (see Simple Atrophy, page 50), finally dying either from ex-
haustion or from  some intercurrent disease which it has become
too feeble to resist.
  Treatment.—Success in treatment depends so largely  on a
correct knowledge of the etiology, in  both acute indigestion and
resulting atrophy,  that we can hardly do more than treat its excit-
ing causes.  If these are remediable, then we may hope for success;
otherwise  not.  We may peptonize, sterilize, Pasteurize ever so
skillfully and yet  fail  wofully.  The child  is unable to assimilate
these  physico-chemical  compounds,  as  is too often the  case.
Failing in these, the physician naturally turns to the wet-nurse, but
even she is not an infallible panacea for these cases.  Often it is
impossible to obtain one at all, and when found it is by no means
certain that her milk will agree with her foster child.   This is par-
ticularly apt  to happen  when her breast  is older  than the ailing
babe.  In  such cases breast milk is apt to disagree from  its rich-
ness, for human milk grows richer in cream and curd with lacta-
tion.   Or, as more frequently happens, the digestive organs of the
starving child have become so seriously impaired that the babe is
unable to assimilate any kind or age of milk.  In the choice of a
wet nurse it  should  be remembered that, as a rule, slight, fair-
complexioned women furnish the best breast milk.   The lacto-
meter invented by Dr. L. Emmet  Holt will be found  a most con-
venient instrument for testing the cream value of breast milk, but
the best criterion of its value may be found in the pleasure  that the
child experiences in nursing and its subsequent increase in weight. 
56
DISEASES OF  CHILDREN.
   Prognosis and Prophylaxis.—With Dr. Starr the  writer
 believes that these marasmic patients need never be despaired of
 until chronic diarrhea or spurious hydrocephalus supervene, but it
 is far better to prevent the causes of marasmus than to attempt to
 combat their doleful results later.  The slightest indigestion in a
 bottle-fed baby should be remedied at once.  Flannel bands, ster-
 ilized foods, and the abolition of the uncleanly, long nursing tubes
 would save many a life that is now sacrificed to laziness.  Further-
 more, take the newborn child's temperature at least twice  a day
 for  the first three or four days after birth.  Any sudden  rise of
 temperature  (102-1060), not otherwise explained, betokens a dan-
 gerous, rapid wasting, and calls urgently for the free use of  water
 or artificial feeding until the arrival of the mother's milk.

                    2. MUCOUS DISEASE.
  Definition.—A name  given by  Eustace Smith to a group of
 symptoms, attended with impaired nutrition, due to an excess of
 mucus in the entire alimentary canal.
  Occurrence.—As a " symptom-complex'' frequently met with,
 but  doubtful, except for convenience, whether it should be con-
 sidered as a distinct disease, for it is not associated with anatomi-
 cal lesions other than those of chronic indigestion, and possibly
 those of incipient rachitis, or  tuberculosis.
  Symptoms.—A soft,  flabby tongue, indented and  smeared
 with mucus, is particularly characteristic of this disease.  (Starr.)
 We  find  the child languid  and pale, sallow, easily tired, and
 sleeping poorly at nights.   It loses flesh, and there are frequently
 dark sepia circles underneath the eyes, and  sudden changes  of
 color in the  face,  now flushed, and now deadly white, as if faint.
 A curious  irritability is also characteristic, the child being fretful,
 capricious, and crying needlessly, languid by day and disturbed  in
 sleep by night terrors.  The appetite is  capricious, and the abdo-
 men large  and protruding; the  limbs  small  and  wasted.  The
 child is usually constipated, and the  stools scanty and consist  of
small,  dry lumps, containing  a large  quantity  of free mucus,
and  their passage is  generally attended  with straining, and
sometimes with prolapsus ani;  or  constipation and diarrhea
may alternate, there being a week  or so  of  constipation, and 
DISEASES OF INNUTRITION.
57
then a dozen or more loose  passages, constituting the  so-called
" bilious attacks."
  The breath  is  often  extremely  offensive,  especially  in  the
morning,  the  tonsils being  coated  with a thick, foul smelling
secretion,  although  fetor of  the  breath may be present with
perfectly clean tonsils, the odor in such cases being due to the
perverted secretions  of the post-pharyngeal glands.  Again, there
may be headaches,  with jaundice and  wandering abdominal or
thoracic pains.
  The skin  early  becomes impaired in  its functions and is often
rough  and harsh, especially  on the chest and arms, which are at
times covered with branny epithelium.  The lymphatics are prone
to enlarge upon slight provocation, but do not necessarily suppurate
or remain swollen.   The temperature is slightly, if at all affected.
Urine generally loaded with urates and high colored.
  Course and Prognosis.—This condition of  affairs is by no
means constant, there being  intervals between the bilious  attacks
of apparent convalescence, but they are not of long continuance.
The bad symptoms again return, and at  last culminate in another
crisis,  from  which  the child emerges thinner and weaker.  A
hacking cough and intestinal worms not infrequently complicate
this stage of the disease, which may persist until fatal exhaustion.
  Etiology.—Excess of gastric and intestinal mucus ferments
and decomposes the food with which it comes into contact, thereby
rendering it indigestible and slow of absorption, while the resulting
acid coagulates the  mucus  and  interferes with peristalsis.  The
stools of infants always contain more mucus than those of adults,
and many causes tend  to increase  this mucus to an abnormal
amount.  Among such may be mentioned scarlatina, measles, and
whooping-cough, which  latter  Eustace  Smith believes  the most
frequent cause of mucous disease, as excess of mucus is swallowed
in  pertussis,  and  intestinal  derangement is  one  of its constant
complications ; hence its great mortality in young children.  The
beginning of second dentition is also  a favorite time  for the
appearance of  mucous disease, for similar causes.
  Differentiation.—Not easy, especially from incipient tuber-
culosis, to which it apparently  predisposes.  The absence of
afternoon temperature and  presence of drowsiness after eating,
       E 
58
DISEASES OF CHILDREN.
night terrors, and " worm-eaten " tongue are all helpful in the way
of diagnosis of mucous disease.
  Treatment.—The cause being well known, treatment must be
directed to  the removal of the excess of mucus from the aliment-
ary canal.   Either  of  the following  is  useful  for keeping the
bowels cleared of mucus and poorly digested food :—

                              (27)
      R.   Sod. bicarb.,   ..........3J
           Fid. ext. sennae,.........^iij
           Inf. gent, comp., .... ad ...   .  ^iij.
      Sig.—Teaspoonful before eating.—Starr.

                             (28)
      R.   Sod. bicarb.,..........   2 gm.
           Sod. phosphat.,.........   8 gm.
           Syr. rhei. arom.,.........15 c.c,
           Cascara cordial..........45 c.c.
      Sig.— 3J-'j mane et nocte.—H.

  But regulation  of diet is more necessary than medication.   Ex-
clude as far as possible  all starchy foods, cake and candy, tea and
coffee, but allow fish, milk, eggs, and lean meat,  celery, aspara-
gus, raw oysters,  and lettuce, making from time to  time a diet list
like the annexed.  Also see to it that  the child is kept in  flan-
nels, for  " children dressed for beauty,  with four  or five inches of
bare leg,  nine times out of ten  suffer  from chronic  indigestion or
bronchitis."  (Starr.)  Every morning the child  should be given
a sponge bath (6o°) in a properly warmed room, then rubbed with a
crash towel and anointed with vaselin,  cold  cream, or oil of ses-
ami.  Out-door exercise on pleasant winter days, and as largely
as possible  in summer, greatly hastens  recovery, which is almost
certain with patience and persistence on the part  of the physician.

                          DIET TABLE.
  Breakfast.—Lime-water and milk, soft egg, stale bread.
  Lunch.—Beef tea and cracker.
  Dinner.—Chop  or lean beef, no potatoes nor more than one vegetable,
    custard or nogg.
  Supper.—Milk and crackers, or oysters, raw or stewed.
M.
M. 
DISEASES OF  INNUTRITION.
59
                        3. RACHITIS.
  Synonyms.—Rickets ;  innutrio ossium.
  Definition.—Innutrio ossium is a constitutional defect  by
which the bones are illy nourished, and become malformed in
consequence.   Name derived  from  rachis, the spine, from its fre-
quent deformity.
  Varieties.—(a) that  in which no lime salts are deposited ;  (b)
that in  which  those already deposited are carried  away (osteo-
malacia).
  History and Occurrence.—First described by Glisson in
the seventeenth century.  May, but rarely does, occur in inter-
uterine life (congenital rickets).  Most  frequent from the  middle
of the first  year to the  end  of the second year  in  life.  About
equally divided between boys and girls.  The most frequent of
the diseases of children in the larger cities of Europe ;  among
Italians and negroes in this country is increasingly frequent.
  Pathology.—Rachitis consists in  a cessation of the deposits
of the earthy constituents of bone in the  layers of cartilage cells
whicrTform  normally between the epiphyses and the shafts.  Con-
sequently these layers of cartilage  do  not ossify,  and the earthy
matters already deposited in the center of the bones are taken up
by the continuous tissue changes, and not replaced by new mate-
rial.  Furthermore, no new deposit of calcareous salts takes place
under the periosteum, which thickens and appears vascular and
succulent.   The bones likewise appear hyperemic and softer, and
therefore can  be easily cut with scissors, especially in rachitis of
the cranium.  The periosteum cannot be loosened without draw-
ing away with it small portions of the  attached  bone, which .
appears  soft and  spongy directly  beneath the periosteum,  but
grows more compact toward the center.  In  rachitic bones the
calcareous salts are  diminished about one-half, and even when
the rachitis has been  cured, it leaves behind it distinctive  marks.
These consist in a final ossification of the whole former soft mass
of bone into a  compact,  thick, bony substance, thus  retaining its
pathological original thickening (sclerosis, or eburnatio).  The cra-
nium  remains larger, and its vault thickened.  The weight of the
bone  is  strikingly increased,  occasioning the bending  of  the 
60
DISEASES OF  CHILDREN.
hollow bones, which remain bent, if they have not received timely
treatment, e.g., if there has been  marked rachitis of the thorax,
atelectatis  is  apt to be  left behind.   Rachitis of the cranium—
craniotabes—which is observed as  early as the third month, con-
sists of a hypertrophy of the cartilaginous layers of the  sutures,
which therefore  appear broader.  The fontanels are larger, and
ossify later, and so very gradually that the great fontanel has been
found open until  the  ninth year.  The cranial bones, especially
near  the sutures, are soft.   The occipital protuberances alone al-
ways remain hard ;  and often can be found more or less numerous
soft spots, from the  size of a pea to  a cent, on the occiput, or a
larger portion of the bone  is yielding and parchment like. The
latter condition  is sometimes found also in  healthy children.  In
the round,  soft places the bone is  entirely  absent; the thick
and  opaque  pericranium  and  dura  mater  touch  each other.
This, according to Kormann,  is caused  by the  pressure of  the
convolutions  of the brain  on  the softened bone.  The growth
of the facial bones  is  also  defective,  and this arrest of  develop
ment is seen  most  markedly in the  cutting of the teeth.  When
rachitis  occurs early, the first tooth   frequently does not  appear
until  toward the end of the first year;  or  if the rachitis begins
about the end of the  first  year of life,  then  the pause between
the first and second  period of dentition  is  disproportionately
long.  The  teeth  already cut are  deficient in enamel, early
become black, and  frequently fall out, though this is denied by
Carpenter, except in syphilitic children.
  The rachitic  trunk  is short and  possesses the  characteristic
pigeon or chicken breast deformity—pectus carinatum.   Usually
there may be found also  on its surface a horizontal depression or
furrow, known as Harrison's Groove, which may be detected during
the first year of life.  The cartilaginous, sternal extremities of  the
ossified or softened ribs can be felt projecting as  thick knobs,  the
so-called rachitic rosary.  The development of the  ribs is also
retarded, and  these are frequently found  bent by pressure in  lift-
ing, or from their yielding  during inspiration to the pressure of
the atmosphere, and the inward traction of the diaphragm; thus
the thorax becomes flattened laterally, occasionally drawn  in con-
cavely, and the sternum in consequence curves anteriorly, and 
DISEASES OF INNUTRITION.
61
the apex  of the ensiform appendage projects prominently.  The
transverse diameter of the thorax is lessened, and its anteropos-
terior  diameter enlarged, although the  cavity  of the chest is
smaller on account of the arrested development of the ribs.  This
is the origin of the acquired complicating atelectasis of the lungs,
which in proportion  to its gravity is one of the chief sources of
danger to rachitic children.
   The  dorsal and lumbar  vertebras are also softened, and by
carrying the child erect the spinal column becomes curved on
itself posteriorly—kyphosis.  This disappears when lying  on the
abdomen  or lifting the child by the  shoulders.  There  is also
observed, quite often, a  lateral curvature—scoliosis—of the spine
which is  always  complicated with a spiral twisting of the same.
Simple kyphosis  may  disappear, but kypho-scoliosis  becomes
permanent if not early corrected.
   Rachitis of the pelvis develops itself at the same time with that
of the thorax, and leads to those changes of form which are gen-
erally recognized later, and especially to be dreaded in girls, since
these  malformed  pelves make  future confinements dangerous.
These alterations in the form of the pelvis arise from standing or
walking too soon,  and especially from sitting on a hard floor.
   Rachitis of the extremities resujts in a curvature of the softened
long bones from  the traction of the  muscles  attached to them.
Injuries often of a very trifling  nature may convert these  curva-
tures  into fractures.  The earlier  the functions of the limbs are
taxed, the greater  are these curvatures ;  early attempts at walking
produce the well-known  bow-legs  and  tottering walk ; premature
creeping causes knock-knees.  Like other sick children, rachitics
learn  to walk of their own accord later than  usual.  If they have
already commenced to run about, they forget how at the onset of
rachitis, and must learn anew to walk from their second to fourth
year,  sometimes much later.  Rachitic children can very easily
thrust  their toes into the mouth, on account of the ligaments of
the joints being relaxed.
  Course.—When   recovery  from  rachitis  begins—generally
about the second  year, though  often much  later with improper
diet—the cranial  sutures and fontanels  become  smaller.    The
thickened pericranium again deposits earthy matters, at first in the 
62
DISEASES OF CHILDREN.
frontal bones, which now appear considerably thickened, giving
the cranium a square appearance—caput quadraium.   Finally, the
loss of bone substance  in  the occiput is  repaired  with earthy
matters, and retarded development again  proceeds more rapidly
than normal.  The bones begin to  grow again,  whereby  their
cortical portions become very compact and thick.  All the curva-
tures may become gradually remedied, and only  the infractions
remain persistent.  It is  only when  rachitis has been of several
years' duration that the body remains small, forming a marked
contrast to the relatively large head.
  Prognosis is generally good for  recovery from disease itself,
but the  complications are often dangerous, e.g., in craniotabes,
laryngismus stridulus may produce  death ; in  thoracic rachitis
with kyphoscoliosis we  may have  fatal results from secondary
atelectasis, cardiac hypertrophy,  capillary bronchitis, or lobular
pneumonia.   Pelvic rachitis is not infrequently the cause of death
in later childbirth.
  For complete cure there ought not to be the slightest disturbance
of digestion, but  frequently this is a  disagreeable complication  of
rachitis, thus  aggravating the  disease and  greatly delaying its
recovery.
  Prophylaxis.—Good  air,  proper  food, and  a  wet-nurse  if
necessary.   (Goodhart.)  One of the  most preventable of diseases.
  Etiology.—The bad  health of the parents may act as  a pre-
disposing or hereditary cause, but the exciting cause is always the
want of fresh air and proper  nourishment.  Inter-uterine rachitis
is the result  of deficient nourishment of the mother, or of a patho-
logical condition of the placenta.  Rachitis  attacks both children
who have not been nursed at all and those who have been nursed
too long, and, furthermore, those who have been fed too early with
starchy  food, which  easily produces diarrhea, and,  lastly,  those
who have passed through any serious disease affecting  unfavorably
the digestive organs, e.g., measles, pneumonia, and diarrhea, are
liable to be afflicted with  rachitis.  It is also found that more chil-
dren are attacked in  large cities than in the open country, and
toward the end of winter  than  during summer.  Rachitis always
begins before the close of the first period of dentition.
  Symptoms.—Generally during or  after  a persistent diarrhea 
DISEASES OF  INNUTRITION'.
63
there appear increasing  uneasiness  and  sensitiveness  to  touch,
especially in lifting.  The  phosphates in  the  urine are increased
three or four times, for the earthy constituents of bone  are elimi-
nated from the body, not deposited;  soon follow profuse sweating
and bronchial catarrh.  The growth  and form of all the bones are
disturbed, most evidently in the rachitic extremities.   First comes
swelling of the wrists—articular ends of the radius and ulna—and
then  follows the thickening of the ankles, or the distal articula-
tions of the tibia and fibula.   This thickening results from an
exuberant growth of the cartilages, the traction  of the muscles
passing over the joint, and the reciprocal pressure between the
articular extremities themselves.   On account of this hypertrophy
the  long  bones  increase  less  in length  and  become flexible.
Consequently the traction of the muscles inserted in  the bones
produces numerous  changes of  form, giving  rise to  various bone
distortions, and quite often to bending of the long bones (infrac-
tions) of the lower leg and forearm, whose return to their normal
position is  prevented by the action of the same muscles.  The
forearm and thigh appear bent  anteriorly outward, the upper arm
to the outside, and the tibia and its  lower third  is bent anteriorly.
Craniotabes, or rachitis of  the cranium, manifests itself in profuse
sweating of the head, which bores into the pillow with continual
uneasiness,  and this  continuous rubbing  of the head  to and fro
produces, later, complete baldness of the  back  part of the head.
A change of position pacifies the child, most perfectly when it is
lifted up or laid on its abdomen, thus leaving  the  back  part of
the head free from  pressure.  Pressure  upon the exposed brain
leads to various forms of convulsions, and especially to  spasm of
the glottis.   In  rachitis of the thorax, as a rule, the children cry
on being lifted, but are quiet on being laid down.
   Progress.—Generally the disease is without fever and is chronic,
lasting for several years, and, if neglected, resulting in permanent
deformity of the bones.
   Dietetic  and Hygienic—Very often protracted  nursing is
to blame and must be prohibited, and feeding on soup, meat juice,
milk, and eggs must be ordered.  In addition to cleanliness, plenty
of fresh air  must be insisted on, and, where possible, salt baths
are valuable adjuvants. 
64
DISEASES OF CHILDREN.
  The following diet table may prove of value :—

   DIET TABLE FOR RACHITICS, TWELVE TO TWENTY-FOUR MONTHS.
Breakfast.—Milk or cocoa, with toast or cracked wheat.
// A. M.—Milk and lime-water.
 2 P. M.—Chop, gravy, and stale bread; cauliflower.
 6 P. M.—Like breakfast, or egg, if not meat at noon.
 8 P. M.—Milk and lime-water.

                             (29)
      R.   Olei morrhuse,
           Glycerince,  ...... aa.......^ ij
           Ext. malt,...............% iv
           Ess. gaulther.,.............3J.
Mix thoroughly and give one to two teaspoonfuls an hour after meals.—H.

  Medicinal, etc.—Cod-liver oil, either phosphorized or in  the
form of the above emulsion, stands  at the head of all remedies.
But in the giving of cod-liver oil it should be remembered that only
that which is assimilated is of any value, and that it is most quickly
assimilated when given about an hour after eating, when it is not
apt to spoil the appetite for the  next  meal.  Others  speak very
highly of the syrup of the lactophosphate of lime in rachitis, also
of minute doses of phosphorus.
  2d. Removal of all disturbances of digestion by the use of pep-
sin, etc., before meals.  If  diarrhea, check by opiates or astrin-
gents, as tannate of quinine or cato.
  3d. In craniotabes, it is necessary to provide some suitable rest
for the softened occiput, such as a horse-hair pillow with a pear-
shaped aperture for the head.   For the sweating  of the head wash
it frequently (hourly) with cold vinegar or water  containing alum.
  4th. When  there is  rachitis of the chest, lift the children care-
fully by the neck and buttocks.
  5th. When the disease has  already run  its course supports  are
of no  use, but resection of wedges of bone from the deformed
limbs must be made, but in  the earlier stages of the disease defor-
mity apparatus is of immense value.  No rachitic case should ever
be left to nature to correct, but should be taken as early as possi-
ble to the orthopedic surgeon whenever possible.   Simple bowlegs 
DISEASES OF  INNUTRITION.
65
can  usually be corrected by  pressure and aggravated cases by
forcible straightening, even should this result in fracture, which is
usually followed by good results if treated immediately with plas-
ter bandages.

                      4. SCROFULOSIS.
   Synonyms.—Scrofula;  scrofulkrankheit, " King's Evil."
   Definition.—The writer  is one of those who is old-fashioned
enough to believe that there is, in many children, a pretubercular
tendency, remediable if treated in time, to which it is convenient,
if not scientific, to  affix the name of scrofula, since the majority
of these  children recover and  may  never suffer from general
tuberculosis.
   Etiology.—The  predisposing cause  is  descent from weakly
parents, one of them at least generally being in a cachectic  condi-
tion  from chronic pneumonia, phthisis  pulmonalis, syphilis, pre-
vious scrofula, etc.  But  scrofula is not always  hereditary ; too
often exciting  causes produce the disease de novo.  These  causes
are, faulty nutrition, such as too much starchy food before the ninth
month, excess of bread, potatoes and vegetables in  second  and
third year,  bad air  in underground lodging, or from too  many
persons in a room, or the general bad air of large cities.
   Symptoms.—Scrofula, which is often joined with an especial
quickness of intellect and comprehension,  may remain for  a time
latent until some  external  influence causes its outbreak.   This ex-
citing cause may  be vaccination, a wound, frequent chilling of the
skin, or certain diseases, especially measles or whooping-cough,
always  to be dreaded  in all families in which the elimination  of
effete material is known to be  tedious.   Hence, even a cold
does  not get well, but returns again  and again and is attended
with chronic engorgement of various organs, as  the lymphatic
glands, eyes, and mucous membrane.  The subcutaneous tissue
often becomes adipose.  The muscles and the surface of the skin
are anemic and relaxed, the latter perspiring easily.   On the skin
we may find eczema simplex  or  rubrum, whose  vesicles dry  in
yellowish-brown crusts, beneath which fluid generally oozes forth.
This is especially so on the face, nose, ears, and hairy scalp, form-
ing there eczetna capillitis.   Or we may find tinea capitis, porrigo, 
66
DISEASES OF  CHILDREN.
or impetigo, distinguished  by pustules  which form scabs, or
ecthyma, beneath whose large pustules the skin ulcerates.  Lupus
is found under the varieties, exfolians, exulcerans, serpiginosus—
which  latter is the  so-called salt rheum,  found especially on the
face, nose, and cheeks.  Lichen is known by  groups of whitish
papules, and often requires, like the previous-mentioned eruptions,
a very  long time for its cure, which can be hastened only by  con-
stitutional treatment.   The same  is true  of the inflammation of
the glandular  apparatus in the border of the eyelids—adenitis
meibomiana hordeolum—where the  lids thicken and the lashes fall
out.  The mucous membrane of the nose is especially apt to be
affected with a chronic catarrh which produces eczema and inter-
trigo of the upper lip  and nostrils, and  the swelling of the upper
lip and nose, the condition known as scrofulous ozena, resulting
from the ulceration of the periosteum of the cavity of the nose.
Not infrequently there is  a separation of a  sequestra, which al-
ways makes itself known  by a most offensive odor, and a thin,
purulent discharge.  Moreover, the  mouth often shows hypertro-
phied  tonsils and  chronic pharyngitis, as a complication  of the
above.
  The  eyes  are prone to herpes conjunctivitis et cornece and kera-
titis scrofulosa  and episcleritis with  secondary blepharospasmus,
with spasm of the lids (nystagmus) in consequence of photophobia.
The  most important of these is keratitis,  which may lead  to the
loss of sight, perforation of the cornea, and formation of staphy-
loma.  Superficial or deep cicatrices are certain to  remain.  These
are the nebulous maculas  corneas,  or white spots,  which interfere
more or  less with vision, according to their  position.  A chronic
catarrh of the  external auditory  meatus  may  affect the ear, ac-
companied with an offensive discharge and an  eczema of the sur-
rounding  parts.  Otitis interna  proceeds from periostitis  of the
middle ear, and may terminate in caries or necrosis of the petrous
or mastoid processes of the temporal bone, with secondary puru-
lent meningitis and formation of an abscess in the  brain, and sud-
den death, though this is rare.
  In all scrofulous diseases of the  skin, mucous membranes, and
organs of sense, all  the  lymphatic glands  whose  vessels  pass
through the affected   parts become secondarily  hypertrophied- 
DISEASES OF  INNUTRITION.
67
 In a longer or shorter time after the cure of the skin or the mucous
 membranes these  glands diminish in  size, or this may occur in
 the majority of them, while others become caseous or tuberculous.
 Very rarely, in the lymphatic glands of children, the process of
 calcification which is sometimes observed later in life takes place.
 Usually, these glandular tumors, which were at first movable under
 the skin, soften at the  center, and become fastened to  the skin,
 which becomes reddened at this point, through  which at last  the
 gland empties  out its contents—a sero-purulent fluid or pus con-
 taining  particles  of a  caseously  degenerated gland.   If  these
 abscesses, which frequently communicate with  one another,  are
 left to themselves, they change into long fistulous openings, which
 often discharge for years a thin pus, and are sure to leave behind
 them disfiguring, arborescent scars.  But  caseous degeneration
 of the internal lymphatic glands is of even greater importance,
 especially that of the bronchial and mesenteric glands leading to
 bronchial tuberculosis  and tabes  mesenterica.  Since  these  in-
 ternal glands cannot evacuate their contents externally, more or
 less destruction of internal organs must  result from the opening
 of these lymphatic abscesses into the esophagus, intestines, trachea,
 or cavities of the lungs,  or still more rarely fatally  into the aorta.
   Finally, the periosteum and all osseous structures may become
 diseased, producing acute  or chronic periostitis and ostitis  scro-
 fulosa,  now recognized  as tubercular.   This  especially affects
 the spinal column—spondylitis, Pott's disease,  properly named
 spondyarthrocace—and  the tibia,  femur,  and humerus are also
 exposed to  the same fate.  Periostitis rarely ends in resolution,
 but generally  in  suppuration, the  pus  discharging  externally
 through  fistulous openings.  At the same time the bone becomes
 inflamed, and that part  of the bone which is no longer nourished
 by the  caseously-infiltrated  periosteum  generally  dies.   This
 sequestra is cast off by the suppuration of the surrounding parts—
caries seu ulceratio ossis superficialis. The marrow also frequently
inflames, resulting in scrofulous osteomyelitis, or endostitis.  Extra-
vasation of blood into the hyperemic marrow generally produces
suppuration—caries centralis—whereupon the bone likewise dies—
necrosis centralis—as its internal supply of blood is cut off.  Finally,
the periosteum  also shares in  the inflammation, and the result is 
68
DISEASES OF CHILDREN.
 the same as in scrofulous periostitis, except that in such cases the
 fistulous passages always open into the medullary cavity.  Some-
 times there is a wonderful increase in the size of the bone with a
 diminution  of its  substance.   This originates from an absorption
 of the  bone substance  and  a  consequent  enlargement of the
 medullary cavity, while  at the same time the  periosteum throws
 out new layers  of bone, which are partially destroyed by absorp-
 tion—osteoporosis—spina ventosa, etc.
  The joints are  very often  attacked, and in these cases the pus
 resulting from the inflammation of the articular extremities of the
 bone breaks through into the cavity of the joint, and rapidly causes
 there an ichorous inflammation—arthrocace, especially coxarthro-
 cace.  Or the synovial membrane may become first inflamed and
 produce a large quantity of  the granulations  known as fungus
 articuli—tumor  albus, or "white swelling."  The  most frequent
 and  important of these  are the inflammations of  the hip-joint—
 coxitis scrofulosa,  or hip-disease—and the inflammations of the
 knee-joint—gonitis scrofulosa, or tumor albus genu.  Next in fre-
 quency  are the inflammations of the elbow-joint—olecranonarthro-
 cace—and those of the ankle-joint—podarthrocace,  or tumor albus
pedis—all now believed to be tuberculous.
  Secondarily, as a consequence of protracted suppuration, all the
 internal organs may become diseased. This may take place under
 the form of amyloid degeneration, which most  frequently attacks
 the liver, spleen, and kidneys.
  Progress.—Scrofula is always a chronic disease, but may er.d
 in a perfect cure, even after amyloid degeneration has occurred.
 It may, however, and does not infrequently, lead,  as has already
 been noted, to fatal tuberculosis.
  Prognosis.—The affections of the superficial lymphatic glands,
 skin, and mucous membranes have a tolerably good prognosis.
 The prognosis of scrofulous diseases of the lungs, bones, bronchial
 and mesenteric glands, as well as amyloid degeneration, is worse.
 The appearance of tuberculosis generally allows of no reasonable
 hope after the recognition of the bacillus  tuberculosis in the sputa
 by a competent microscopist.
  Prophylaxis.—Good air and food and the use of frequent cool,
 and in summer cold, salt  baths by those who inherit the hereditary 
DISEASES OF INNUTRITION.
69
diathesis.   Good food is of especial importance, four meals a day,
e.g..—
  Breakfast.—Cocoa, egg, toast, butter ad lib.
  10 A. M.—Warm milk and lime-water, cracker.
  Dinner.—Chop, steak, gravy, stale bread, cauliflower, oysters.
  6 P. M.—Same as breakfast, or peptonized meats.

  Sea air is especially helpful  in  all cases of suspected scrofula,
and can hardly be too strongly insisted upon during the summer,
when the means of the parents will allow it.
  Treatment should be both  general and local.  General treat-
ment is most important, because without it no  permanent improve-
ment  can be made, notwithstanding persistent local efforts, and,
vice versa, general treatment is essentially aided by local remedies.
First of all, good air must be secured  in the country, among the
mountains, at the seashore, or in summer dwellings.   Then there
must also be  good nourishment, at  first a wet-nurse, then milk,
meat, broths,  eggs, ripe fruits, and  the most  nourishing foods.
Potatoes, puddings, and fresh bread are to be entirely forbidden.
Cod-liver oil stands at the head of all medicines (an emulsion may
be commenced with, and later the common oil used), and is to be
given in doses of one-half to one tablespoonful three times a day,
one hour  after meals.  It is  only  contraindicated  in diarrhea,
gastric catarrh, inflammations, and feverish conditions. In case
cod-liver  oil does not agree with the  children, fresh cream, the
iodid of iron,  syrup  ferri (gtt. v-xx), in water, may  be  given
instead ; or iodid of potash  (gr. iij-viij) daily, in syrup of coffee
or  ginger,  or  the  saccharated carbonate of iron, as  much  as
will lie on  the point of a knife, /. i. d., may be prescribed.  Sea
and salt baths are always supporting.  They may be artificially
substituted by  common salt baths (one-half to  one pound), used
at first for one-fourth of an hour, and later for one-half hour.
  Skin diseases demand, first, cleanliness, the crusts then to be re-
moved by oil, etc., and after which removal, ung. prascip. or ung.
oxidi zinci may be applied.  In scald head, the hairs are also to
be removed, and scratching is always to be guarded against by
cutting the nails twice a week, and putting  the child's hands in
bags at night.   Indolent ulcers  are to be stimulated by applications 
70                 DISEASES OF CHILDREN.
of nitrate of silver, and lupus scraped or cauterized with chlorid
zinc or trichloracetic  acid.  Arsenical powders must not be used
with children on  account of the  ease with  which they become
poisoned.  In ozena,  disinfecting  and astringent solutions are to
be applied with a nasal douche or  DeBilviss' spray.
  Scrofulous  ophthalmia,  accompanied by photophobia, requires
local use of ung. hyd. oxidi flav. (gr. ij-^j) and the free adminis-
tration of opiates for pain.  All heating bandages must be left off,
and a single layer of silk tied over the eyes.  Dropping into  the
eye of a solution of sulphate of atropin, or warm collyria of boracic
acid with ext. belladonna (i -.40), one half to one hour at a time,
should be employed several times daily.
  When there is inflammation of the external auditory meatus, use
weak injections  of peroxid of hydrogen and deodorizing lotions
several times a day.  In  deep seated diseases of the eye and ear
the specialist ought always to  be consulted.
  When there is a  swelling of the lymphatic glands the organs
from which the lymphatic vessels arise must be carefully examined.
If the glands remain  enlarged after the cure  of the original dis-
ease, we should  endeavor to bring them to resolution  by painting
them with tincture of iodin or  the use of ung. ext. phytolac. de-
candr.  (3j-^j)-  Inevitable softening  of the  lymphatic glands is
to be promoted by stimulating salves and plasters, and when there
is great softening an  opening may be facilitated  by tapping with
the needle of a  hypodermic  syringe.  Incisions are  contra-indi-
cated because they leave disfiguring, gristly scars, and for the same
reasons, after  the spontaneous opening of an abscess, the callous
borders  of its fistulous openings are to be snipped and the cavity
scraped.  When the periosteum, bone, or marrow is affected rest
is indicated, with cold compresses in the initial stages.  When sup-
puration begins, poultices and proper position should be attended
to,  with the  extraction of sequestra and resection  of the joint
according to antiseptic surgical principles.   In major operations
of this kind the  surgeon's assistance is required, but it should  be
remembered that unless the general constitutional condition is also
looked after, permanent cure can  rarely be  obtained even by his
aid. 
DISEASES OF INNUTRITION.
71
                        5. PURPURA.
  Synonyms.—Morbus Werlhofii, Peliosis rheumatica.
  Varieties.—(a) Purpura simplex, or that where the hemorrhage
is confined to the subcutaneous tissues ; (b) purpura hemorrhagica,
or that where the hemorrhage is from the mucous membranes.  Oc-
casionally hemorrhage takes place from the sweat glands and we
have a hematidrosis.  Purpura rheumatica is  attended with pain
in the joints about which the  spots chiefly appear.  For purpura
neonatorum see Septic Infection.
  Etiology.—May arise from any of a  large number of causes,
some of  which, as  hemophilia and syphilis,  are  congenital.
More frequently it is found as a complication in severe cases of
the specific  fevers, as cerebro-spinal meningitis, smallpox, scarla-
tina, measles, or malaria.  Again it is met with in diseases attended
with serious  alterations in the composition of the blood, hence
purpura may complicate typhus, typhoid, septicemia, pyemia, ra-
chitis,  anemia,  pernicious icterus,  scorbutus,  morbus Winkelii,
acute dysentery, and  serpents' bites.   We  also see various medi-
cinal  purpura caused by the  administration of phosphorus, mer-
cury, quinin, potassium iodid, choral, salicylic acid, and  various
other coal-tar products in those possessing a purpuric idiosyncrasy.
Lastly, there are attacks of purpura caused by mechanical causes
located in either the heart, liver, or kidneys, or from sudden changes
produced in the circulation caused by falls, fright, pertussis, etc.,
and under this  head perhaps is to be included the so-called neu-
rotic purpura.
  Symptoms.—Generally preceded by  a few days of uneasiness
and pain in the limbs, which may escape attention until reddish or
bluish stains appear  upon the skin which do not disappear upon
pressure.  These purpuric spots are known  as petechias when they
appear as minute points, vibices if they are streaky, ecchymoses
if in the form of spots or blotches, which may be combined with
other skin lesions, as urticaria, papules, or bullae.  Purpura sim-
plex resembles  at first flea-bites and then passes  through   the
change of color incident to an ordinary bruise.  Purpura rheuma-
tica is usually attended with  moderate elevation of temperature,
rheumatic  pains, and not infrequently  with  cardiac complica- 
72
DISEASES OF CHILDREN.
tions.  Purpura hemorrhagica is the  variety most to be  dreaded,
for  it is  that form in which bleeding  may take place from any
mucous membrane  or into  any internal organ, often to a large
amount from the nose, mouth, or intestines, less frequently from the
stomach (hematemesis).  Or hemoptysis may announce pulmonary
hemorrhage, or hematuria that into  the kidneys or bladder, and
even  more  serious  are  the internal  hemorrhages  which  may
produce hemorrhage, pleurisy, pericarditis, or meningitis.
  Course.—The disease is rarely  attended  with fever unless
hemorrhage takes place into a serous sac.  Relapses are frequent
even  in p. simplex, which usually lasts about a week.  Purpura
hemorrhagica may  produce  the  symptoms of collapse, filiform
pulse, blanched skin, unconsciousness, or, if the hemorrhage  has
been meningeal, convulsions. The prognosis is good so long as
the hemorrhage is  simply ecchymotic; if into  the serous mem-
branes, the disease is always dangerous.   In hemorrhophilia the
prognosis is discouraging.
  Treatment.—Perfect rest, good nourishment, preferably liquid,
in the form of milk, broths, or soups.   Medicaments :  ergot, ergot-
ine, mineral acids, quinine,  p. r. n.  For pulmonary hemorrhage,
bits of ice, atropin—hypodermically—iron, fl. ext. hamamelis, etc.
For intestinal  hemorrhage,  vinegar enemata,  and in  obstinate
epistaxis, tamponade.   For   that form  known  as peliosis rheu-
matica, tinct. ferri  chlor. (gtt.  ij-v), with a  roller bandage  and
cotton wool about the swollen joints, acts like a specific,
  Prophylaxis.—In hemorrhagic families  special care must be
taken to  avoid all injuries, such as blows, cupping, or even draw-
ing the teeth, for such children, even  with the greatest care, sooner
or later succumb to some trivial injury.

                     6. RHEUMATISM.
  Etiology.—As its name suggests, the disease probably arises
from alteration in the normal composition of the fluids of the body,
usually supposed to be due to an excess  of lactic acid in the sys-
tem, although this has not yet been chemically  proven.  So much
as  this, however, may be taken for granted, viz.: that rheumatism
originates in  imperfect elimination and the retention of waste ma-
terial, which  produces inflammation  of various fibrous and serous 
DISEASES OF INNUTRITION.                73
 tissues of the body.  Chief among these are the joints, heart, and
 pericardium,  although  any fibrous or muscular structure may be
 thus attacked.  These  attacks are usually precipitated by sudden
 changes in temperature, wetting, residence in damp dwellings,
 chilling of the surface of the  body, and errors in diet, especially
 the  free use of malt liquors or the use of heavy wines.   Heredity
 seems to  have much to do with the predisposition  to rheumatic
 attacks, nearly one-third of those thus suffering  having had either
 a rheumatic,  or gouty father  or mother.  This  tendency may be
 shown very early in life, even within a few hours after birth, if the
 mother had suffered from rheumatism at the time of her confine-
 ment.  Unlike the  rheumatism of adult life, more  girls than boys
 suffer, and although it is said not to be often seen before six years,
 the  writer is  convinced that children of much tenderer age often
 suffer severely from rheumatism.
   Pathology.—Injection of the synovial membranes of the joints,
 often with effusion of fluid into them and swelling of the cartilages.
 Fibrous nodules are apt to form about such joints  and sometimes
 upon the tendons of the muscles of the back.   These latter, which
 are rare in adults, are by no  means uncommon in children, and
 vary in size from the head of a pin to a small cherry, but are not
 permanent, usually lasting for only a few weeks, although they
 may persist for months.  More frequently they  appear in return-
 ing crops, and are  usually considered proof  of  co-existing endo-
 carditis or  pericarditis, which  are relatively distressingly  frequent
 in children.  The pericarditis  may spread to  the anterior medias-
 tinum, and fibrous  coagula in the  heart are usual  at autopsies.
 Pleurisy is  frequent, usually left-sided, but  it may also be double ;
 and  less frequently we find  instead a  pleuro-pneumonia.  Ery-
 thema nodosum and urticaria  are probably vicarious manifesta-
tions of the rheumatic poison. '
  Symptoms.—It should  be remembered that articular symp-
toms are relatively less prominent with the child than in the adult.
The  same is true of the profuse acid sweating so  frequent  with the
adult.  On the other hand, wandering rheumatic  pains—the so-
called  "growing pains" — and rheumatic tonsillitis are among
the more frequent symptoms  of rheumatism in children.  Pain,
fever,  swelling of the joints, and  heart symptoms are, of course,
      F 
74
DISEASES OF CHILDREN.
met with in typical cases of rheumatism, but of these the heart
symptoms are the ones which are prone to overshadow the rest,
and  the ones chiefly to  be dreaded.   Pain  is quite apt  to be
slight and more  of the nature of tenderness and disinclination
to move rather  than sharp pain, and  hence is often mistaken
for a sprain.  Fever is, as a rule,  neither high  nor long  con-
tinued, so that the heart symptoms are often the first to attract the
attention of the parents.   It is not always easy to  decide whether
we have to  do with endocarditis, pericarditis,  or both combined;
but while it will be found that both are attended with restlessness,
labored breathing, and elevated temperature, we expect to find a
mitral murmur in endocarditis, systolic and near the apex (ulcera-
tive  endocarditis is  attended  by fever and  chills).  Pericarditis
generally is more painful than endocarditis, generally gives fric-
tion  sounds, with the cardiac  sounds more distinctly at the base
than at the apex.
  Diagnosis.—It is by no means  always easy to make a posi-
tive diagnosis of rheumatism in a child unless there be coincident
heart trouble. A rheumatic family history, recurrent tonsillitis, or
chorea, may give us  valuable  hints as to the attack, but the effect
of anti-rheumatic remedies are often the best means of differentia-
tion in doubtful cases.
  Treatment.—First, and foremost, the child should be  clad in
a flannel nightgown, put to bed, and kept under blankets until
pain and tenderness  have disappeared.  If the joints  are swollen
and tender, they should be wrapped  in  cotton batting after rub-
bing with liniment, one  of the most efficient of which is the fol-
lowing :—
                             (3°)
      R. Olei gaultherise, opt.,
          Spir. chloroformi......aa .....  ^ ss
          Lin. saponis,   ........., . .  . ^iij.      M.
      S.—To be applied for the relief of rheumatic pains.—M. P. H.

  Of internal remedies salicylate of soda justly holds the first place,
though it sometimes produces hebetude and depression of the
heart's action without any appreciable effect in  warding off heart
complications.   Da Costa prefers the bicarbonate  of soda in mint- 
DISEASES OF  INNUTRITION.
75
 water until the urine becomes alkaline, and the author thinks very
 highly of salicin, especially in subacute cases in anemic children.
 Quinin sometimes works wonders after all the usual remedies
 have failed, and opiates are permissible for pain, especially codein.
   Iodides are our chief  reliance in pericarditis and endocarditis
 where absolute rest must be insisted upon.
   Prognosis.—Good as regards life, especially in first attacks.
 General mortality y/2 per cent., but it should be remembered that
 apparent cures very often leave heart lesions behind from which,
 many years later, such children die.
   The course of rheumatism in  the  child depends largely upon
 the  nature and character of its heart complications.  Da Costa
 fixes the average as between two and three weeks ; Goodhart much
 less, but there is hardly  any disease either in the adult  or child
 which is more liable to relapses  and exacerbations upon slight
 provocation.  Resulting  anemia is very prone to be tedious.


                      7. SCORBUTUS.
   Synonym.—Infantile scurvy.
   Definition.—A diet dyscrasia, arising  from lack of fresh food,
 and  characterized by anemia, spongy gums, and  subperiosteal
 hemorrhage.
   Etiology.—Bad hygienic surroundings, combined  with food
 deficient in  fresh vegetables and meat, will invariably produce
 scurvy, even in  persons  previously healthy.  Gradual  starvation
from disease, as typhus, or from improper infant foods, give rise to
 scorbutic symptoms, which are increasingly frequent with the in-
 crease of starchy, proprietary infant foods, especially those that
 do not call for their mixture with fresh milk.  Hence, like rickets,
 infantile scurvy is more frequent in this country, unless much of
that  previously existing  has  been confounded with purpura or
rheumatism by earlier writers.
   Symptoms.—Such children are anemic and irritable and hate
to be handled, and are disinclined to move the lower limbs. There
is marked tenderness about the knee, ankle, or thigh, the latter of
which not infrequently shows a fusiform swelling and loss of use
of the limb.  Then comes swelling of the gums, with tenderness 
76
DISEASES OF CHILDREN.
and  bleeding if teeth  have been  cut.  As in  simple ulcerative
stomatitis, the edges of the gums become swollen, reddish blue, and
the teeth loosen.  In severe cases  ulceration ensues with a gan-
grenous  odor and the dribbling of an offensive reddish-brown
saliva.  Hemorrhage  may  occur also from the tongue,  mucous
membranes, or anywhere from the  surface of the body.
  Differentiation.—In rheumatism the swelling  is  apt to be
circumferential instead of fusiform, and the joints are red  and hot
to the touch.  Ulcerative stomatitis gives a history of some previous
disease, and the oral  mucous membrane  is hyperasmic, while in
infantile scurvy the mucous  membrane  of the cheeks and hard
palate is always anemic.
  Pathology.—According to Northrup, the pathological changes
are those of emaciation, ecchymosis, and subperiosteal hemorrhage
of the femora, often with detachment of the epiphyses.  The tibia
may be similarly affected and the gums are swollen, spongy, and
blood stained.
  Treatment.—Fresh food is the  specific for infantile scurvy, as
it is in the adult, hence the  use of all artificial foods should be at
once interdicted and the child«put upon milk and fresh meat juices.
The  milk may be sterilized  or Pasteurized if it otherwise disagrees
with the child, otherwise it should be used raw, and  the beef juice
should  be  expressed   from partially cooked meat  with a lemon
squeezer, or press, just before giving. If the child is  older, scraped
beef, lettuce,  potatoes, and  acidulous fruits will hasten the cure.
Astringent  mouth washes,  such as  3ss tinct. of myrrh  to ^viij
water, will add much to the comfort of the child, and if gangrene
has occurred swabbing the  mouth with  a dilute solution of per-
manganate of potash  should be  practiced  as required to remove
the odor.  If the anemia is  great, iron will hasten its cure. Dilute
muriatic acid and pepsin may be required for enfeebled digestion
and  quinin inunctions (3j  to |j  lanolin) when the  stomach  will
not tolerate its internal use.
  Prognosis.—Excellent  when  timely change can  be made from
errors in feeding  and hygienic surroundings.  The occurrence
of scorbutus ought to be  considered as  evidence of  criminal
ignorance, to be prosecuted, as are captains who allow it to ap-
pear on shipboard. 
               THE ACUTE INFECTIOUS  DISEASES.             77




                        SECTION V.

      THE ACUTE  INFECTIOUS  DISEASES,
 or those which are known to  be contracted from those previously
 sick of the  same disease, are smallpox, diphtheria, scarlet fever,
 chicken-pox, measles, rotheln,  pemphigus,  influenza,  whooping
 cough,  syphilis, and mumps,  all of which are now believed to be
 due to the  introduction and growth in the body of the specific
 microorganisms producing these various diseases.

                     I. VARIOLA VERA.
   Synonyms.—Smallpox ;  Pocken ; Blattern.
   Symptoms and  Course.—Smallpox and  its modifications
 of varioloid in the child, differ in no respect, either in etiology,
 stages,  course,  or complications, from the same diseases as seen in
 the adult.
   Differentiation.—May be  assisted  by  remembering the  fol-
 lowing  table:—
                                 Latent.   Appears after first rigor.
        Scarlatina,........4-8 days,   18-24 hours.
        Erysipelas,........4-7  "     24-26  "
        Variola..........8-14 "     48      "
        Rubeola,........10-12  "     72      "
        Varicella,........8-14  "     10-12  "

   It should also be remembered that in  smallpox there is first an
erythematous blush, in the midst of which small hard papules  ap-
pear—at first on  the  forehead—on which, by the  aid of a mag-
nifying  glass, small vesicles may be  distinguished.  This  serves
to differentiate  it  from scarlatina and erysipelas, for which it at
first might be mistaken on account  of the initial erythema.   Later
umbilication makes the diagnosis certain.
  Treatment.—During the prodromal  stage, chloral hydrate, or
antifebrin may be used with advantage for the atrocious head and
backaches.  Phenacetin and icebags may be indicated, if there is 
78
DISEASES OF  CHILDREN.
threatened hyperemia of the brain.  Kormann strongly advises the
pricking of each vesicle early with a gold needle, and later touch-
ing with a strong solution of nitrate of silver.  Others speak well
of iodoform in glycerin,  or powdered charcoal on cotton wool,
for pitting is much less  marked when the pustules are protected
from the light.  Diet  should be  light, and the bowels kept open,
and  the fever in  check with antipyretics.   Scratching must be
prevented during the formation of scabs, if necessary, by tying
the child's hands in small  muslin bags.   Dusting with  starch, or
applying  boro-glycerin (50 per cent,  solution) will  sometimes
allay  the  itching, which  often  is intolerable.  Others rely upon
equal parts of oil and lime water containing  subnitrate of bismuth
in suspension, and the  thickened epidermis of the palms and
scales may be softened by a strong solution of potash carefully
applied.
  Threatened septicemia should be energetically combated with
the free use of quinin and alcohol.  Gargling with a weak solution
of permanganate of potash often relieves the  throat, and a four
per cent, solution of cocain lessens the pain  in the ears.
  Prophylaxis.—The prophylaxis of smallpox is one of the most
important duties of the physician, whose neglect in isolating indi-
vidual cases of smallpox,  or carelessness in vaccination, can hardly
be condoned.  Revaccination, no matter how recently performed
before, should be insisted upon  after every  known exposure of a
child  to the disease, for even if it does not prevent the occurrence
of smallpox it will greatly modify its course.
  Vaccination generally protects for from seven to ten years,
and protection begins five days  after vaccination (K.).   It is per-
formed preferably in the spring or early summer, before or between
dentition, therefore best  about  the third or tenth  month, unless
the child should happen to be born during an epidemic of variola,
when vaccination should be made as soon as possible after birth.
  Vaccination  may be made directly from arm  to  arm  from a
healthy vaccinia vesicle, or, as is  more frequently done in this
country, with a bit of  ivory dipped in the lymph from a vesicle on
the udder of a calf suffering from true cow-pox.  It is not neces-
sary to  make an  incision to insert the lymph, as is sometimes
done.  Thoroughly disinfect  the skin and then criss-cross it, pre- 
THE ACUTE INFECTIOUS DISEASES.
79
 ferably over the deltoid, until it begins to ooze serum, and rub-
 bing with the end of the ivory containing the virus, is far  better
 than a deeper incision, as the flow of the blood often prevents the
 very thing it is designed to accomplish. The clothing should  be
 be kept away from the arm until the spot has entirely dried, and
 after this  it usually requires no further attention.   On the third
 to the  seventh day the  point  pricked becomes reddened and
 slightly elevated into a  nodule.  A couple of days later (fifth) a
 clear vesicle appears on the summit of this, and soon shows um-
 bilication, which is the time for taking lymph if direct vaccination
 from it  is now desired.  After the seventh  day the vesicle  trans-
 forms itself into a pustule, its  contents  becoming turbid and the
 surrounding areola  redder.  Often there is also slight fever, rise
 of temperature, restlessness, and thirst  for a day or two.  About
 the  twelfth day the  pustule  begins  to desiccate  and the  scab
 drops off, leaving  an irregular, reddish cicatrix, which eventually
 becomes white, with fine pitting, if typical.
  Vaccination does not always run the simple course here detailed,
 for all its symptoms may be intensified, and added to them the chill
 and  fever of suppuration, convulsions, or fatal  collapse.  Urticaria
 and  erythema are by no means infrequent with neurotic children,
 also  eczema and ecthyma in those predisposed to scrofula, in whom
 sometimes the pustules obstinately refuse to heal, converting them-
 selves into  sluggish ulcers.   Erysipelas  may complicate  when
 children are vaccinated in septic houses, and  in such the erysipe-
 latous inflammation may spread over the entire arm and trunk,
 and  recovery not take place in two or three weeks.  Treatment of
 such cases is, of course, the same as  that of traumatic erysipelas
 otherwise produced.  Syphilis is apparently the only disease which
 can  be  transmitted by vaccination, and hence the greatest care
 should  be  exercised in the selection  of humanized virus,  good
bovine always to be preferred, and vaccination to be repeated  at
least as  often as once in ten years and as much oftener as exposure
takes place, since  in no  other way can we be sure that it still
renders  the child immune to variola.  If this  is thoroughly done
the mortality falls to 0.3 to 100,000. 
80
DISEASES OF CHILDREN.
                      2. VARICELLA.
  Synonyms.—Chicken-pox; sheep-pox; Windpocken ; " crys-
tali."
  History.—Name varicella by Vogel in  1764; its popular name
of chicken-pox, being given from the resemblance of its vesicles
to the chick-pea.
  Course.—After a period of incubation of eight to fourteen days,
either with or without a prodromal  stage of one to three days of
slight chill, short rapid rise of fever, pain  in the limbs, vomiting,
loss of appetite, etc., papules appearand develop in about one-half
a day into vesicles, of the size of a pin-head to a pea surrounded
by a red areola, rarely, and then but slightly, umbilicated. During
the next few days the contents of the vesicles become sero-purulent
and  turbid, and generally after-crops of eruption appear, so that
fresh vesicles and old stand side by side.   After three to four days
their contents dry  into a  thin crust, which  becomes detached in
two to three days, and unless there has been scratching, no cicatrix
is left, but only a  red spot.  The vesicles appear thickly on the
back, but the largest ones are generally found on the face, where
they remind one of variola pustules. Often  they may be found
in the fauces also,  causing cough.
  Diagnosis.—The chief interest connected with varicella lies in
its differentiation  from variola, especially in  its modified  forms.
This is not always possible from  a single examination, but it may
be helpful to remember that the papulation  is more marked and
prolonged in smallpox where the papules are a marked feature,
while in chicken-pox the eruption never feels shotty, and becomes
almost at once vesicular.   Pustulation is the rule  in variola, the
exception in varicella, which is a very mild disease  of brief dura-
tion, while the temperature remains high for five or six days in
smallpox, rises again  on the sixth to  ninth, and continues elevated
for ten days longer.
   Treatment.—Chicken-pox rarely requires any treatment, ex-
cept perhaps a mild laxative and dusting with starch to allay the
itching, which is sometimes annoying.
   Prognosis.—Always favorable except in those tubercular pa-
tients who are badly housed, and whose vesicles, instead of heal- 
THE ACUTE  INFECTIOUS DISEASES.
81
ing, become necrotic and constitute  the  so-called varicella gan-
grenosa.
                      3. SCARLATINA.
  Synonyms.—Scharlach; scarlet  fever; " morbilli ignei."
  History.—First described by Dr. Doring, of Breslau, in 1625,
but up  to the time of Sydenham (1670) was  supposed to be a
variety  of measles, nor  was its contagiousness understood until
investigated by Fothergill in 1750.   Since the disease came into
America in 1735, it has constantly spread, until to-day it has be-
come endemic in all our large cities,  and  rightly the most dreaded
of the exanthemata of childhood.  One attack, as a rule, protects
from a return, though well attested reports of second and third at-
tacks are on record, and  recurrent attacks of sore-throat in nurses
and physicians caring for scarlet fever patients are very common.
The coexistence of scarlet fever and measles, or scarlet fever and
varicella, is also possible.
  Etiology.—It could be wished that we were possessed of more
accurate knowledge in regard to the bacteriology of this disease,
all  of whose symptoms  are best explained by a microbic origin.
The specific bacillus is probably that figured by Dr. Edington, of
Edinburgh, and  named  by him bacillus scarlatinas.  According
to Dr. Shakespeare, this  may always be  found  in the blood of a
scarlet  fever patient for the first two  or three days of the disease,
and later in the desquamating scales. The latter are probably the
usual means for  its dissemination, though the methods by which
they may be  carried are  almost legion.   It is entirely possible that
the contagiousness of the urine  and  feces claimed by some is due
to these poisonous particles  which they contain.  It is universally
conceded that the stage  of  desquamation is the most dangerous,
and during this the poison is frequently carried from one house to
another by means of  clothing, a third person, milk, letters, books,
toys, and almost  everything handled by those sick of scarlet fever,
though  the  contagiousness  of different  epidemics  seems to vary
greatly.  Children  under six months usually escape, and  those
up to a  year are fairly exempt.
  Symptoms and  Course.—The period of incubation varies
from two to eight days, followed by the onset of the disease lasting
twelve to forty-eight  hours, characterized by chilliness, nausea, 
82
DISEASES OF CHILDREN.
high fever (io3°-io6°  F.), thirst, languor, and sore throat,  with
swelling of the lymphatics of the neck.
  The scarlatinal eruption usually appears within forty-eight hours
after the onset of the disease, as a scarcely  perceptible scarlet
flush or pin-point eruption, not unlike the color of a boiled lobster.
This begins on the neck or cheeks and in forty-eight hours spreads
over the entire body, either as a uniform redness or in large patches
—S. variegata.  Ruddy children show the rash more distinctly,
which is intensified by  the heat of the bed, crying, and hot baths.
Until the eruption  is well out, the fever continues high, often ex-
tremely so—io5°-io7°—the  pulse quick  and  sthenic, except in
cases of malignant scarlatina, when there may be general depres-
sion, delirium, and collapse.  There is always a moderately pain-
ful sore throat and pharyngitis. The tongue is furred with a bright
red tip and borders, "strawberry tongue," or the papillae may be
greatly swollen  and cause  the  granular  appearance known as
"raspberry tongue."   These symptoms disappear  on the fourth
day, after which the fever has only evening exacerbations, unless
inflammatory complications  cause a fresh increase.  Next comes
the stage of desquamation  or "scaling."  Those places which
first became red fade in like  order, though for awhile the loins and
thighs increase in redness. Accompanied with great itching of the
face and neck  its epidermis becomes cracked and cast off in
shreds, or lamellae, the hands and tips of the fingers shedding these
most abundantly, especially  after a  well-marked erythema.  Des-
quamation also occurs from the attacked mucous membranes of
the tongue, throat, trachea, kidneys, and intestines.
  This is the natural course  of a typical case of scarlatina, but we
find variations, such as—
  (a) Scarlatina sine angina, or a scarlatina without a  sore throat.
  (b) Scarlatina sine exanthema;  very difficult to diagnose and
usually very fatal in its results, only recognized by the appearance
later of  scarlet  fever  among  other members of the  family.  In
some of these cases desquamation occurs, proving that an erup-
tion probably took place, of only a few hours' duration.
  (c) Scarlatina papulosa is  another variety, in which the papillae
of the  skin become  swollen  and the whole surface of the  body
assumes a "goose-skin " appearance. 
THE ACUTE  INFECTIOUS DISEASES.
83
  (d) Scarlatina  miliaria is a modification  of the last, in which
these papillae are  covered with vesicles.
  (e) Scarlatina petechialis ; most dangerous of all. See Purpura.
  Complications and Sequelae.—The most frequent of these
is an intensification  of  the  ordinary angina of scarlatina into a
diphtheritic form, in  which more or less of the tonsils and uvula
is covered with a  grayish-white membrane. When this is removed
the superficial layers of the  subjacent  mucous  membrane will be
found destroyed,  and in malignant  epidemics of this variety  of
scarlatina this may proceed to actual gangrene of the tonsils and
their surrounding parts.  Or the diphtheritic inflammation may ex-
tend up the Eustachian tubes and result in permanent deafness.
Or a croupy metallic cough informs us  that the  membrane has ex-
tended into the larynx.   When the nostrils are similarly affected
with a diphtheritic coryza, there is a profuse, thin, excoriating dis-
charge from  the  nose,  often exceedingly offensive in odor, and
septicemia is usually not far distant.  Even in mild forms of diph-
theria, septicemia is possible from  the later  inflammation and
suppuration of the parotid, or lymphatic glands, though, as a rule,
it will be found true  that the involvement of the lymphatic glands
is  in direct proportion to the severity of the throat lesions.
  (b) Diarrheas and dysenteries sometimes occur during the same
stage of the disease,  and are produced probably by desquamation
of the intestinal epithelium.
  (c) The tubuli  uriniferi, like the intestines, normally shed  their
epithelium at  this time—epithelial casts in urine—but often there
is a true  hyperemia  of the cortex, and  even inflammation of the
convoluted tubes associated with  this,  so that hyaline casts also
appear in the urine,  and if a large portion of the  kidney is impli-
cated, death  may result from the uremia of  a  morbus  Brightii
acutus, or from dropsy, described later.
  (d) More limited  disease of the kidney may  cause localized
edema, such  as ascites, hydrops pleurohydrothorax, hydrops peri-
cardii, edema of the  lungs, or dropsical effusion into joints.  Such
complications not infrequently follow a short apparent convales-
cence, during which  the children recover their appetite and exhibit
nothing abnormal except perhaps slight lassitude.  Then appear
loss of appetite, depression and pain in the region of the kidney— 
84
DISEASES OF  CHILDREN.
one or both.  The amount of the urine is greatly diminished (siv-
gx in as many days).   It is concentrated, bloody,  and contains
albumin and casts.  In a few days the whole body becomes bloated,
hands, face,  and feet  simultaneously, and respiration becomes
short, superficial, and labored, so much so that the child can sleep
only in the sitting posture, and grasps eagerly any object which
promises to aid the pectoral muscles in their effort to expand the
chest.  If the case is further complicated with hydropericardium,
the pulse becomes small and  irregular and precordial distress  is
very marked.  Such cases generally end fatally,  either from fatty
degeneration of  the kidney and consequent uremia, or suddenly
from heart failure or edema of the glottis.   But if the kidney lesion
be confined to a small area, the albumin may gradually disappear
from the urine, the dropsical effusion may be absorbed, and a slow
recovery effected.
  (e) All varieties of scarlet fever  implicate to  a greater or less
degree the lymphatic glands of the neck, giving rise  to cervical
adenitis,  which varies from slight engorgement to a  brawny collar,
encircling the neck!  Excess of zeal in treatment of these swollen
glands often leads to suppuration, sloughing, and death from ex-
haustion or hemorrhage.
  (/) More rarely  serious cerebral affections, such as paralyses,
blindness, aphasia,  loss of memory, or idiocy, remain as sequelae
of scarlatina.
  (g) Rheumatic pains in the joints should have been spoken  of
among the symptoms of the third stage of scarlatina, and articular
rheumatism,  with or without  pleuritis or endocarditis, is one  of
its not infrequent sequelae.  It  may  successively  attack  all the
joints of the body, and occasionally leads  to suppuration.
  (h) Noma has also been known to follow scarlatina, in very un-
sanitary  localities, and  multiple abscesses are by no means infre-
quent.
  Prophylaxis.—Next to the  care  which  should be taken  to
restrict the spread  of smallpox, it is  incumbent upon the family
physician to see that similar care is exercised in regard to scarlet
fever, which is contagious from the initial sore throat until the last
branny scales, usually  between the  fingers or toes,  have been
removed. Six weeks' quarantine is none too long for an average 
THE ACUTE INFECTIOUS  DISEASES.
85
case of scarlatina, and this must be lengthened if desquamation is
not finished by that time.  If possible, other children should be sent
from the  infected house, until  recovery has  taken place and all
rooms occupied by the sick and their attendants have been disin-
fected.  This is most easily done  by burning a pound  of sulphur
in each room, closed as tightly as possible, and then thoroughly
scrubbing and ventilating before again occupying  the room.   All
sheets, bedding,  towels,  and articles that  can be  washed should
be immediately thrown  into boiling water as soon as used,  and
visiting friends and neighbors absolutely forbidden.  Sulphocarbo-
late of soda has some reputation as a prophylactic (gr. ij-v. t. i. d.).
   Treatment.—For the initial sore throat, vomiting, and fever,
little medication  is required.  If the nausea is annoying, the fol-
lowing will be found useful:—

      R.   Aquse calcis,
             "   cinnam.,   .....aa ......  30 c.c.
           Tinct. gelsetn.,   ............2 c.c.    M.
      Sig.—Teaspoonful hourly until relieved.—H.

   Chloral in small doses is the author's favorite method for  con-
trolling the nervousness  and discomfort of the earlier stages of
scarlet fever, and may be given as follows :—
                             (32)
      R.   Chloral hydrat.,.........2-4 gm.
           Aquae camph.,..........15 c.c.
           Syrup aur. cort.,.........45 c.c.      M.
      To alternate with other remedies to quiet restlessness. ■
   Others  speak very highly of  tinct. aconite given in first stage
until its full effects are produced, e.g.,  a drop every hour until its
physiological effects  are  obtained.  If malignant  from the onset,
prompt stimulation  by the  liberal  use  of  wine and whiskey, and
packing with wet sheets, wrung  out of hot water and  sprinkled
with mustard, hold out the best prospects of relief.  At the same
time the  throat  should  be carefully looked after, and  sponged
every two or three hours with undiluted peroxid of hydrogen, fol-
lowed with the liberal use of the steam atomizer, whose cup contains
gtt. v-xv,  olei eucalypt., or  better, Sander's eucalyptol.   Even in 
86
DISEASES OF CHILDREN.
mild cases, the inunction of the skin at least twice daily with car-
bolated vaselin, or  oleum theobromas, adds much to the comfort
of the patient, helps to limit the spread of the disease, and pre-
vents chilling of the body.
  Should the eruption be tardy in making its appearance, it may
be hastened by the mustard pack, or rubbing  the body with dry
mustard or hot vinegar.  Threatening cerebral symptoms during
the prodromal stage justify the use of cold to the head, and the
internal use of phenacetin and ergot with a purgative dose of calo-
mel, followed by some mild saline.  Failing strength, even when
the fever is  at its height, calls for quinin inunctions  and the in-
ternal use of alcohol to its full physiological effects, for, as in diph-
theria, there is a remarkable tolerance of alcohol, as ^ss or more
of the best whiskey can be given every half hour, with no symp-
toms  of intoxication and with  marked relief to the patient.  In
similar conditions, the Germans  generally advise camphor  and
musk in full doses.
  During the entire course of the disease the urine ought to be ex-
amined daily—twice, if there are any  suspicious symptoms—for
albumin and casts, and scanty urine should be combated with the
free use of lemonade, liquor ammonii acetatis, and  if these fail
minute doses  of calomel (one-tenth grain every two hours) and
caffein. If,  in spite of these, the symptoms of acute Bright's dis-
ease appear, with threatening anasarca, infusion of digitalis (3ss-
Z] p. r. n.) should be tried and the excretion from the skin encour-
aged by means of hot vapor baths, wet packs, or even jaborandi,
provided its after depression be  counteracted  by the free use  of
some generous wine. Should these fail, relief must be obtained by
means of  purgation, unless diarrhea is already present.  In ure-
mic convulsions  the  inhalation of  chloroform,  hypodermics  of
morphin,  or rectal  injections of  chloral and bromid (gr. v-x)
will usually ward off a single attack, but will not prevent their re-
turn and usually a  fatal termination.  Milk diet must be insisted
upon during kidney complications and iron and bitter  tonics for
general anemia.
  Prognosis.—The degrees of implication of the cervical lym-
phatics furnish a  valuable criterion as to the probable outcome of
the attack.  The mortality varies with the epidemic, varying from 
THE ACUTE INFECTIOUS DISEASES.            87
 3 to 33 per cent.   According to Dudley, in ioo cases, albuminuria
 may be expected in 49, adenitis in 19, otitis in 10, acute nephritis
 in  8, diphtheria in 4, arthritis 3, mitral lesions 2, and pneumo-
 nia 1.

                        4.  MORBILLI.
   Synonyms.—Measles ;  Masern ;  rubeola.
   Etiology.—Contagiousness very great, beginning with the pro-
 dromal stage ; by many supposed from microorganisms found in
 the nasal and pharyngeal mucus and  urine, hence very easily car-
 ried in soiled linen and by third persons.  Children  under one-
 half year are exempt.  Repetitions of the  disease are not at  all
 rare.  See German measles for differentiation.
   Symptoms and Progress.—After an incubation of 10-12
 days appears the prodromal  stage of  three to five days.  This
 is characterized by coryza, injection of the conjunctivae, sometimes
 with photophobia, hoarseness, and a dry cough.  Generally vigor-
 ous children do  not wish to lie down ; while the feeble ones feel
 languid in consequence of their loss  of appetite, and  in such the
 evening fever may produce delirium.  In the beginning  of the
 prodromal stage  there is  an  immediate rise of temperature; but
 this sinks in one-half to one day to the normal, then increases again
 to 1040, with morning remissions, until the second stage (eruptive),
 which begins on the fifth day.  The  exanthema commences first
 on the face, on the cheeks  or nose, and spreads thence in a day
 over the whole body, in the  form of small, pea-sized, bright or
 bluish-red, round, irregular spots or  patchy rash, which become
 more or less confluent, but there can always be found  interspaces
 of  normal cuticle between patches.   The lymphatics  are slightly
 swollen.  In rare cases we find the summit of each spot crowned
 with a yellowish vesicle (morbilli miliaria), but usually  the redness
 increases until the flushed spots become elevated a little above the
 sound skin.  These may be distinguished from the papules of small-
 pox by stretching the skin, which causes the papule to become im-
 palpable to  touch in measles, but does not remove the shotty feel
 of the  variola papule.   Upon  the completion of the eruption the
 fever reaches its  highest  point, and thereupon  follows a  critical
decline (crisis), when all the symptoms diminish in severity.  From 
88
DISEASES OF  CHILDREN.
the third day the eruption begins to fade in the same order as it ap-
peared, leaving in its stead a brownish hue, due to the deposition
of pigment  stain.  The tumefaction of the skin diminishes, but
the bronchial catarrh increases on account of a similar eruption on
the bronchial mucous membrane.   During the third, or the stage
of desquamation, the epidermis is  cast off in fine, mealy scales
(similar to bran), and the  general  condition improves so  rapidly
that  the children are now ready to walk  about.  The bronchitis
occasionally persists for several weeks, and requires constant  care
from the physician.  Measles may begin on the feet and legs or
may exhibit any of the following variations:—
  (a) Ecchymosis into the measly patches—morbilli-hemorrhagici
—occasionally  complicated  with  severe  hemorrhages  from the
mucous membranes, or diphtheritic affections of the same, e.g.,
of the conjunctiva, nose,  pharynx, larynx, or vagina.  Premature
menstruation noted in many of these cases.
  (b) Unusual implication of the mucous membranes, in the shape
of excessive coryza,  conjunctivitis, blepharitis, from the implica-
tion of the conjunctiva, or keratitis pustulosa with its complica-
tions.  Hyperemia of the glottis may give rise  to  a continuous
irritation, which produces a highly paroxysmal cough, resembling
pertussis.  Or the abundant secretion of the bronchial tubes  may
flow into the alveoli  of the lung, and result in the lobular pneu-
monia, which is often found in the  youngest children.  The  des-
quamation of the intestines  sometimes leads to a diarrhea, simu-
lating dysentery, and difficult to check.
   Sequelae.—(a) Chronic bronchitis, with bronchiectasis,  lung
atelectasis,  and  pneumonia, which  frequently  runs a  chronic
course,  predisposing  to miliary tuberculosis, caseous degeneration,
and a rapidly fatal termination,   (b) Whooping-cough often fol-
lows measles,  (c) In scrofulous children, eczema of the face and
hairy scalp, purulent inflammation of the middle ear, chronic otor-
rhea, or blepharitis, etc.;  more rarely noma occurs.
   Prophylaxis.—Perfect isolation  is only  necessary in those
families where phthisis has already occurred, or where the children
are suffering from bronchitis.
   Treatment.—During the height of the fever cold  drinks, as 
THE ACUTE  INFECTIOUS DISEASES.
89
lemonade, and a  mildly diuretic  expectorant  mixture are desir-
able, e. g.:—
                             (33)
      R .  Liq. pot. citratis,............30 c.c.
          Syrupi ipecac.,............5  "
          Tinct. opii camph.,...........10  "
          Succi limonis,.............15  "
          Tinct. gelsem.,.............2 "      M.
      Sig.—Teaspoonful in water every two hours, or as required.—H.

  If headache annoys, cool  cloths are to be applied to head and
dilute hydrobromic acid substituted for the paregoric in the above
mixture.  Should  further remedies  be required, phenacetin (gr.
ij-iv) will be found useful.
  After the height of the disease has passed, for a couple of weeks
great care should be taken to keep the child  in a room with  an
even  temperature, until the sensitiveness  of the skin  has disap-
peared and the bronchial catarrh is entirely recovered from.
  Minute doses of  morphin in  cherry laurel water, and syrup of
tolu, will be found helpful in cutting short the paroxysmal  cough-
ing which sometimes persists after an attack of measles.
  When the cough is exceedingly persistent and caseation of the
bronchial glands is feared,  the child should be  placed upon cod-
liver  oil, extract  of malt, and syrup of the iodid of iron, and if
possible taken to the country for a while.
  Prognosis.—In well-to-do families the  mortality ought not to
reach more than 5 per cent., but among the very poor, or where the
disease  flourishes  in a virgin soil, as in the Fiji Islands in 1875,
the mortality is frightful—one-quarter of the entire population dying
from the disease.

                        5.  RUBELLA.
  Synonyms.—German measles ; Rotheln ; bastard measles.
  Etiology.—Undoubtedly due to  a specific  organism, not the
same as that  of either  scarlet fever or measles, since previous
attacks of either do  not protect from rubella, which rarely occurs
twice, except as a recrudescence.
  Symptoms and Course.—After a period of incubation of
about fourteen days, the prodromal  stage begins, lasting a varia-
      G 
90
DISEASES OF CHILDREN.
ble length of time, from two hours to as many days.  It is,  as a
rule, without fever, or of a very moderate  amount, shows swollen
lymphatics of the  neck, injected conjunctivas and swollen  lids,
slight malaise, and mild catarrh of the air passages.  This is fol-
lowed by the eruptive stage (one-half to three days), during which
the exanthema appears,  sometimes  with  a lively fever of  brief
duration and sharp itching of  the  skin.  The  eruption  occurs
first  on the face  and neck and then over the entire  body, ex-
tremely like an attack of measles, except that it is less circum-
scribed and more scarlet in color.  With the eruption every trace
of fever disappears, and  in twenty-four to thirty-six hours the
child's skin begins to regain its normal color.  Slight desquama-
tion  may follow.
  Differentiation is often difficult and can only be made  from
the entire course of the disease.  Fever ordinarily disappears in
twenty-four to thirty-six hours ; later the exanthema  begins to
fade.  The eruption of rubella is multiform, and it is claimed that
it never arranges itself crescentically, as measles does.   The en-
largement of the post-cervical and auricular glands is claimed by
some to be pathognomonic of the disease, but similar enlargements
may be found in rubeola and in dentition.
  Prognosis.—Good.  There are no sequelae.
  Treatment.—Dusting with corn  starch to allay the itching of
the skin, and a dark room if the conjunctivitis is troublesome, are
all that are usually  required.   Cool  drinks may  be allowed if
craved by the child, or sponging if the temperature rises too  high.

                       6.  LA GRIPPE.
  Synonyms.—Epidemic influenza ; Russian influenza.
  History.—Described some 250 years ago,  but  practically un-
known in America until 1890, when a fearful epidemic swept over
the country, with recrudescence in 1891 and 1892, and again mildly
in 1895, killing and crippling more than the late Civil War.
  Etiology.—Preeminently a contagious disease, spreading from
person to person, not even nursing children being exempt.  More than
one  form of microorganism has been found in the sputa of  these
cases, and undoubtedly some one of these  is the contagium vivum
of this  disease, but of the modes  of entrance into the body we 
THE ACUTE  INFECTIOUS DISEASES.
91
know little.  The earlier cases of the epidemic  are apt to  be the
most violent, the patient, especially if young, being overwhelmed
with the virulence  of the  poison, as in the foudroyant forms of
diphtheria or scarlet fever.  Its period of incubation is apparently
of very short duration.
  Symptoms.—Invasion is rapid with young children, announc-
ing itself by headache, earache, chill, or convulsions, and delirium
and fever often high (105-107).  The poison thus introduced may
attack either the respiratory, the intestinal, or the nervous system.
Bronchial  catarrh is a frequent complication, threatening  life by
the violence of its  onset and yet generally with a better prog-
nosis than when the cerebro-spinal system bears the brunt of the
attack.  Cough is apt to be  persistent and very annoying and
syncopal attacks prone to occur.  Depression of the heart's  acfon,
out of all proportion to physical symptoms, is one of the frequent
and alarming symptoms, in many of these cases ; or  exhausting
vomiting and diarrhea, simulating  cholera morbus, may tax the
skill of the physician, as will also the extreme irritability and
fretfulness on  the part of the child.   As may  be inferred  from
personal experience, headache and general muscular aching  is as
well-nigh intolerable to  the  child as it is to the adult. On the
other hand, we find in some of these children a  heaviness closely
approaching coma, but even  these resent the slightest touch or
attempt to examine by the physician.   The course of the disease
with children is discouragingly slow, for  while the acute symptoms
subside within two weeks, sequelae of indefinite duration remain.
  Sequelae.—Glandular enlargements and parotitis.  Also abscess
of the  antrum and cellulitis, with or without  metastatic abscesses.
Chronic conjunctivitis and suppurative otitis are more frequent,
and the latter may terminate in meningitis, especially if the child
is of tubercular parents.  Earle adds  to this  list  rheumatism,
chorea, nephritis, and periostitis, and  Althus, neurasthenia, hypo-
chondriasis, melancholia, and delirium.
  Treatment.—Phenacetin  and salicylate of soda  stand  at the
head of remedies for the relief of the muscular pains of this dis-
ease, but they should never be pushed  to subsequent prostration.
Hot punches containing wine of coca are grateful in the early
stages  of influenza  bronchitis, which should be  treated from the 
92
DISEASES OF CHILDREN.
beginning with  stimulating instead  of  depressing  remedies.
Opiates should be avoided  as  far as possible in the treatment of
the intestinal catarrh, and bismuth, salol, and saccharated extract
of coto used in their stead.  Syrup hypophosphites, malt, and liquid
peptonoids for retarded convalescence.
  Prognosis.—Bad in  the  fulminating form, in others recovery
may be expected, except in tubercular children.
  Prophylaxis.—Influenza is a contagious disease and may be
spread by handkerchiefs, clothes, and cuspidors, all of which should
be disinfected after use by influenza patients.


                       7.  PERTUSSIS.
   Synonyms.—Whooping cough ; tussis convulsiva.
  Etiology.—Epidemic and  very contagious, especially  in the
third stage, infection taking place  through the breath and expec-
torations, and also through third persons  or  pieces in the wash,
hence  its spread through schools, children's homes, and hospitals.
The contagion undoubtedly resides in a microbe carried from one
person to another, probably the  bacillus  tussis convulsivas, de-
scribed by  Afanassiew in 1887, who  explains the characteristic
symptoms as arising from  the irritation of the  superior laryngeal
nerve  by the toxines of this bacillus.
   Symptoms and Progress.—After an incubation from 2-7
days, the first stage, of premonitory symptoms, occurs (stadium in-
crement!), which lasts from 1-3 weeks, and is characterized by a
bronchial catarrh and a teasing, dry cough, with  tickling in  the
throat and a slight evening rise of temperature. Very gradually this
cough becomes convulsive, occurring in the  paroxysms which at-
tend the second stage of the disease (stadium nervosum).  This is
the only one which is diagnostic  of  pertussis, for in it occur the
so-called spasms (3-50 in a day), which are occasioned by the at-
tempts of the child to expectorate the mucus which gathers in the
top of the windpipe.   These paroxysms are  of varying duration,
according as the mucus which  the child attempts  to raise is tena-
cious  or fluid, and whether the inspired air becomes  carbonated
or well oxygenated.  Changes of  temperature, sneezing, anger,
j oy, or laughing and violent movements of the body are all excit- 
THE ACUTE INFECTIOUS DISEASES.             93
ing causes of these attacks, which may be rare or frequent, accord-
ing to the intensity of the disease.
  One of the paroxysms may be induced for diagnostic purposes
by pressing with one finger the root of the tongue, until coughing
occurs, ordinarily beginning with a series of short coughs quickly
following each  other, and  succeeded by prolonged whistling in-
spiration, during which  the  child seeks  for some  support for its
head,  ordinarily  by placing  its elbows  on a fixed  object and
holding the chin between its hands.  During these paroxysms the
face and hands grow  livid, for these  attacks  are  produced by a
spasm of the glottis, which so narrows  its chink that little air can
reach the lungs, and what blood is circulating there fails to get its
proper supply of oxygen.  To counteract this, all the inspiratory
muscles  are put to their  greatest activity.  The stagnation  of
blood, resulting in congestion of the pulmonary artery, produces
dilatation of the  right heart and the entire venous system com-
municating with it, hence the cyanotic hue of the face, the ecchy-
moses of the eyeballs, and even hemorrhage from the eyes or ears
or nose  sometimes  observed, and sometimes  the  straining is  so
great that  the urine and  feces  are passed involuntarily.  The
paroxysms  are terminated by the removal from  the trachea of
thick,  glairy mucus  either by vomiting or coughing, more  fre-
quently the former, during which hernia or prolapse of the rectum
have been known to  occur.
  If the  paroxysms in a day are limited in number and the vom-
iting  infrequent, the general condition of the  child may be but
slightly, if at all, affected, except that the face becomes bloated,
but if, on the other hand, the paroxysms increase in frequency,
especially toward evening, in such cases the children lose strength
rapidly, breathe with difficulty after each attack, and finally fall
asleep from exhaustion.  Lassitude,  peevishness, and general
anemia complicate these cases, and  in very young children the
paroxysms may produce convulsions and sudden death from suffo-
cation.
  On the other hand,  satisfactory progress toward recovery is
marked by the  mucus becoming more fluid and coughed out with
less  difficulty.  The  third stage (stadium decrementi) cannot be
sharply differentiated from  the  paroxysmal, which  is gradually 
94
DISEASES OF CHILDREN.
merged into the third by decrease in the frequency of the attacks
and the violence of the vomiting.  The duration of this stage  is
very indefinite, owing to the liability of the child to relapses, and if
enlargement of the bronchial  glands has taken  place, these re-
lapses  may  be almost indefinitely repeated, but in  general im-
provement is known by the  absence  of whistling inspiration, re-
turn of the natural color to the face, and the better tolerance  of
food by the  stomach.
  Pathology.—Autopsies in  fatal cases give no other lesions for
pertussis than  those of its complications, unless it may be unusual
irritation  of the posterior wall of the larynx in the  interaryte-
noid region, the so-called  " cough region " of von Herff.  All
other lesions arise from deficient expectoration of the thick, glairy
mucus, and its subsequent  descent  by gravity, with the produc-
tion  of catarrhal  pneumonia  and acquired atelectasis.  This  is
most frequent in infants, from their  custom of largely lying on
their backs.  The  onset of such complication maybe suspected  in
a child apparently improving, in whom sudden laborious breathing,
working of the alas nasi, appear, with fever and dry cough.   In
such cases death is alarmingly frequent, either from edema of the
lungs or convulsions.   When  recovery can  be hoped for, the alas
cease  to  dilate, and the cough again becomes characteristic  of
pertussis, but  even then a chronic pneumonia or a partial caseous
degeneration  of the bronchial glands is apt to follow. Anemia,
caused by too frequent vomiting and exhaustion, reveals  itself  in
edema of the  face and often of the remainder of the body.  The
most trivial of the complications attending pertussis are the small
ulcers of the  frenum produced by its friction against the lower
incisors during the violent  paroxysms of coughing, the so-called
whooping-cough ulcer.   These  ulcers  heal very easily,  if the
child can be induced to retract the tongue  during the paroxysms
of coughing.  Gastro-duodenal  catarrh, arising  from  swallowing
masses of slime and too frequent vomiting,  is one of the frequent
and dangerous complications of pertussis, since  its  anorexia rap-
idly weakens  the  already debilitated child.  Hyperemia of the
brain,  produced by straining during coughing, sometimes occasions
capillary extravasation, violent pain  in the head, vomiting, con-
vulsions, and coma,   Tubercular meningitis is  also  one of the 
THE ACUTE INFECTIOUS DISEASES.
95
possible complications of pertussis, especially when there is ac-
companying caseous degeneration of the lymphatics.  Pemphigus
is one of the complications to be dreaded, as it betokens profound
debility.   Among the rarer sequelae are dilatation of the bronchi,
chronic pneumonia with  caseous degeneration  of the bronchial
glands, secondary tuberculosis, hernia, prolapsus recti, emphysema,
pleurisy,  empyema, pueumothorax, edema  of  the glottis,  and
various cerebral palsies.
  Prognosis in general is fair, although the mortality for earlier
months of life is still very high, Dolan placing  it third among
the fatal diseases  of children in England.   In  this country the
mortality ranges from 3 to 15 per cent.; the younger the child the
more unfavorable the prognosis.  Death may occur in very young
children from suffocation during an attack, though such accidents
are rare.   Convulsions are not  unusual,  though  usually not as
dangerous as might be expected.  The mortality of the third stage
is  the  highest, owing to  the dangers  of its  many complications
previously mentioned, also  heart  strain, too often overlooked.
Glycosuria is a frequent complication, though not invariably so as
once claimed.
  Prophylaxis consists mainly in the removal of children, es-
pecially those  predisposed to tuberculosis,  from cities during an
epidemic of pertussis, so long as the disease continues.  Vaccina-
tion protects for ,a while  from pertussis, hence  all unvaccinated
children  should be vaccinated during the prevalence of  an  epi-
demic  of whooping  cough.   Two months'  isolation should  be
insisted upon ;  three,  if necessary.
  Treatment.—So large a number of specifics have been recom-
mended for the cure of pertussis that the superiority of any of them
may reasonably be  doubted; the more so, since in one  epidemic
a remedy  may appear of great value and yet fail  dolefully when
put to the test in the next.  This seems to be especially true of the
preparations of belladonna, which may be given either in the form
of the  powdered root, one-tenth to one-sixth of a grain twice or
three times a day, until the pupil shows the characteristic dilata-
tion produced by the drug, after which smaller  doses should be
given.   The preparations of opium are also largely  used to  combat
sleeplessness in appropriate doses. Carbonate of  potash has some- 
96
DISEASES OF CHILDREN.
thing of a reputation as a solvent for the tough mucus, and may
be profitably added to  the expectorant  mixtures ordinarily  used
during the second and third stages of the disease.  Chloral hydrate
in full doses is of real assistance in the  second  stage, for which
others recommend morphin in minute doses.   Bromoform in one-
half to one drop doses, suspended in syrup, has in a limited  num-
ber of cases fully met the editor's expectations.
  In the later stages tannate of quinin  or  alum is of value, as
are also powdered Peruvian bark and the sacchara'ed carbonate
of iron, if the child can be induced to take them  in  full enough
doses.  A change of air also sometimes works wonders.  Volun-
tary inhalation can scarcely  be  practiced by children under four
years of age, but when this can be done the following formula will
be found  of use  in a steam atomizer.   The author much prefers a
hand-bulb atomizer, from which the spray can be thrown directly
into the nares and fauces of the child during the paroxysms,  which
are frequently cut short by this treatment.   A  two  per cent, solu-
tion of carbolic  acid or resorcin is well  adapted for this purpose,
though some prefer a saturated solution  of ammonia bromid,
e.g.: —
                             (34)
      R.   Sat. sol. ammon. bromid,
           Cherry laurel water, .  .  .  . aa.....f ^ ij. -     M.
    SlG.—For use in steam atomizer three or four times daily.

                             (35)
      R.   Antipyrin,..............0.50
           Syr. prun. virg..............2.0  c.c.
            "  tolutan,  .............40 c.c.
           Codein,.............p. r. n.         M.
  Sig.—Teaspoonful every two hours, for cough, will be found of advan-
      tage when  the child is not debilitated from any cause.—M. P. II.

  The vapor of cresolin or sulphur seem to modify the force of the
disease but will  not abort it, as  claimed, and  the  same is true of
the extravagant claims as to  the value of quinin  or resorcin insuf-
flations.   These should be blown directly into the pharynx, and,
if possible, drawn into the larynx, but while they modify the vio-
lence of the paroxysms, they do  not cut short the disease, and can 
THE ACUTE INFECTIOUS DISEASES.
97
 less conveniently be used than the sprays previously mentioned.
 Every effort should be made to diminish the number of attacks by
 means  of the  avoidance of their exciting causes, e.g., running,
 calling, loud or angry talking, etc.  Tickling the palate with a
 finger facilitates the removal of tenacious  slime by vomiting when
 the  child is found unable  to expectorate it  unaided.   Should a
 child become comatose during an attack of coughing, it  should be
 laid upon its back and cool  compresses applied to its head.  Diet
 should be as nourishing as possible, for a portion of the  food is
 always lost by  the vomiting which follows the paroxysms ; hence
 milk, peptonoids, eggs, or other concentrated nourishment should
 be given immediately after the occurrence of the attacks, as often
 as required, and stimulating drinks and dry  food, such  as bread,
 potatoes, should be avoided.  Pure air must be provided in as great
 abundance as possible, but unfortunately it is only in summer that
 children can spend much of their time out-of-doors, since chilling
 is most dangerous to such  children, hence the course of pertussis
 is generally more tedious in the fall than in the early spring.  The
 occurrence of fever during the progress of pertussis is  always to
 be dreaded, as it usually  betokens broncho-pneumonia.  The
 usual remedies for tardy convalescence and bronchial adenitis
 should be employed when recovery is unreasonably delayed.

                     8.  DIPHTHERITIS.
   Synonyms.—Diphtheria ; putrid sore  throat; Braune.
   Definition.—Etymologically,   diphtheria  means  simply   a
 membrane, and hence  may be  properly applied to any form of
 croupous membrane upon the mucous membranes or any abraded
 spot upon the body.  Careful study has proven that these mem-
 branes are  produced by various causes, and hence they are con-
 veniently  divided into simple fibrinous, pseudo-diphtheritic, and
 true  diphtheritic.   In  the present article the term  diphtheria will
 be restricted to those  membranes in which the Klebs-Loeffler
 bacillus may be found.
  Etiology.—It seems to  be fairly well  established that diph-
theria is primarily a local disease, due to a localized infection by
the Klebs-Loeffler  bacillus, either pure and simple or associated,
as is more  frequently the case with streptococci.   This surface 
98                 DISEASES OF CHILDREN.
diphtheria is of comparatively little importance until the reabsorp-
tion  of its  toxalbumins  into the  system takes place,  for  it  is
claimed that the Klebs-Loeffler bacilli never enter the blood nor
are found in distant organs.  (Dillon Brown.)   Inoculation of ani-
mals with the  toxalbumins  of the Loeffler bacillus produces the
sepsis,  paralysis, and visceral changes so well known at autopsies.
Hence we may expect to find two groups of symptoms in diph-
theria,  viz., those occasioned by the local diphtheritic growth and
those due to the absorption  of toxalbumin poisons produced by
the diphtheritic  membrane,  which poisons, together with strepto-
cocci and other forms of bacteria, produce the dangerous compli-
cations of diphtheria which have become the  scourge of all  large
cities.  It is doubtful whether a perfectly sound mucous membrane
will  permit  the growth upon it of the Loeffler bacillus, and it is
certainly true  that a catarrhal condition or  abrasion of the oral
membrane invites  the presence  and determines the locality of a
diphtheritic membrane.   Cold and dampness favor its growth and
bad air is especially conducive to its rapid  spread.  The conta-
gion of diphtheria is of short range but of persistent vitality, and
may be  communicated  by the  breath,  third persons,  infected
clothing, rooms, and dwellings, in which the poison may persist
for years.
   Symptoms.—During the prevalence of diphtheria every sore
throat  should  be regarded with suspicion, for we may have diph-
theritic infection with so little membrane, or so located that it es-
capes our attention. Usually, however, after 12 to 48 hours' exposure
difficulty in swallowing is first noticed, or the  disease may mani-
fest itself in the malignant  form with a chill, succeeded by a sud-
den  rise of temperature (io3°-io4°).  In milder cases the tempera-
ture rises quickly and drops to  normal in four days, but in  more
malignant  cases may  continue high for weeks, the heart  being
dangerously irregular.
   Diphtheria attacks, by preference, the back  part of the mouth,
appearing  at  first as a localized redness of  the  tonsils, palate,
and uvula.   At one or more points  upon  these appears  either
a curdy white or a grayish membrane.   Thickened voice, diffi-
culty in swallowing, and occasionally hoarseness also follow, while
a very unfavorable symptom is the regurgitation of food, especially 
THE ACUTE  INFECTIOUS DISEASES.             99
liquids, through the nose, due to paralysis of the muscles of de-
glutition, from inflammatory swelling of the throat.   Opening of
the mouth is  always difficult, but not uniformly so.  The cervical
lymphatics are often swollen ; often  there is resulting stiffness of
the neck.  Similar symptoms with no  visible membrane in the
throat may be explained by membrane  in the  nasal cavities—an
even more dangerous form of the disease—coryza diphtheritica,
characterized  by the escape  of a  copious,  offensive,  sanguino-
purulent discharge from the nostrils, either one or both, bad odor
to the breath, and signs of systemic poisoning.
  Again, the  membrane may spread downward into the larynx,
giving rise to stenosis of the larynx, the so-called diphtheritic croup.
If the membrane has been so slight or  so located as to escape the
attention of the physician, the diagnosis of this form  of diphtheria
from catarrhal laryngitis is by no means easy.  The temperature
chart is  often helpful  in this matter, for in  laryngeal diphtheria
the temperature is  apt to keep  high,  io2°-io4°, as a rule, much
higher than in catarrhal croup.  In diphtheria of the larynx,  after
thirty-six hours of hoarseness or cough, the  unmistakable marks
of laryngeal stenosis appear, viz., labored breathing, aphonia, sub-
clavicular depression of the thorax, cyanosis,  or marble-like white-
ness.  These increase in intensity, and persist, either with or with-
out slight intermissions, until the false membrane has been coughed
out or the child dies from suffocation.
   Differentiation.—The differential  diagnosis of the various
forms of false membranes found in the mouth is often  clinically
impossible, nor is it justifiable to pursue an  expectant plan  until
bacteriological cultures confirm one's diagnosis. The initial lesions,
even in serious cases, are often so light  that valuable time may be
lost waiting  for the results of  the initial culture (12-24 hours),
which often  requires second and third cultures to make certain
the  diagnosis.  Hence Jacobi's rule to  treat  every  membrane
as  if it might be true diphtheria is the  only safe method.  Of
course, no means should be neglected to subsequently arrive at
an accurate diagnosis.  The Health Departments of many of our
large cities furnish culture  tubes in which to  place bits of the sus-
picious membrane  for differentiation by the  city microscopists.
For the removal of the  membrane  a pair of sterilized forceps or 
100
DISEASES OF CHILDREN.
a bit of freshly whittled wood should be used, and  the  membrane
cleansed in  two per  cent, sterilized solution of boric acid before
drawing it over the culture medium.  The first growth of the col-
onies requires about twenty-four hours, and by an  expert may be
recognized by the  naked  eye, but microscopic recognition of the
well known clubbed Klebs-Loeffler bacillus is the only absolute proof
of the existence of true diphtheria.  It should be remembered that
the Loeffler bacillus may persist in the secretions of the mouth for
a long time after  the disappearance of the membrane,  and that
during all  this time the  child  may communicate the  disease.
Faucial membranes  in slight cases  are shed in one to two days,
leaving behind only the  mucous membrane slightly thickened.
In  more severe cases the membranes  are  not cast off until the
fifth or  eighth day, and immediately re-form.    They  always
leave behind them, on  the mucous  membranes, deeply ulcerated
wounds, bleeding easily and cicatrizing  very slowly.  Or the pro-
cess also locates itself on the mucous membrane of  the cheeks,
gums,  nasal cavities, lacrymal duct, and conjunctiva,  or, works
downward into the  esophagus, larynx,  or trachea, even  into the
finest bronchioles—bronchitis diphtheritica.  Exanthemata, either
scarlatiform  or purpuric, are very  frequent in  diphtheria, and
since the use of Heilserum their appearance has been laid to its
use, but such eruptions were known long before antitoxin.
  Complications.—Sudden death may occur  from  an over-
whelming of the nervous system by the virulence of the toxal-
bumins produced in  the fulminating  form of the disease.  Death
from asphyxia may occur, within  twenty-four hours, in  diphtheritic
laryngitis, from an  extension of the membrane into the bron-
chioles.  Hemorrhage,  following  sloughing  of  the  diphtheritic
membranes, is another  of the serious  and often  fatal complica-
tions of diphtheria.  Albuminuria is by some  claimed to  be  diag-
nostic of true diphtheria,  and if  not  invariably so, it is extremely
frequent, although Kormann thinks the existence of a nephritis
with secondary edema  complicating  diphtheritis is  proof positive
of its being a case of scarlatina  sine exanthema.    Pneumonia is
another of the  dangers often  dreaded,  and arises either from  an
extension of the membrane downward,  or more often from hypo-
static infiltration of the lungs.  Myocarditis and diarrhea are also 
THE ACUTE INFECTIOUS DISEASES.
101
to  be mentioned among  possible  complications,  and cervical
adenitis of varying degree is always present.
   Diphtheritic paralysis may appear early in  the disease, though
as a rule it does not appear earlier than from one to five weeks.
It is  a true multiple, peripheral neuritis, closely resembling that
following typhoid fever or from poisoning from mercury or lead.
The  lower limbs are those most frequently affected,  although
diphtheritic paralysis may  affect  the  eyes, as partial amaurosis,
hypermetropia, or as varying paralysis of the innervation  of the
muscles of the eye.  The symptoms of diphtheritic paralysis  gen-
erally begin in the soft palate and are  shown by a snuffling voice,
sometimes hardly intelligible, and loud snoring  during sleep.  A
portion of the food, especially fluids, pass  out through the  nose.
Examination shows the pillars of the fauces relaxed and the uvula
apparently elongated and lying upon the back of the tongue.  The
paralysis next extends to the larynx.  The voice becomes weak,
hoarse, unreliable, and hollow, and the epiglottis closes only im-
perfectly, allowing  a portion  of the  ingesta  to  enter.   Such
materials must  be  coughed out with  difficulty, or if they  have
entered deeply, on  account of  the diminished  sensibility  of the
larynx, severe bronchitis or pneumonia may result.  The  most
dangerous complication is a simultaneous paralysis  of the respira-
tory muscles.    Paralysis of the extremities is usually  preceded
by a sensation of formication, then the movements of the hands
or  feet become uncertain  and  their  sensibility greatly  blunted.
Then their use is lost in  part or entirely, progressively from the
part first affected, so that the head may fall forward or backward,
and, in fact, every muscle  in the body may become paretic.  In
such cases death occurs from paralysis of the heart.
  A high degree of anemia always follows a severe case of diph-
theria and this is one of the sequelae to be carefully  watched, even
after apparent cure.  Such  children are pale,  weak, and  reveal a
bellows murmur over the  heart (anemic only), and in the worst
cases  the pupils are largely dilated, loss of consciousness is fre-
quent, and sudden death may occur from heart failure after appar-
ent convalescence.
  Prognosis.—Not unfavorable if confined to the pharynx,  ton-
sils, and nose, if properly treated.  On the other hand, the mortal- 
102
DISEASES OF  CHILDREN.
ity is very great in extensions of the  disease to the larynx, and
other  complications—such as hemorrhage, anemia, pneumonia,
etCii—are greatly to be dreaded.  Diphtheritic paralysis has gener-
ally a good prognosis, except in  case  of paralysis of the  heart,
which causes sudden death.
  The Willard Hospital statistics show  a mortality  of 46^ per
cent,  in  true diphtheria without  laryngeal  complications;  after
intubation 71^ per cent., but it should be remembered that  there
is no infallible guide  for prognosis in diphtheria.  It is one  of the
most dreaded and one of the most fatal diseases  of childhood,
and no one can predict from the beginning of any case what its
termination will be.
  Treatment (Local).—There  is the widest  possible difference
in regard to the local treatment of diphtheria, but  the writer has
never found reason to regret early, frequent, and efficient local ap-
plications.  Whatever  views we  may entertain in  regard  to the
etiology of the disease, the presence of localized gangrene can but
add to its dangers.  The throat can at least be rendered aseptic
by proper care, and this too often is  entirely neglected or  so in-
efficiently done that it practically amounts to nothing.  The least
painful and most efficient  method of treating a diphtheritic throat
is by means of swabbing  it  every two hours with  reliable peroxid
of hydrogen,  diluted just before using  with two parts of  aquas
calcis.  This does not stain  or affect the sound tissues as do  pyok-
tanin, carbolic acid, subsulphate of  iron, or permanganate  of
potash, which so discolor the mucous membrane that we cannot
judge of the progress of the diphtheritic membrane.
  If now we follow with Hoadley's gargle or Loeffler's solution,
we shall coat the throat  with a resinous film which  largely pre-
vents the entrance of septic germs through the abraded surfaces.
At  least such is a reasonable explanation of the.beneficial effect
of these remedies  when used conjointly, so long as  the membrane
reappears.  In children old enough  to  gargle  there will be no
need for an atomizer, but in those unable to  do so, the Hoadley
mixture should be used through a hand-bulb atomizer, at intervals
not greater than three-quarters of an hour, day and night.  Others
advise local applications of lime-water,  pancreatin, papayotin,
lactic acid, etc., for the purpose  of dissolving  the  membrane, or 
THE ACUTE  INFECTIOUS DISEASES.            103
 use  the  electro-cautery.  Vaginal diphtheria may be treated by
 scraping off the  membrane wherever  found, and  applying stick
 nitrate of silver to the surface beneath, or packing with iodoform
 gauze.
                    Modified Hoadley's Gargle.
      R .   Tinct.  myrrh,..........5 iij
           Listerine.............15 j
           Mel despumat.,.........%iv
           Sat. sol. potass, chlorat.,......^ iij.
      Sig.—Use every thirty minutes.  (H.)

  Medicinal.—In threatening laryngeal complications the author
 has  more confidence in  the following than in all  other  internal
 medications, the  same to be pushed until the  stomach or bowels
 rebel.
      R .   Hyd. chlor. corros.,........gr. j
           Am. chlorid...........gj
           Spir. frumenti,.........f ^ iv.
      SlG.—Teaspoonful in water every hour.   (M. P. H.)

  In the  same danger others recommend highly calomel subli-
 mations, 15 to 30 grains being used every 2-4 hours.  The child
 should be rolled in blankets, so  that only its face is exposed
 and then held near a steam  atomizer in which a tin pan  should
 be  substituted for its usual  boiler.  On  this  pan the calomel
 is sprinkled and  the alcohol lamp placed beneath until the subli-
 mation is complete.  Salivation  is rarely produced  in the child,
 though  not infrequently in the attendants,  and  the  coughing
 caused by these  vapors is  often  annoying, but the treatment is
 undoubtedly of great value where it can be efficiently administered.
  Fresh  air and regular feeding with nutritious food, of  which
 good milk and eggs are the best, are fully as necessary as medica-
tion, for without these medication will fail in a long fight as cer-
tainly as an army without  supplies.  Antitoxin, at the time of
writing, appears  to be a valuable  adjuvant to  the treatment of
diphtheria, but it should be remembered that its  only just claim is
that  it antidotes the  toxalbumins produced by the  growth of the
Klebs-Loeffler bacillus.  By its use in the Berlin hospitals, the
mortality in the diphtheria wards has been  reduced from 33 to 13 
104
DISEASES OF CHILDREN.
per cent.  It is the blood serum from an immunized horse, and is
used by hypodermic injection, preferably in the back, and in  the
author's hands has  more than  met its  claims, if used early.   It
does not protect, as does vaccination, against subsequent attacks,
nor will it cure diphtheritic nephritis, paralysis, or later complica-
tions of diphtheria.
  A resume of this scope is not the place for the discussion of the
rival  claims of incubation  versus  tracheotomy,  for the relief of
diphtheritic  stenosis of the  larynx.  The first has proved  so uni-
formly unsuccessful in the practice of the writer, that he naturally
prefers  the  operation after  which  some  of  his patients have
survived, but he is entirely willing to admit that  others obtain most
excellent  results  from  intubation,  which  is an  operation  to
which consent may often be obtained when obstinately refused for
tracheotomy.
  It should always be borne in mind that the safety of your patient
is  not assured by the disappearance of the membrane from  the
throat, for a goodly proportion of diphtheritic patients die either
from nephritis  or heart paralysis during apparent convalescence.
Hence the  urine should be carefully examined  for at least two
weeks after the throat is clear and  a  recumbent position  insisted
upon for the same length of time.  Diphtheritic paralysis is often
very slow  in recovery, but it may  confidently be expected to yield
to the continued use of strychnia, massage, and electricity.
  Trouble in swallowing may be minimized by feeding with cubes
of bread dipped in soup, milk, or beef juice, when swallowing
liquids causes coughing.   Iron and fresh air are our best remedies
for post-diphtheritic anemia.
  Prophylaxis.—During  an  epidemic of  diphtheria daily in-
spection of throats at school and  in the family should be  insisted
upon, and upon the first appearance of congestion the Hoadley
gargle, or a weak solution of bichlorid (i : 5000) used as required.
A diphtheritic patient should be isolated as carefully as one suf-
fering  from scarlet fever, and equal care taken to disinfect  the
room before its use by others.  Indiscriminate kissing of children is
always silly and often dangerous, unfortunately not to the kisser.  No
operation  should be done upon the throat or nose when diphtheria
is prevalent, at which time  every case of sore throat should be 
THE ACUTE INFECTIOUS DISEASES.
105
regarded with suspicion, for a case of diphtheria, too mild to be of
much annoyance to its possessor, may communicate a  virulent
attack to one less immune (Jacobi).

                9.  PAROTITIS  EPIDEMICA.
  Synonyms.—Mumps;  Ziegenpeter.
  Etiology.—Capitan  describes  pathogenic microbes found in
the blood and saliva of persons suffering from  epidemic parotitis.
Believed to be carried chiefly by respiration, and is most preva-
lent in damp and cold weather.
  Symptoms.—After an incubation of about fourteen days pre-
monitory symptoms occur.  These are chill, with increased tem-
perature, lassitude and loss of appetite; but only in very  irritable
children convulsions and delirium. In two or three days pain is
felt in the region of the ear, and is increased by opening the mouth
or swallowing.  There is swelling about the parotid without red-
ness, and if the submaxillary lymphatic glands swell at the same
time, not only the region of the ear and cheeks, but also  the side
of the neck, is greatly enlarged, while the subcutaneous  cellular
tissue on that side may become edematous up to the ear, and pits
on  pressure.  Opening the mouth is  hardly possible, speech is
indistinct, and the head bent to one side.   Very rarely the other
parotid is affected a few days later, in a like manner, the height of
the inflammation falling from the  second to the  fifth day,  the dis-
ease terminating,  as a rule, by resolution in  about a week.  Occa-
sionally the inflammation proceeds to suppuration, and discharges
externally into the  external auditory meatus or into the middle
ear (difficulty  of  hearing  and deafness from  perforation of  the
membrane of the drum).  The well-known simultaneous inflam-
mations of the testicles and ovaries in adults is not often observed
in children.  The possible complications are brain symptoms, in
consequence of the  disturbance of circulation,  temporary facial
paralysis, from the pressure of the inflamed and swollen gland,
which may  also remain permanently indurated  after suppuration.
  Prognosis.—Very good, unless septic parotitis is mistaken for
the epidemic form.
  Treatment.—Warmth  over the parotid region.   If  there is
great  swelling or cerebral symptoms  use  leeches or scarification
      H 
106
DISEASES OF CHILDREN.
and phenacetin or Dover's powders as required, and when there
is induration, iodin  or cod-liver oil.  When suppuration  is immi-
nent, employ poultices, of which muriate ammonia  and  aconite
leaves (3ss-^j) make one of the best.  When pus forms the cavity
should be opened and treated antiseptically.
  Prophylaxis.—Rendu believes that the time of greatest con-
tagion is at the end of the stage of incubation, or just before the
appearance of the parotid swelling.  If this is true, quarantine  is
practically useless, unless the time of exposure can be accurately
fixed.
                    10. TUBERCULOSIS.
  Etiology.—The  contagiousness  of tuberculosis  still  being
under dispute;  a brief discussion of the disease may here serve as
a connecting link between the acute contagious and the endemic
infectious diseases of childhood.   According to Ratchford, heredi-
tary tuberculosis is the most prolific source of anemia in childhood,
which may be  confidently expected whenever tuberculization of
the lymphatics occur, and, vice versa : " pronounced anemia with-
out apparent cause is  strongly suggestive  of  concealed  tubercu-
losis."  It should be remembered that the  bacillus tuberculosis is
not  directly transmitted from mother to  child, but  only a trans-
mitted predisposition to tubercular growths in the tissues  of the
child, which predisposition is readily excited into activity by cold,
poor food, or dwelling in damp or dusty dwellings, especially those
housing other tubercular patientsj whose dried sputa preserve their
virulence for a long time.
  Unresolved pneumonia, or chronic suppuration, should always
be just ground  for anxiety, since  caseous emboli from these may
at any time be carried by the circulation and deposited elsewhere
in the body to act as foci for tubercular degeneration, as has been
repeatedly proved by the  introduction into the circulation  of the
lower animals of bits of rubber or other foreign materials.  Hence
it is that acute miliary tuberculosis not infrequently rapidly super-
venes upon  measles, or follows caseation  of the cervical, bron-
chial, or peritoneal lymphatics.
  Pathological Anatomy.—Same in the child as in the adult.
  Symptoms.—May reasonably suspect  latent  tuberculosis in
child with extreme paleness of face, bluish sclerotics, progressive 
THE ACUTE INFECTIOUS DISEASES.            107
 emaciation, cold extremities, and afternoon rise of temperature.
 The spinal symptoms of tubercular  meningitis and tabes mesen-
 terica, can be found under their appropriate  heads.
   As in  the adult, tuberculosis  may take the form of (a) acute
 miliary  tuberculosis, or  (b) subacute infectious tuberculosis, or
 (c) chronic tuberculosis,  either general or more frequently local-
 ized, differing in no essential respect  from the same  modifications
 as found in the adult.
   Prognosis  is always  bad, especially  after the appearance of
 coolness  of the extremities and nose, edema of the joints, and
 thrush.  An increase in the weight of the body makes the prognosis
 somewhat better, at least for the present.  Meningeal tuberculosis
 almost always ends  fatally within a  short time, and even when
 there is an apparent  cure there always remains a tendency to  a
 relapse.
   Tuberculosis in children is more apt to run a rapid course with
 an early fatal termination, than with the adult, but every supposed
 case of tuberculosis does not necessarily have a fatal termination.
   Prophylaxis.—In phthisical or tuberculous families, the chil-
 dren ought always to  have a healthy  wet-nurse, and  later, scrofu-
 iosis is to be guarded against by means of  nutritious diet, good air,
 and  cold  bathing.   If  scrofulosis has  already broken  out, espe-
 cially where the lymphatic glands are already caseous,  it must be
 treated in the most  energetic manner  possible.   In such families,
 all bronchial catarrhs,  pleurisy,  or hemoptysis, especially after
 measles and whooping cough, as well as  otorrheas (caries of the
 temporal bone), and suppuration of the bones are to be dreaded.
  Treatment is mainly dietetic and  hygienic, and consists of the
 most nourishing food, eggs, cream, raw beef, butter,  and the best
 of air, cool and dry, in which to daily practice forced inspiration,
 under the doctor's directions.   The Adirondacks, Upper Michigan!
 and  Colorado have a well deserved  reputation for  the relief of
incipient  phthisis.  Tuberculosis  of  the  bones demands  early
and radical surgical treatment, with hopeful results possible. Cod-
liver oil is the most reliable of all  internal remedies, but only the
oil that is assimilated  is of any value. 
108
DISEASES OF CHILDREN.
                      SECTION VI-

     ENDEMIC INFECTIOUS  DISEASES OF
                     CHILDHOOD.

                   i. TYPHOID  FEVER.
  Synonyms.—Enteric fever, infantile remittent;  Nervenfieber.
  Etiology.—Differs in no wise in its origin from  the typhoid
fever of adults, though its symptoms are so much  milder  in the
very young that its occurrence before two years is strenuously de-
nied by many writers, and Northrup still insists that engorgement
of Peyer's patches, considered diagnostic of typhoid, cannot be so
considered in autopsies made upon  young children.
  Symptoms are often  so mild in children as to escape notice
except perhaps the headache, lassitude, and afternoon rise of tem-
perature.  Prodroma absent in young children or unnoticed, and
diarrhea generally moderate in degree and  not typical in appear-
ance.   Tongue often  heavily coated  and  rose  spots generally
present as in the adult.  Temperature ranges from  ioi°-i03° with
bronchial  symptoms exceedingly frequent  in children, as a rule,
replacing the abdominal type of typhoid of the adult, and it should
be remembered that the temperature curves  may be very irregular.
  Differentiation is often difficult and sometimes impossible in
the earlier days of the disease, which closely simulate the onset of
tuberculosis, or  meningitis.  Hepatic incompetence  gives us a
similar train of  symptoms,  hence, the differentiation must  be
made from the temperature record and the presence of the follow-
ing cardinal symptoms of typhoid in the child, viz. ; Headache or
apathy, persistent fever with evening exacerbation, and rose spots.
Bowels often constipated, and bronchitis generally present.
  Treatment.—Largely expectant and  dietetic,  for the writer
believes that these cases need but little  medication except the free
use of lithia water, cool sponging and a milk or koumiss diet.
Whenever the temperature reaches 1030 a cold bath or sponging
should be preferred to the ordinary antipyretics, although  phena- 
         ENDEMIC  INFECTIOUS DISEASES OF CHILDHOOD.     109

 cetin is permissible to relieve headache. Good ventilation is a sine
 qua non for satisfactory treatment of these cases and the imme-
 diate  disinfection of all  dejecta and chamber vessels should be
 insisted upon.  If  diarrhea is present salol and bismuth, or the
 salicylate of bismuth are usually sufficient to confine the passages
 to two  a day, less than which it is not desirable to restrict them to.
 Up  to  the  end of  the third week the diet should be exclusively
 liquid,  consisting largely  of  milk, barley, or chicken broth, etc.,
 without eggs.  Relapses are easily produced in the child by errors
 of diet or  overfeeding, and very apt to occur with the returning
 and voracious appetite of the convalescent child.
   Prognosis.—Generally better than with the  adult, especially
 if the child can receive the care  and nursing  of a good hospital
 where the mortality ought to be as low as five per cent.
   Complications.—As  the  typhoid  of  children  is generally
 milder  than that of adults, its  complications, as might be expected,
 are generally lighter and  less dangerous.   Hypostatic congestion
 of the  lungs is the one most frequently met with  and needs most
 watchfulness on the part of the physician.  Parotitis, pleurisy, and
 peritonitis are also possible complications, but like intestinal hem-
 orrhage are comparatively infrequent  in  the child.  The same
 may be said of laryngitis, cellulitis, and other forms of post-typhoid
 sepsis noted by various authors.

            2. CEREBROSPINAL MENINGITIS.
   Synonyms.—Epidemic spinal meningitis ;  spotted fever.
   Etiology.—Undoubtedly due  to a specific  infection, which is
 often spread by massing large bodies of men, as in army barracks
 and prisons.  The majority of those attacked are children,  and of
 these fewer males than females.  The disease, pathologically, is a
 purulent or a  puro-gelatinous  inflammation of  the pia mater and
 arachnoid of  the brain and spinal cord.  Very  frequently small
 points  of  suppuration, extravasations  or (embolic) softening are
 found in the substance of the brain.
  Symptoms.—The  disease begins without a definite stage of
incubation, and generally without premonitory symptoms, but with
immediate frightful  vomiting, shivering (1060) and convulsions in
little children, or pains in  the back, head, and limbs, until con- 
110
DISEASES OF CHILDREN.
sciousness disappears.  If this occurs at the very beginning of the
attack  (the so-called  fulminating  cases),  the pains are wanting,
and in  such  cases generally a fatal  termination  rapidly occurs.
The cervical and dorsal vertebras are sensitive to pressure, and
sometimes this is true of the whole spine, from the head down-
ward.  At the same time there is great hyperesthesia of the skin, the
limbs soon become  partly paralyzed.   The muscles  are often
tetanically contracted, bending backward  the cervical  portion of
the spinal  cord—opisthotonos—and  when the tetanus or clonic
spasms increase there is often loss of consciousness.  The pupils
are often dilated, but changeable.  The  chills repeat themselves,
and the  temperature, with slight  intermissions,  continues high.
The tongue is dry, and at first  the  bowels  are constipated, later
diarrhea, and sometimes albuminuria,  occur.   The skin is hot
and dry by turns, or exceedingly moist, and occasionally showing
roseola or petechias, and frequently on the fourth day  a herpetic
eruption on the  face.   The spleen is often moderately enlarged,
and all  these symptoms make it  very easy in  the beginning to
confound this disease with typhus, tubercular meningitis, or an
acute exanthema.  Imperfect reabsorption of a meningeal exuda-
tion may produce permanent disturbance of sight, hearing, or lead
to a partial paralysis of the lower extremities. Absorption of pus
leads to pyemia, heralded by a chill.  The duration of the disease
may be from  a few hours to several months, due to complications,
such as acute fatty degeneration of the liver and kidneys, endo-
carditis, purulent inflammation of the joints,  parotitis, pneumonia,
chronic hydrocephalus, suppurative  inflammation of  the dorsal
muscles, etc.
  Prognosis.—On an average forty per  cent, die ; the majority .
from meningitis ; a few from  secondary disturbances,  and some
even later, from chronic hydrocephalus.  Death may occur either
in a few days or after a duration of several weeks.
  Prophylaxis.—Prompt removal of children  from the infected
places—barracks, orphan asylums,  etc.; avoidance  of sudden
changes  of temperature, or undue exertion ; and  regular  mode
of living.
  Treatment.—(i) Try to diminish  inflammation by leeches on
the head, cupping along the  spine, and cold applications or ice 
         ENDEMIC  INFECTIOUS DISEASES OF CHILDHOOD.     Ill

bladders to the head and spinal cord ; (2) lessen the fever by cool
baths and colder  affusions ;  (3)  removal of the constipation  by
calomel or vinegar enemata; (4)  subcutaneous  injections of mor-
phin for the pain ; (5) wine,  iron, etc., for  exhaustion, and  (6)
iodid of potash for the absorption of the  exudation, if the child
survives.
                3. INTERMITTENT FEVER.
  Synonyms.—Malarial fever ;  chills and fever.
  Etiology.—No age is exempt from intermittent fever ; even the
fetus in  utero can be  infected from a malarious mother,  or  by
the milk  from a  nurse suffering  from intermittent fever, whose
cause is now  generally admitted  to be specific  microorganisms
introduced into the blood.  Their growth produces such changes
as to cause autointoxication, which causes the chill and the reac-
tion from this the fever and salutary sweating which follows.   As
might be supposed a child's organism is more easily affected than
an adult's, and one attack predisposes to others. The infection
takes place  by means of  contaminated  drinking water, or  the
breathing of air which contains specific microorganisms, and con-
sequently the disease  is confined to certain districts,  especially
swamps, overflowed lands, etc., where these definite organisms
are produced.   By deepening the  rivers, preventing their frequent
overflow, and cultivation of the country, the disease can be  made
to disappear, as has been done largely in  the older parts of  the
country.
  Symptoms and  Progress.—In children  above  two  years
the disease generally runs the same course as with adults, but with
younger  the course of intermittent fever  is  different.   In  these
latter the stage of incubation is as  indefinite as usual, lasting from
a few hours up to  several  weeks, and the  attacks are generally
quotidian but without being confined to any definite point of time.
Tertian and  quartans are rarer, and abortive attacks are common.
The chilly stage is usually replaced by repeated convulsions (one
quarter to one hour) with coma, small pulse, coldness of the skin,
livid extremities.   During the attack the temperature often reaches
1050 F. (40.5° C),  the pulse becomes full  and  strong, producing
great excitement and  restlessness, and a flushed appearance,  for
two to four  hours, after which very frequently we have none or 
112
DISEASES OF CHILDREN.
only very slight perspiration.  The  enlargement of the spleen is
greater than in the adult, and can only be confounded with larda-
ceous degeneration, syphilitic gummata, or leukemia.  In chil-
dren the malarial  cachexia also appears as early as the first or
second  week, producing  anemia, weakness, loss of  appetite,
emaciation, and hence frequently  mistaken for tuberculosis, or
caseous degeneration of the glands, etc.  In addition there may
be tumefaction of the liver, diarrhea, and  edema ; with a high
degree of  cachexia, dark  brown pigments appear in the blood
(melanemia), and malarial neuralgias—especially of the trigeminus
—are not at all infrequent.
  Prognosis.—Not entirely favorable  for children under  two
years, especially in those  localities where the fever appears in a
malignant form.
  Differentiation.—It should always be remembered that gas-
tric disturbances, nausea,  anorexia, and epigastric distress with
young children, often replace the chill;  with others a daily con-
vulsion may be substituted for the cold stage, and the fever is more
persistent, and less apt to terminate with the typical sweating stage.
Again an abdominal neuralgia closely resembling colic may  ap-
pear  nightly,  anS  resist all ordinary  treatment until its malarial
origin is recognized.  Enlarged spleen is considered, by some, as
absolutely diagnostic of malarial poisoning.  (Vining.)
  Treatment.—As with the adult, the cinchona preparations  are
our most reliable remedies.  The dose should be regulated in  ac-
cordance with the age of the child,  and should, if possible, be so
administered that the full  amount  should  be given  at least  two
hours before the expected  paroxysm.  When the obstinacy of the
child  prevents this,  quinin  inunctions Oj to gj lanolin)  should
be resorted to, unless your little patient can be beguiled into taking
quinin tannate in the agreeable chocolate lozenges in which it  can
be obtained.  A single large dose of  quinin, preferably the bisul-
phate may be  given in rectal suppositories, but this method is  not
adapted for continued use.  If possible, the child should be removed
from the malarious district, but when this cannot be done, it should
be kept on  small doses of arsenic, Fowler's solution, to prevent the
occurrence of malarial anemia, and the splenic complications so
frequent after  chronic malaria. 
        ENDEMIC  INFECTIOUS DISEASES  OF CHILDHOOD.     113

                             (13)
      R.  Quin. sulph...............1 gm.
          Am. glycyrrhizin,  ...........2  "
          Simple syrup,.............60 c.c.    M.
  SlG.—Teaspoonful every hour until the desired dose has been taken.
                                                   —Curtis.

  Prophylaxis.—Removal,  if possible, from  swampy or low-
lying districts, and,  if this is impossible, avoid exposure during
the  early morning and evening  hours,  and the use  of boiled
water only.

                  4. EPIDEMIC COLITIS.
  Definition.—An  acute inflammation of the mucous membrane
of the colon, possibly diphtheritic in character, and frequently epi-
demic at the same time  with diphtheria, or intermittent fever.
  Etiology.—Occurs chiefly during, or  after a very hot summer
or in tropical localities,  but rare  in children under one year;  after
that, until the  fifth year, quite frequent.
  Symptoms.—After  an incubation of  a week or ten days, with
or without a chill, diarrhea makes its  appearance, and shortly in-
creases greatly in frequency, often to twenty or thirty motions a day,
and is accompanied with great  straining at the anus, tenesmus,
tingling in  the limbs, with griping pains  in the abdomen, which
becomes painful to pressure.  At first small quantities of fecal mat-
ter may be present in the stools; but the succeeding discharges
become glairy, consisting of pure mucus—the  so-called white of
an  egg  passage.  Sometimes  they are uniformly and sometimes
partially colored red, from hemorrhage of the colon, constituting
the true bloody dysentery.  The stools have a mawkish, sourish
smell, and  differ in  appearance according to the degree of the
hemorrhage and the distance of the bleeding place from the anus.
If a diphtheritic destruction of the epithelium of the mucous mem-
brane has taken place, then  the  dejections have a carrion-like
odor, and are mixed with  shreds of mucous  membrane.  The
stools are often of a dingy or reddish-gray color, and contain con-
siderable pus from the ulcers  resulting from the casting off of the
diphtheritic  membrane.  In such  cases  the attempt to give an 
114                DISEASES OF CHILDREN.
enema is always difficult and may occasion convulsions.   In the
beginning there is either no elevation of temperature or very little,
and in severe cases there  is a fall ; but  when there is ulceration,
the temperature is  always increased, attended at times with deli-
rium and convulsions.
  Prognosis.—After four to six days, in the sporadic cases with-
out diphtheritic membrane, and after  ten to fourteen days  in epi-
demics, the stools again resume their fecal odor and appearance.
The mucus and  pus, as well as the tenesmus,  gradually become
less, the appetite improves,  and emaciation ceases, unless diph-
theritic ulcers have formed.  Emaciation then is marked, the fever
higher than before, and violent abdominal pains and vomiting often
precede peritonitis, with or without  intestinal  perforation.   Fre-
quently the disease ends in a chronic dysentery, by which is meant
a chronic  ulceration of a part of the  intestine, which may finally
heal, with great cicatricial contraction, and sometimes, as might
be expected, with stenosis of the intestine.  Cessation of tenesmus
is not always to be regarded as  a favorable symptom, since it may
be due to a paralysis of the sphincter.
  Death often occurs in these cases, but more frequently it arises
from the sequelae of dysentery.   These  are caseous degeneration
of the mesenteric glands (tabes mesenterica), pyemia, abscess of
the liver,  with  icterus, marasmus, anemia, and prolapse  of the
rectum, from tenesmus.
  Treatment. —i. All fecal accumulations are immediately to be
removed by gr. ss of calomel, repeated every three hours.  Opium
is then the best remedy, and, if possible, should be given by the
physician  himself, in enemata  of a  thin,  lukewarm solution of
starch, containing a number of  drops of laudanum, equal in num-
ber to the years of the child, or  chloral hydrate maybe substituted
for the laudanum.
  2. All drinks  should  be lukewarm and mucilaginous.   Cow's
milk, unless sterilized, is to be avoided,  and children at the breast
are not  to be weaned, but barley water or white of egg in steril-
ized water is to be given for thirst, which is often excessive.
  3. Tannate of quinin and salol are  among  our most reliable
remedies in the latter stages of  the epidemic variety, where great
care should always be given to  the disinfection of the stools. 
DISEASES OF THE NERVOUS SYSTEM.
115
                    SECTION  VII.

    DISEASES  OF  THE  NERVOUS SYSTEM.

        (A.) THE BRAIN AND  ITS MEMBRANES.

                   i. ENCEPHALOCELE.

  Synonyms.—Meningocele seu hydroencephalocele.
  Differentiation.—A fluctuating tumor, from the size of a hazel-
nut to a child's head, generally found on the occiput, more rarely
at the top of the nose, or at the greater fontanelle.   Around the
periphery of the tumor a circular opening can be felt beneath the
tense and thinned integument, unless this has  ruptured during
birth.  Within the tumor cerebral substance can be felt, either
with or without fluid.   Compression reduces the size of the tumor,
but causes pain and sometimes convulsions.
  Prognosis.—When life is preserved, chronic meningitis usu-
ally follows with a fatal result in after years; and even if recovery
ensues, the intellectual faculties remain defective.
  Treatment.—Attempts at replacement usually fail, especially
when there is a large collection of fluid in the sac.  Tapping, in
such cases, sometimes produces relief, but is very apt to cause con-
vulsions.  When successful, it must be frequently repeated, and
small amounts drawn off each  time.  Failing in this, compresses,
or a perforated metal plate, should be worn over the tumor.


            2. ACEPHALIC  MONSTROSITIES.
  Headless monsters—acephalia—completely deficient of brain
except the medulla oblongata, have been born, generally with
other malformations or  imperfectly developed elsewhere.  They
may be  born alive, but are always non-viable.   Partial deficien-
cies in the brain, especially of the larger hemispheres or the smaller
parts of the brain, are sometimes found associated with a defective
formation of the bones of the head or face—hemicephalia.  Micro- 
116
DISEASES OF  CHILDREN.
cephali possess abnormally small skulls, whose  sutures are often
strongly united at birth, giving them a hideous appearance.  The
forehead is absent, the arch of the skull  is flattened, and the nose,
from its relatively large size, projects well forward, like the bill of
a parrot.  Viable, but  generally,  though  not  always, imbecile.
And, finally, a  less marked degree of microcephalia is acquired
by a premature ossification of the  sutures of the skull after birth.
These  unfortunate, because half-imbecile children,  may attain a
great age, though deficient in intellect and speechless if their cra-
nial capacity is less than 28 c.c.  Monophthalmi are hideous mon-
sters, possessing only one  eye, with arrested development of one-
half of the face and cerebrum.


                   3.  HYDROCEPHALUS.
  Synonyms.—Water on the brain ; Wasserkopf.
  Definition.—In its widest sense, hydrocephalus  embraces all
accumulations of serous fluid within the  cavity of the skull.
  Varieties.—Internal or ventricular, or external (arachnoidean),
edematous, etc.,  or congenital,  acquired, symptomatic.   Simple
hydrocephalus is  usually defined as that unattended with malfor-
mation  of the  brain.  Scaphocephalus  is  the name  applied  to
hydrocephalus limited to the lateral ventricles.
  Frequency.—Of  200  cases, Steiner found  100  internal,  80
edema of the pia mater, 10 external (between arachnoid and dura),
and 10 were simple cerebral edema.
  Etiology.—Either  congenital or  acquired,  the  first  usually
internal,  and, according to Meigs, arising from inflammation  of
the membranes lining the ventricles, similar to that  of the perito-
neum which produces  ascites.  May also be due to tumors at the
base of the brain.  Hydrocephalus is  not infrequently  due  to
syphilis, in which form the characteristic symptoms appear earlier
than from other causes, insomuch  so that a syphilitic origin may
be justly suspected in all cases existing earlier than 3^ months.
  Pathology.—Hydrocephalus being  strictly speaking a symp-
tom and not a disease per se, the autopsy should reveal the lesion
which produces the cerebral effusion.  This may be  due to tuber-
cular deposits in the pia (see  Tubercular Meningitis,  page 122),  or 
DISEASES OF  THE NERVOUS SYSTEM.           117
to tumors located  within or at the base of the brain, or any cause
which produces thickening of the ventricular walls (syphilis, chronic
inflammation,  etc.).  This  causes  an excess of interventricular
fluids, finally shown by distention of the scalp, while the bones
are thinned or actually wanting in spots, where  only membrane
can be  found, especially toward the occiput (craniotabes).   On
opening the skull  the  enlarged  brain protrudes en masse, with
flattened convolutions and  leveled sulci and gyri.   The walls of
the distended ventricles are greatly thinned by  stretching, very
easily torn, and sometimes actually perforated—Steiner once hav-
ing seen the foramen of Monro distended sufficiently to pass an
egg—optic thalami and corpus striata flattened, the crura separated,
and cerebellum crowded  up against the bones.  The brain struc-
ture is lardaceous  and dense with white, fat-like  spots.   (Lamb.)
Fluid varies from four ounces to six pounds.
   Symptoms.—Congenital hydrocephalus  produces  dystocia,
and if sufficiently great may require puncture to permit birth.   If
less in degree the child may live and show  all the characteristic
malformations of hydrocephalus.
   Acquired hydrocephalus usually begins with symptoms strongly
resembling those of tubercular  meningitis, viz., crying,  vomiting,
headache, fever, possibly delirium,  and partial paralysis, especially
of sight, the pupils becoming dilated and fixed, or nystagmic, with
best vision in the bright sunlight.   Hearing is generally unaffected
and pulse and respiration  unchanged.   Appetite often  voracious
and capricious, though digestion remains normal.  Acquired hy-
drocephalus  never produces the very great deformity of the con-
genital variety, because the sutures become  more or less ossified,
but the head is elongated antero-posteriorly, and if the fontanelles
have not closed they project outward,  and often pulsate with each
cardiac  impulse.   Congenital hydrocephalus often produces  the
most hideous deformities by its unarrested progress, the temporal
bones becoming so oblique that the tips of the ears can no longer
be seen  from above.  The forehead, likewise, bulges forward,  the
orbits become shallow, and the eyes project forward  and look
downward,  or become  strabismic,  and the  attempt to establish
collateral circulation enlarges and makes turgid  the veins of the
forehead and scalp. 
118
DISEASES OF CHILDREN.
  Prognosis.—Life may be long preserved, and the child even
reach maturity, if the amount of effusion is  small, and no inter-
current disease complicates ;  for the majority of deaths take place
not directly from hydrocephalus, but from  subsequent  bronchitis,
pneumonia, or the exanthemata.  Coma, convulsions, exhaustion,
and pyemia also occasion a number of fatal cases.
  Treatment, as yet, is very unsatisfactory, although compres-
sion, venesection, and a vast number of drugs have been tried.
The general health of the child is to be preserved, its diet regulated,
and  intercurrent disease  carefully watched.  Tonics and mild
diuretics  are theoretically  indicated, but yield very unsatisfactory
results.   Tapping has been successfully resorted to by Keen, and
craniotomy with puncture into  the subarachnoid space,  without
permanent drainage, has been  favorable reported upon by others.
In syphilitic hydrocephalus  potassium  iodid holds out the  best
hope of success.

              4. HYPERTROPHIA CEREBRI.
  Varieties.—Either congenital or acquired, general  or partial.
  Etiology.—Both rickets  and scrofula  predispose.  The skull
is unduly large and prematurely ossified in the congenital form;
the acquired  form  can  be diagnosed from hydrocephalus  only
before the closure  of the fontanelles, and  by the absence of the
characteristic deformities of hydrocephalus.
  Symptoms.—Intellect varies from  fairly good to  imbecility;
especially in later stages,  from  occurrence  of " cretinism."


     5. HYPERTROPHY AND SCLEROSIS  OF BRAIN.
  Occurrence.—Fortunately rare in America.
  Pathological Anatomy.—Increase in connecting nucleated
substance—neuroglia—the brain becoming hardened like cartil-
age, with subsequent atrophy.
  Differential  Diagnosis.—Enlargement, chiefly  over ears;
eyes not strabismic.   Often very difficult to  distinguish from hydro-
cephalus or meningitis.
  Etiology.—Rickets, congested brain, bad dwellings, and poor
air, lead  poisoning, etc. 
DISEASES OF THE NERVOUS SYSTEM.
119
  Symptoms.—Complicated, sooner or later, with convulsions,
paralysis, blindness, or neuralgia.
  Duration.—Very uncertain, and prognosis always bad.
  Treatment can only be symptomatic.

                  6. ATROPHIA CEREBRI.
  Etiology.—Always  secondary  and  associated  with  some
other disease, such as general atrophy subsequent to cholera in-
fantum, or thrombosis of the cerebral sinuses, etc.
  Symptoms are those of  cerebral  anemia (which see),  viz.,
depression of the anterior fontanelle, overriding of the cranial
bones, threatening collapse, etc.
  Prognosis.—If due to simple inanition  it is fairly hopeful ;
from all other causes very bad.
  Treatment.—See Cerebral Anemia.

7. IDIOCY AND RETARDED  MENTAL  DEVELOPMENT.
  Occurrence.—By no means infrequent with children.
  Etiology.—Arises either from—
  (a) Arrest of  growth (microcephalics) ;
  (b) Arrested development, e.g., feeble-minded; or
  (c) Disease, e.g., hydrocephalus, sclerosis, etc.
  Varieties.—(a)  Transient, as post-typhoid, measles,  choreic,
or (b) Congenital, (c) Acquired; generally associated with  some
bodily defect,  such as deafness, eclampsia, heart  disease, etc.
Differentiation  is  not always  easy, but as helpful toward this, it
should be remembered that  in the normal development of  chil-
dren, a child  follows light after two weeks  (smiles about same
time).  Natural squint for one month ;  later, abnormal.  Holds
objects in hands  at three  months; knows faces  by three to four
months.   Holds up head about three months, and always keeps
tongue in mouth, if bright.   Recognizes names  at eight to  nine
months ;  able to stand on feet at nine months ; talks from nine to
sixteen months.   Anterior fontanelle should close at  same  time
when child is able to walk  (about eighteen months).  Any marked
variation from these data constitutes backwardness, of all degrees
from this to absolute idiocy. 
120
DISEASES OF CHILDREN.
  Treatment.—The only  satisfactory treatment of these cases
is that by  specially-trained  teachers in public institutions, or in
private  schools for the weak and feeble-minded, which  accom-
plish wonders, even  in  very unpromising cases.  In cases of
arrested growth  surgery has attempted  a cure  by means of
craniectomy.  Operation justifiable, but results as yet not brilliant.

                   8. ANEMIA  CEREBRI.
  Synonym.—Hydrocephaloid irritation of the brain.
  Etiology.—Clinically convenient to discuss at this  point, al-
though it is really a symptom, or sequela, of any disease in child-
hood which leads to a high degree of emaciation, or great depletion
of the fluids  of the body (cholera infantum,  chronic  diarrhea,
hemorrhage, etc.).
  Symptoms.—Restless boring of the occiput into pillows ;  in-
cessant  movements of the head  to and fro, hence baldness of
the occiput; clutching at the head and  scratching  of the face.
The eyeballs are rolled upwards and not unfrequently  there are
rigid flections of the upper and lower extremities—thumb in  fist,
etc.  There is also stiffness of the neck, which may escape atten-
tion  until the child  is placed in the sitting posture.  These chil-
dren often  moan pitifully and incessantly until they become too
feeble to do so any longer.   The typical pulse  and respiration of
tubercular  meningitis will  serve to differentiate between the  two
diseases.
  Prognosis.—Bad, but not necessarily hopeless.
  Treatment.—Primarily must be directed to the initial disease,
but much in the interval may be done for the relief of the child.
All depleting measures must  be avoided, in spite  of the popular
impression  in these cases that the disease has " gone to the head "
and that leeches and ice-bags are required.  On the contrary, the
frequent use of stimulants, wine, coffee, and opiates will yield the
best  results.  Caffein and strychnia are also valuable.

              9.  INSOLATIO (SUN  STROKE).
  Symptoms.—Headache  and  reddening  of the face, neck,
and  arms—erythema—after  long  exposure to  sunlight.   In  the 
DISEASES OF THE NERVOUS SYSTEM.           121
 course of twelve hours there may appear loss  of consciousness,
 furious delirium, injection  of the conjunctivae, contraction of the
 pupils, and  strong pulsation of  the  carotids with fever.   The
 pulse is quickened and rhythmic.
   Progress.—Usually in from  one-half to two days deep sleep
 ensues, from which the children  awake conscious and  without
 fever.   More rarely death occurs early with  increased stupor-
 edema of the brain and edema of the lungs.
   Prognosis.—Almost invariably favorable.
   Treatment.—Ice or cold effusions to the shaven head ; vine-
 gar enemas.  Calomel after the return of consciousness.

                 10. HYPEREMIA  CEREBRI.
   Etiology.—Strictly  speaking a symptom  and not a  distinct
 disease.  May be premonitory of meningitis, apoplexy or hyper-
 trophy, or result  from arrested circulation,  due to cardiac or pul-
 monary lesions, facial erysipelas, etc.
   Symptoms.—Tension  of the fontanelle, if it is still open, but
 if it has closed there is marked injection of the retina (ophthalmo-
 scope).  Redness  of the face and conjunctiva may also be pres-
 ent or  absent.  The cerebral disturbances of high fever and acute
 infectious diseases must not be regarded solely as hyperemia, but
 as the  effects of the fever or toxemia upon the  brain.
   Prognosis varies according to the fundamental lesion.  Al-
 ways doubtful.
   Treatment.—Ice-bladders on  the  head, local  blood-letting,
 lessening  the heart's activity (veratrum, aconite, etc.), with large
 doses of calomel and cutaneous derivatives; ergot in full doses.

  ii. MENINGITIS CEREBRI  SIMPLEX ET  PURULENTA.
  Etiology.—Commotio  cerebri, traumatic injuries of the skull,
traumatic  erysipelas, or insolatio, or the influence of great cold,
excessive mental  exertion, or the extension of a neighboring in-
flammation from  the  ear, more rarely from the eye, or venous
thrombosis.   Septic meningitis in typhoid, pneumonia, etc.
  Symptoms.—Usually  vomiting,  though this may be absent,
violent headache, retracted  abdomen and increased temperature,
      I 
122
DISEASES OF CHILDREN.
especially of the head ;  convulsions.  The disease usually reaches
its height in one or two days, and is characterized by furious deli-
rium and  often violent convulsions  and rigidities.  The features
are wild and the pulse irregular, frequently slow.
  Course and Pathological Anatomy.—Recovery is pos-
sible, though  rare.  A favorable termination may  be  hoped  for
with an abatement of the more violent symptoms.  Extreme ema-
ciation and persistent feebleness of the mind not  unfrequently
attend  cases which survive.  Death usually in three to six days,
and the autopsy shows the dura and pia covered with a yellowish-
green fibrinous or  purulent exudate.  Or adhesions between  the
pia, the arachnoid and the cortex of the brain, the former appear-
ing as a dense membrane.
  Prognosis.—Poor.
  Treatment.—If any is hopeful, it might be on the line of mer-
curial inunctions, oleate or blue ointment, to the shaven scalp two
or three times daily, with cold affusions or  ice in  the  intervals.
Ergot and bromids in large doses may relieve the  headache and
delirium.


              12. TUBERCULAR MENINGITIS.
  Synonyms.—Acute hydrocephalus ; morbus Whythi.
  Pathology.—Basilar meningitis caused  by tubercular deposit
in the intima  of the vessels of  the pia.
  Symptoms and Course.—Prodromata are usually obscure
and characterized chiefly by unusual irritability, gnashing of  the
teeth, starting in sleep,  and pain in the forehead. Frequent vomit-
ing, without any relation to indigestible food, is a suspicious symp-
tom, especially if to this be added increasing headache and irregu-
lar  evening exacerbations of fever.  The  pulse now  becomes
quickened ; previously it is curiously irregular, and sometimes there
is delirium, especially at night.   The countenance is flushed, sleep
is disturbed and broken with a sudden sharp cry—cri encephalique.
Or  there may be somnolence, clutching at the hair, and  irregular
twitching.   In a few days the neck  becomes rigid—most marked
when the child is sitting—with later general opisthotonos.  Or there
may be unilateral facial paralysis, the mouth dropping on one side. 
               DISEASES OF THE NERVOUS SYSTEM.           123

 The eyelids are half closed, the conjunctivae  injected, and the
 pupils, when visible, unequally dilated, and often showing a hazy
 zone about the edge  of the iris—Skeer's line.  With  this may be
 associated difficulty of hearing and slowness of apprehension, the
 child answering only after repeated  questionings, or not at all.
 About midway in  the  disease  the pulse becomes  slow (60-40)
 and wavy, while the temperature continues high.  If the fontan-
 elle  is open it  becomes protuberant  from effusion into the ven-
 tricles of the brain  and respiration drops to ten to twelve in  a
 minute.  The course of the disease is perplexing from its apparent
 improvement at times, when the  appetite returns, consciousness is
 normal, etc., but  these  are usually fallacious,  for they precede
 deepening  coma and often hemiplegia.   The child loses control
 of its sphincters, the face is pale  or livid, and pressure upon the
 skin leaves persistent redness behind—tache meningeal.   Tem-
 perature high.  The average duration  of the disease is about
 fourteen days, which may be extended to twenty, death, as a rule,
 resulting either from eclampsia or from edema of the lungs.
   Differentiation and Prognosis.—The diagnosis of the on-
 set of tubercular meningitis is often difficult, if not impossible.  In
 certain of its symptoms it closely resembles gastric catarrh, in
 others cerebral hyperemia, and in the early course of the disease
 it may easily be mistaken for typhoid fever (vide p. 108).   The
 relation of pulse to respiration and temperature should be carefully
 observed, as an aid  to the differentiation.   Vomiting,  constipa-
 tion, and the retracted or scaphoid belly are among the indicative
 later symptoms, and when the ophthalmoscope can be used it
 may reveal tubercularization of the retina also.   Unfortunately, in
 the great majority of these cases the diagnosis must be confirmed
 by an autopsy.
   Pathological Anatomy.—Usually an increase of fluid in the
 ventricles of the brain, with infiltration of  contiguous parts with
 serum.   Pia at the base  of  the brain covered with a fibrinous ex-
 udate, and  showing by transmitted light along  its blood-vessels
 disseminate or coalesced  reddish-gray nodules from the size of the
 point of a pin to well-marked patches.  Associated with  this may
be caseous  degeneration of the  brain-substance and  localized
hemorrhage, and very rarely there is cicatricial thickening of the 
124
DISEASES OF CHILDREN.
cerebral membrane.  Miliary tuberculosis of other organs—liver,
bronchial glands, spleen, etc.—can usually be demonstrated.
  Treatment as yet is extremely unsatisfactory.  The earlier
methods of blistering, purging, and mercurials are useless and the
same will probably be found true of the  proposed draining of the
subarachnoid spaces, after which recoveries have been reported.
Gibney reports a remarkable series of recoveries under large doses
of ergot and  the bromids.  Iodoform inunctions to the shaved
head are highly spoken of by competent German authorities, but
neither of these methods  have produced any permanent results in
the hands of the writer.  Ollivier suggests many of the  reported
cures were not those of tubercular meningitis but of hysteria.
   13. Encephalitis,  or inflammation  of  the brain substance,
either with or without the  formation of abscess, differs in no respect
in the child from its course in the adult.   The same is true of—
   14. Pachymeningitis  interna hemorrhagica.
   15. Hemorrhagia cerebralis et cerebromeningealis.
   16. Embolism of the cerebral arteries.


     17.  THROMBOSIS OF THE CEREBRAL SINUSES.
   Etiology.—Marasmic conditions (five-eighths of all attacks),
after Asiatic cholera, or cholera  infantum, with atrophy of the
brain, post-typhoid fever, or profuse suppurations.  Also arises  from
compression  of a sinus,  or veins of the neck,  of the superior  vena
cava, by enlarged lymphatic glands or abscesses, or from inflam-
matory processes in  the neighborhood of the sinus—over  one-
fourth  of the  attacks in children—especially from  caries of the
temporal bone, ozena, or ecthyma of the head.
   Symptoms.—Sudden loss of  consciousness,   somnolence,
tetanic contractions of the muscles  of the neck and  back, tetany
of the  fingers and toes, nystagmus, and possibly paralysis of the
facialis and oculo-motorius,  with finally embolism of the pulmo-
nary arteries.  According to Gerhardt  its location may be  diag-
nosed as follows :—
   1. Less tension in the external jugular vein  of one side than the
other denotes a thrombosis of  the transverse and inferior petrosal
sinuses of the side with the diminished tension. 
diseases of the nervous system.
125
  2.  A circumscribed, edematous tumor behind the ear denotes a
thrombosis of the  transverse sinus and of the veins back of the
ears.
  3.  Venous  hyperemia of the fundus of the eye by ophthalmo-
scope, with slight exophthalmus and edema of the upper eyelid, or
of the whole half of the face, denote most frequently a  thrombosis
of the cavernous sinus.  In addition, there are also the symptoms
of irritation or paralysis of the ophthalmic branch of the fifth nerve,
and the nerves of the muscles of the eye, although the  thrombosis
of transverse and inferior petrosal sinuses also present the same
symptoms.
  4.  Cyanoses of the face and tension of the anterior fontanelle,
with circumscribed perspiration of the forehead  and  nose, with
epistaxis, indicate thrombosis of the superior longitudinal sinus, or
bilateral thrombosis of the transverse  sinus.
  Course.—The  formation  of  a  thrombosis is  always accom-
panied with an elevation of temperature and a quickening of the
pulse in marasmic children, with whom death occurs in from one
to five days.  In inflammatory thrombosis death sometimes«does
not take place before the twenty-first day.   Recovery in the latter
case is  possible,  as has been proven, by  organization of  the
thrombus, fatty degeneration, and subsequent canalization of the
vessel.  Even in embolic infarct of the lungs this may  happen,
provided the  embolus was not septic.
  Prophylaxis.—Prevention  of  collapse, if there is diarrhea
(see Cholera Infantum, etc.), careful treatment of the suppuration
of the middle ear.
  Treatment in inflammatory thrombosis should be the appli-
cation of ice  to the head, and the internal use of quinin.  Wine,
ether, and musk are indicated in the marasmic variety.  Aromatic
spirits of ammonia will also be found  serviceable.


                  18. CEREBRAL TUMORS.
  Etiology.—Either  congenital or acquired, and may be either
cysts, gliomata, enchondromata, entozoic, aneurismic, sarcomata,
carcinomatous, or more frequently syphilitic gummata, caseous
tubercles, or results of traumatism. 
126
DISEASES OF  CHILDREN.
  Pathological Anatomy.—Localized caseous  degeneration
closely resembles the like affection  of the bronchial glands, and
may be distinguished at the autopsy from cerebral abscess by the
absence of pus in the tuberculous spots, which are,  as a rule,
located in the  peripheral, gray substance of the brain, which be-
comes adherent to the  pia and dura.  Foci are also found  in the
corpora striata, and may calcify, or cicatrize, but more frequently
terminate life by the occurrence of secondary miliary tuberculosis
of the meninges, lungs, or bronchial glands.  Cerebral carcinoma
is rare in children, and when  seen is always medullary, and gen-
erally primary.
  Symptoms,  as with the adult, vary with  the location  of the
neoplasm.
  Treatment.—Palliative, or operative, according to the location
of the growth.

(B.) DISEASES OF THE SPINAL CORD AND ITS MEM-
                         BRANES.
         i. SPINA BIFIDA, OR HYDRORRHACHIS,
  A congenital deficiency in the bony covering of the spinal cord,
appearing as a fluctuating tumor, when the membranes are  intact,
usually located in the sacral region, though it may also be cervical.
Harelip, extrophy of the bladder, and other congenital malforma-
tions are frequently associated. Spina bifida may consist, according
to its  location, of merely a longitudinal slit  in the bones  of the
spinal column, or  a broad, pedunculated tumor, with greater or
less absence of the vertebras which should cover it.  It may be
flat, ovoid, pear-shaped, or like a tail, and is  covered either with
normal or atrophic cuticle, or this may be entirely gone, the spinal
cord covered only with its arachnoid and dura.  These may be
ruptured  during birth,  or in  utero.  Spina bifida  fluctuates,  and
contains the spinal  fluids, in which, especially if the cutis is ab-
sent, one can  observe  respiratory movements.  The spinal cord
may run normally, but when there is a division of the lower lum-
bar vertebras a part of the cauda  equina is generally contained in
the tumor.  By pressure the tumor  is always somewhat lessened,
but  at the same time hydrocephalus,  when  it is  present, is in- 
DISEASES OF THE NERVOUS SYSTEM.
127
creased.  Pressure frequently produces convulsions, and is always
painful.
  Progress.—If the sack has  been ruptured during birth death
soon follows from meningitis spinalis suppurativa ;  even if the child
is born alive,  with the coverings intact, they may become gan-
grenous, and end life by septic meningitis.  Or life and the cover-
ings may remain intact  and the latter  gradually thicken,  and
sometimes paralysis of the  bladder, rectum,  and  feet intervene
thereafter.   Very rarely is life preserved for a term of years.
  Treatment.—Repeated  punctures, with the withdrawal each
time of a small amount of fluid and the injection of diluted tinc-
ture of iodin, in the  hands of Dr. Brainard, gave many reported
recoveries.  Others have not been  so fortunate, their cases dying
from spinal  meningitis, though latterly a gratifying series of cures
after plastic operations have  been reported, Robson for instance
reporting 16 recoveries  after 20 operations, strict antisepsis  of
course being preserved.
  Other tumors of the cord are met with, either of the gray sub-
stance, or external neoplasmata, or joined or partially developed
twin births.   There is also a very rare form of tumor, consisting
of hypertrophied Luschka's glands.
  Hyperemia,  inflammation and hemorrhage into  the cord pre-
sent in the child the same symptoms and require the same treat-
ment as in the adult, hence hyperemia, spino-meningealis, mye-
litis, hemorrhagia spinalis et  spino-meningealis need no extended
discussion here.

                     2. NEURALGIyE.
  Are frequently met with in childhood ; especially frequent are
migraine  and  the  abdominal  neuralgia referred to  on  page
128.  Megrim may be differentiated from ordinary bilious head-
ache by the absence of previous  indigestion, foul tongue, etc.,
by  the  periodicity  of megrim,  its sudden onset, disturbances  of
vision, hearing, etc., and by its abrupt  cessation  and excellent
health in the  intervals  between  its paroxysms.  It  undoubt-
edly is a neurosis  and  often hereditary,  probably  due to  an
excess  of  retained uric  acid.   Its  treatment  should  be  both
prophylactic and alleviative.  The latter  can usually be promptly 
I2S
DISEASES OF CHILDREN.
accomplished by means of full  doses  of antipyrine or antifebrin,
in aromatic spirits of ammonia and water, or fluid ext. ergot
(npcv-xx).   The prevention  of the return of these attacks re-
quires restriction of meat diet and regulation of life and study by
the physician, for otherwise these " storms " become a settled habit,
often recurring, although  they  have no appreciable effect upon
length of life.
  Pleurodynia,  or  intercostal neuralgia,  is  often malarial in
origin, and can be promptly relieved by full  doses of quinin  and
applications of a menthol lotion.
  Cardialgia—neuralgia cardiaca—may be caused by acute in-
digestion, malarial poison, or in anemic girls before menstruation.
Similarly neuralgia vesicalis is caused, both from  stone  in the
bladder, vesical catarrh, thread-worms or masturbation.
  Treatment.—Pro re nata.


              (C.)  NEUROSES OF MOTILITY.

               (a.) TETANUS TRAUMATICA.
  Traumatic tetanus is not infrequent with boys, its more frequent
causes being toy cap pistols,  or punctured infected wounds.  For
symptoms see p. 26.
  Prognosis is more favorable than  in adults, or in the tetanus
of the newborn.
  Treatment.—Morphine,  woorara  (0.01-0.25  Per dose),  and
extract calabar bean,  are best administered subcutaneously.  The
removal of  foreign bodies from wounds, ears, or nasal cavities
should also be  carefully attended to.  Tetanus antitoxin gives
promise of being of great value in the treatment of tetanus.

                      (b.) ECLAMPSIA.
  Synonyms.—Convulsions,  Krampfe ; " Inward fits."
  Definition.—Tonic or clonic spasm of the voluntary  muscles,
either in whole or part, accompanied with loss of consciousness.
  Etiology.—The causes of eclamptic attacks in children are so
numerous that it would be impossible to mention them all in a
work like this, but they may be conveniently divided  into (a) 
DISEASES of the nervous system.
129
thermic, (b) toxic, (c) symptomatic, and (d) reflex.  Such attacks
are seen  most  frequently between birth and the  completion of
dentition.   Incomplete eclamptic attacks—"inward  fits "—often
attend indigestion with flatulency and colic, especially in bottle-fed
babies.  Eclamptic attacks are most common with rachitic and illy-
nourished children,  and in the  so-called  neurotic families, with
whom convulsions may be hereditary.  Symptomatic or reflex con-
vulsions may be produced by continued pain at any point, or from
pressure on the head during birth, tubercular or simple menin-
gitis, craniotabes, etc.  Toxic eclampsia follows alcohol and other
narcotic poisoning, and is often seen in the preeruptive stage of
the exanthemata, though here possibly it is due to the high temper-
ature as well.  A toxic convulsion in children often  replaces the
malarial chill of the  adult, and the  same may be  seen  in pneu-
monia, etc.  Breast milk, disordered by anger, etc., on the part of
the mother, may do  the  same, and auto-poisoning, from the pro-
duction of toxic leucoma'fnes in  the intestines, is  undoubtedly the
cause of not a few of the convulsions of early childhood.   Ther-
mic convulsions are liable  to  occur whenever the child's temper-
ature reaches 1040 F.
  Symptoms.—The mildest form  of eclampsia is that  in which
there is a slight  drawing to one  side of the  eyeballs,  quivering of
the muscles of the  face—risus  sardonicus—or twitching of the
extremities during sleep.   Or the child may have a veritable attack
of " night terror," awaking screaming and bewildered, for a vari-
able length of time.  If the causes of these attacks be not removed,
they are  repeated with  greater frequency, until  at last  a true
eclamptic attack appears.  An ordinary eclamptic attack usually
consists of several convulsive paroxysms, with intervals of uncon-
sciousness and  insensibility.  During  these  all the voluntary
muscles may become rigid or twitch, the teeth  gnash,  the eyeballs
roll, and foam run from  the mouth.  Respiration is irregular and
quickened from implication of the glottis and the  inspiratory mus-
cles, and death  may  ensue  from asphyxia.  Generally, however,
the spasm of  the  glottis relaxes  under  the  accumulation of
carbon dioxid  in the  blood,  and life  is thus provisionally pro-
longed.   The  urine  and  feces  may  be  involuntarily  passed.
An eclamptic  attack ordinarily ends in  sleep or coma, proportion- 
130
DISEASES OF  CHILDREN.
ate in length  to the previous attack, from a few minutes to a half
hour or more.
  Prognosis.—Milder attacks  frequently  repeat themselves, if
the  cause persists, while severer attacks  may  occur but once.
They may terminate in immediate death, though this is the excep-
tion  rather than the rule.   It may be said, in  general, that the
younger  the  child the more unfavorable the prognosis.  Repeti-
tion of convulsions, persisting more than a few minutes, point to
serious disease of the central nervous system, and in such cases,
although life  may be preserved, permanent injury, such as idiocy,
paralysis, hydrocephalus, etc., is liable to be left behind.
  Treatment must, of course, always be directed to the removal
of the cause, when this can be found, but often  immediate relief
must be afforded  before the exact etiology can be discovered.

                             (3o)
      R.  Potass, bromid.,.........4
           Chloral, hydrat.,.........1
           Aqua pura,........   . . 60.              M.
      Teaspoonful every twenty minutes for child one year old.
  By the mouth, or in double doses by the rectum, until the con-
vulsions are  quieted.   If we suspect intestinal  obstruction, the
bromid may  be preceded by full dose of calomel (gr. ij—iv) placed
on the tongue.
  If the exciting cause is still in  the stomach, a prompt emetic of
gr. j  turpeth  mineral may give most satisfactory results.  Where
the temperature is heightened, nothing will give better results than
sufficient antipyrine  to  bring it to normal, conjoined with warm
baths and cutaneous  derivatives—mustard to  feet, calves, etc.,
which are especially helpful in cerebral  congestion.  The child
should be completely undressed, both for the purpose of properly
examining it and for ease in giving a bath if  necessary,  which
should never, in the excitement of the occasion, be made  hotter
than the mother or nurse can put her tongue into with safety.

                        (c.)  EPILEPSY.
  Definition.—Epilepsy differs in childhood only in a few minor
points from  epilepsy as seen  in the adult.  Chief among  these 
DISEASES of  the nervous system.
131
 may be mentioned the fact that  with children the aura is usually
 absent or not recognized by them, and epileptic attacks recur more
 frequently with  the child.  The paroxysms are, as a rule, lighter,
 and falling may not occur, the vertigo epilepticus taking its place.
 This constitutes the minor form whose attacks  do not last over a
 minute.   But  there is also  a  grave form in which the child  falls
 with a sudden outcry, perhaps inflicting serious injury upon itself
 in so doing, and showing all  the symptoms of graver epilepsy in
 the adult.
   Etiology.—As varied as in the adult. Haig believes that epi-
 leptic attacks are precipitated by an accumulation of uric acid in
 the blood, resulting in spasm of the vaso-motor system of  the
 cerebral arteries.   It is well proven that continued irritation of any
 kind, such as a tight prepuce,  pressure from a scar,  constipation,
 etc., may bring on epileptic fits in a child predisposed thereto,  but
 the essential nature of epilepsy is not clearly understood unless we
 agree with those who consider  it a degenerative process intermedi-
 ate between iodicy and insanity.
   Prognosis.—At best only fairly hopeful.   Puberty, onanism,
 and the  use of alcohol make the attacks more frequent.  The
 milder forms  of epilepsy have no effect upon the mind, but  the
 grave forms produce mental hebetude, and at last imbecility.
   Differentiation.—Eclampsia can only be distinguished from
 epilepsy by the frequency of the attacks in the latter.  Simulated
 attacks may be known by  the  absence  of cyanosis during  the
 attack  and the lack of subsequent pallor of the skin.
   Prophylaxis.—Marriage should not be permitted among epi-
 leptics, and epileptic mothers  should employ a healthy wet-nurse
 (K.).   Over-exertion,  especially  mental, should  be carefully
 avoided,  as  well as fright, pain, and the reading of  exciting and
 pernicious literature.
   Treatment must first of all aim to remove exciting  causes.   If
 tumors, or cicatrices press upon or irritate nerves, such  tumors  are
 to be extirpated.  Worms must  be expelled and onanism pre-
vented.  Derivatives of cantharidal collodion, mustard, or pustu-
 lating ointments are useful in cerebral troubles, while trephining
 may be  necessary where the bones of  the  skull are depressed.
 Where these things are impossible, or have proved of no avail, 
1:52
diseases of children.
strict attention must be paid to the diet and the preservation of the
general health of the  patient.   The food must be good,  but not
largely nitrogenous, and  spirits are to be avoided.  Frequent ex-
ercise in the open air, daily movement of  the bowels, repeated
baths and sweatings, with journeys to warmer climates, are all of
value.  Education should be preferably at home rather than at
school.   Medicinally this recipe is useful:—

                             (3i)
      R.  Pot. bromidi.,..........3 vj
          Sodiibromidi.,..........3'J
          Tinct. cinch,  comp.,.......§j
          Simple elixir,...........1 nj-           ^.
      Sig.—Teaspoonful four times a day.

Bromism may be remedied by adding small  doses  of Fowler's
solution three or four times a day.
   It should also be remembered that, in many children, the con-
tinued  use  of the bromid produces  constipation and  sluggish
action of the  kidneys  which may require attention, especially in
the way of the free use of lithia or pure spring waters.


                  (d.) SPASMUS NUTANS.
   Etiology.—A  rare affection  of  early  infancy, occurring as
early as the sixth or eighth month, following  either  trauma,  ex-
hausting disease or eclampsia.   Milder attacks are supposed to be
reflex ;  severe ones are thought to result from pathological changes
in the brain itself, whose exact nature are as yet unknown.
   Symptoms.—This affection is essentially a spasmodic  nodding
of the head, continuous or intermittent, often preceded by twitch-
ing of the facial muscles, nystagmus, or cramping of the muscles
of the arms.
   Prognosis.—Spontaneous cures  are possible in the course of
a few months.  These are those cases which'are produced by tran-
sient reflex irritation.  The prognosis, in those of central origin,  is
unfavorable, for such often terminate in idiocy or epilepsy.
   Treatment.—Removal of cause, when this can be discovered. 
DISEASES OF THE NERVOUS SYSTEM.
133
                   (e.) CHOREA MINOR.
  Synonyms.—St. Vitus' Dance, Veitstanz, " Tic."
  Definition.—Involuntary movements of more or  less of the
striated muscular fibers, increased by attempts at coordination and
ceasing during sleep or unconsciousness.
  Etiology.—More frequently seen in girls than boys, but gener-
ally of shorter duration than with males.  Owing to the general
nervous instability of the child, chorea is one of the most frequent
nervous affections of childhood, especially in neurotic families, or
where education has been unduly pushed, or such children have
been severely  frightened.  The causal relations of rheumatism and
eye-strainto chorea, while not proven, are strongly  suggested  as
exciting causes  from their frequent association, especially in the
case of rheumatism  with complicating endocarditis.
  Symptoms.—The involuntary movements of the muscles are
not at first very clearly marked, but later restlessness shows  itself
during the whole day, either in all the muscles of the body, or the
muscles of the head and face may be exempt, and the extremities
attacked—either alike, or on one side, or crisscross, i. e., the  right
arm and the left leg, or vice versa.  Sometimes  the restlessness is
greater on one side  than the other; but the muscles are never for
an instant perfectly still,  except in quiet sleep.   Even vivid dreams
produce choreic movements.  The arms  shake and  are jerked
out of place ;  the  fingers  are sometimes  flexed, sometimes ex-
tended and pick aimlessly at the  clothing.  When such actions
are noticed, the child  becomes  more and  more awkward and its
movements less under control.   The feet totter and jerk irregu-
larly,  the gait is uncertain and stumbling, until, in the severer forms
of the disease,  walking becomes impossible.  Where the head and
trunk are implicated, they are moved to and fro in all sorts of
shakings,  bowings  and  jerkings.  The  child may  vary this  by
" making faces," running out its tongue,  etc.   Speech  is always
difficult and generally stammering.  Deglutition, from the impli-
cation of  its  muscles, exceedingly precarious, so much so that
pills ought never to  be given in these cases.  An attempt at masti-
cation often results in biting the cheek or tongue and involuntary
gnashing of the teeth  follows  swallowing food.  The choreic 
134
DISEASES OF CHILDREN.
movements are increased by attempts  to prevent them, so that
such children become at times entirely unable to write, eat or
walk so long as they are watched, especially if they expect to be
reproved for their  clumsiness.   In very prolonged cases  the
memory may become weakened.
  Pathological Anatomy.—None pathognomonic of the dis-
ease.   " Now this affection arises from some humor falling upon
the nerves," wrote Sydenham more than 200 years ago, and the
latest physiological  experiments seem to show that this " humor "
arises from xanthin  and  its  derivates.   The most frequent  lesion
found  is the  occurrence of endocardial vegetations about the
valves of the  heart.
  Progress and Prognosis.—Chorea may be cut short by inter-
current disease, but it usually culminates in from three to six weeks,
then remains  in statu-quo from five to seven weeks, and from this
point begins to improve, though liable to frequent relapses, but ulti-
mate recovery almost invariably ensues (six months average).  Epi-
lepsy, idiocy,  death following coma,  and chronic chorea are, how-
ever, possible sequelae.
  Treatment  must be directed  to the general condition, espe-
cially if there is anemia or chlorosis,  which require iron, good food
and air.  Worms must be expelled  by means of cathartics and
anthelmintics; improper  residence, if possible, is to be changed,
and onanism and rheumatic diseases of the heart should be care-
fully looked  after.  Chloroform  inhalations may be (rarely) em-
ployed in violent paroxysms, and when the violence of the move-
ments prevents sleeping, we should endeavor at night to make the
child's position as comfortable as  possible by  well  fitting and
padded braces.  Great care should be given to the mental condi-
tion of the child, who should not be allowed to be either frightened
or threatened, on any account,  nor  should it be sent to a public
school.  Rewards and encouragement should be freely resorted to,
and massage  is a valuable adjuvant to any method of treatment.
Goodhart advises forced  feeding, and when the  child can be put
under suitable care the  annexed  diet table will  be found of great
value,  remembering that chorea  is a disease of malnutrition, re-
quiring butter, cream and fats. 
DISEASES OF THE NERVOUS SYSTEM.           135
                           DIET TABLE.
   6.30 A. M.  Oss warm milk.
   8.00  Oss milk and  ^ iij bread and butter.
   9.45  % ss Malt Extract, or cocoa.
   10.00  Massage for fifteen minutes, followed by Oss warm milk.
   12.30 P. M.  Rice pudding, milk, potatoes, and vegetables.
   4 45  Oss warm milk, £ iij bread and butter and soft egg.
   7.00  5 ss Malt Extract, followed in half hour by Oss milk.
   At the end of ten days the bread and butter are to be increased
 to four slices at  the 8 and 4 o'clock meals, and a chop or steak
 added at the noon.   Of drugs, Calabar bean (0.05 gm. powder t. i.
 d.) and arsenic have the  best reputation for the relief of chorea.
 Arsenic is  best given to children as Fowler's  solution, increasing
 the  dose one minim  daily until  symptoms of arsenical  poisoning
 appear, when the dose should be diminished one-half, or discon-
 tinued for one week, and then recommenced at the minimum dose.
 Antipyrine, when not otherwise contraindicated, has a  decidedly
 beneficial effect in lessening the violence of chorea, and can be
 used with advantage also in what are usually known as choreiform
 spasms.  The writer  has obtained excellent results  from salicin
 (gr. v t. i. d.) in chorea of rheumatic origin, and  in similar cases
 Atkinson speaks highly of chloral hydrate and fl. ext. cimicifuga
 combined, as follows :—

       R-. Chloral hydrat.,.........zij
          Ext.  cimicifuga,.........f3 ij
          Elix. simplicis,.........J iij.       M.
       Sig.— 3J q. 3 hours.                           (Atkinson.)

                   (f.) CHOREA MAJOR.
   Synonyms.—German Saint Vitus' Dance ;  Hysterical chorea.
   Definition and   Differentiation.—Usually distinguished
from ordinary chorea by the rarity of the major variety and by its
disturbance  of consciousness and abolition of reflex movement.
  Etiology.—It is especially apt to attack girls about the time of
puberty, and generally appears upon retarded or irregular men-
struation. Much more rarely boys are attacked  about puberty ; 
•   136
DISEASES OF CHILDREN.
and  it is well authenticated  that the  disease is hereditary, but
generally a predisposition to this condition arises from improper
education by a hysterical mother.  The previous  conditions of the
brain are unknown, except  that there is heightened irritability of
the sensorium and the motor nervous system.
  Symptoms.—After  a prodromal period, which varies and is
marked by dreams,  restless sleep, anxiety, timidity,  pains in
the  head  and  back, and  disturbances  of digestion,  violent
paroxysms  appear with varying frequency and duration—a few
minutes to  several hours.   These attacks consist of the  most
complicated  and apparently  voluntary movements—dancing,
jumping, and climbing.  At the same time, or  instead of these irra-
tional motions, the patient chatters the most nonsensical stuff until
the paroxysm passes by, when the girl falls into a long deep sleep,
from which she  awakens without any  remembrance of what she
has been doing or saying.
  Progress and Prognosis.—Sometimes the disease is limited
to a  single attack, or  there may be  a succession of them upon a
single day.  Or  they may occur at  intervals of several weeks, or
even further apart.   The prospect for life is always favorable,
though not for intellectual vigor, for such girls are  very apt to be-
come mentally unstable women.
  Treatment should be directed, first of all, to  the regulation of
menstruation, for when this  is accomplished it usually  brings a
cure with it.  This generally requires an improvement  of the
general condition of the child, any  relapse from which is liable to
bring on again the paroxysms.  Improper reading and company
must be carefully looked after, and especially  care should betaken
that no one relates to  the child what it may have said or done
during  the attack.   Iron, quinin,  and manganese  are helpful
against the chlorosis and anemia, cathartics for constipation, with
mustard foot baths, or mustard plasters to the thighs,  and salt sitz
baths for suppressed  menses.  During the attacks care should be
taken to prevent injuries  to the body.  Often  we can bring the
patients back to consciousness by sudden cold effusions, or a sharp
reproof, as in true hysteria.   Hydrotherapy is well spoken of by
French physicians, but  drugging is  to be avoided and gymnastics
substituted. 
DISEASES OF THE NERVOUS SYSTEM.           137
                    ARTHROGRYPOSES.
  Definition.—Tonic cramp of localized groups of muscles.
  Etiology.—Most frequently in weakly  children from one to
three years of age, and by preference among boys and during the
cold season of the year, or in convalescence.  The disease is either
symptomatic of various cerebral lesions, e.g., caseous degenera-
tion, apoplexy, etc., or is idiopathic with unknown causes ;  in the
latter case it is without fever.
  Symptoms.—Individual groups of muscles, especially of the
extremities, are  persistently contracted.   Sometimes there  are
edema and erythema of the limbs in addition.   By examination,
it seems as if pain only arose from the action of the opposing mus-
cles. Generally both sides of the body are simultaneously  affected,
e.g., both arms are flexed to a right angle at the elbow, hand  and
metacarpal joints, and the thumb emballed in the hand.  Or the
feet  may be extended, with contraction of the muscles of  the
calves, while the toes are either extended or bent.  Alteration in
the disposition often attends these cases, the child being depressed
and sad without reason.
  Progress and Prognosis.—The disease is usually of pro-
tracted duration and with frequent relapses, and prognosis is favor-
able only in the idiopathic variety.
  Treatment.—The main thing is to maintain the  strength by
means of good diet, iron, quinin, etc. The cramp of the muscles
may be combated by means of baths, warmth, the internal use of
opiates or hydrate of chloral, and external narcotic rubbings.


           NEUROPATHIC FACIAL ATROPHY.
  Etiology depends upon a deficient development  of  one-half
of the  face.  Its peripheral causes  are burns, scrofulosis of the
cervical glands, abscess of the tonsils, etc., while the central ones
are apoplexies, etc.  Girls are more frequently attacked than boys,
and in the majority of cases the left half of the face is  the  part
affected.
  Symptoms  and Course.—Either half or the whole of the
face may become affected by the  extension of the atrophy.   The
      J 
138                DISEASES OF CHILDREN.
parts are pale, the bones remain small, and  the muscles less de-
veloped than normal.  One-half of the tongue is apt to be atro-
phic, and one eye smaller than the other.   The hair falls out or
turns gray upon the affected side, which appears considerably older
than the other.  No changes in the arteries.
  Prognosis.—Bad.
  Treatment by electricity up to the present time has been with-
out results.


  MOTOR PARALYSES, CENTRAL AND PERIPHERAL.
  The traumatic and rheumatic paralyses of  children differ in no
respect from those of adults.  We have already made mention  of
diphtheritic  and symptomatic-central-paralyses, which  are found
in connection with  lesions of the brain, spinal  cord, and bones,
but there are four other forms of paralysis which especially deserve
our attention.
                     Essential Paralysis.
  Synonyms.—Anterior poliomyelitis, infantile paralysis.
  Etiology.—The period of dentition, especially during the cut-
ting of the molars, seems to act as a predisposing  cause.  Most
frequently exposure to cold is the exciting cause, although essen-
tial paralysis sometimes follows typhoid fever or the  exanthemata,
and in others the only thing  abnormal noted has  been persistent
constipation or passive congestion of the brain.
  Pathological Anatomy.—Atrophy of the trophic centers  in
the anterior  horns of the gray matter, though later extension may
take place to other parts of the cord. The motor cells are shrunken
with granular degeneration  of the involved nerve  elements and
subsequently of the affected muscular fibers.
  Symptoms.—Partial or entire loss of motion and sensibility in
one or both of the  upper, or more often, of both the lower ex-
tremities. Such paralytic attacks may come on suddenly, or  be
preceded by fever, difficult  dentition, or by eclampsia, and  some-
times the paralyzed part is the seat of sharp pain for several days.
The paralyzed arm  hangs helplessly down and cannot be raised,
but sometimes, when only the muscles of the upper  arm are para-
lyzed, the motility of the fingers is preserved.  It is  also rare that 
DISEASES OF THE NERVOUS SYSTEM.           139
all the muscles of the paralyzed feet are affected.  The sphincters
of the bladder and rectum  are intact, even when the child drags
both feet in walking.
  Progress.—Sometimes  the  paralysis  disappears  entirely  or
partially after  two or three days, or  in as  many week's, without
leaving any sequelae behind, or it may persist  for months.  In the
latter case it leads to atrophy of the inactive muscles, which is
especially noticeable  in  partial paralysis  of the shoulder  with
atrophy of the deltoid, or in the lower leg with contractions, such
as club-foot, genu valgum, etc.  With these are associated a weak
pulse, a lowered temperature of the skin, and sometimes edema of
the affected members, and, lastly, imperfect development of the
paralyzed member.
  Prognosis is favorable for life, but not always so for recovery.
  Treatment.—Symptomatic.   None of the remedies usually
employed can shorten the course of the disease.   During the first
week the affected  limb should be kept warm, and stimulating em-
brocations should  be tried.  After the paralysis has persisted for a
month, we should endeavor to overcome the muscular  atrophy by
means of electricity and  massage, daily applied. Of drugs, the
only ones of real value are the iodids and strychnia in some form
or other, long continued.  Ergot is  thought  to be  useful if the
case is bad at the  onset.

     Paralysis Myosclerosica,  Atrophia  Musculorum
                        Lipomatosa.
  Definition.—A thickening of some and atrophy of other mus-
cles, but the distinguishing feature is a sub-paralysis of them all.
  Etiology.—Bad nourishment, poor dwellings, rachitis, scrofu-
losis, or other nutritional diseases.  It nearly always attacks boys.
  Symptoms.—If the disease  begins early in  life, children do
not learn to walk until late, and walking is difficult, such children
become easily tired, and  have pains  in their legs, which increase
in size.  Finally, the gait becomes uncertain,  and walking is only
possible on the toes.  Rising becomes difficult, and can be accom-
plished only  by strenuous exertions.  The thoracic  muscles are
atrophic, while the muscles of the  calves of the upper and lower
thigh and of  the  upper arm are either all or partially hypertro- 
140
diseases of children.
phied.   In the latter condition atrophic  spots and knotty projec-
tions alternate with each other in the same muscle.  At the same
time the normal curvatures of the spine become exaggerated, pro-
ducing lordosis and  kyphosis.  The electric contractility of both
the atropine and hypertrophic muscles is diminished, while, curi-
ously, taste is apparently heightened.  The disease usually pursues
a steady course  for the worse for  several years, though  rarely a
halt is observed.   As chronic atrophy of the  muscles advances,
dyspnea increases  until suffocation  may appear.
  Prognosis.—Bad.
  Treatment of  any value is as yet unknown.

                  Paralysis Nervi Facialis.
  The same form  of disease that occurs from pressure of the for-
ceps (see page  38) can also be brought on later in life by caries
of the petrous portion of the temporal bone, induration of glands,
or scars in the neighborhood of the facial nerve.
   Symptoms.—At first the paralysis is recognizable only during
laughing, crying, or speaking, because then the muscles of one side
of the face remain quiet;  later, the paralyzed half of the  face be-
comes expressionless, even when in rest.   The affected corner of
the mouth hangs  down and tears  flow over the cheeks, while in
central paralysis the uvula hangs awry.
   Progress and Prognosis vary according to the cause of the
disease.  After petrosal caries, persistent paralysis almost always
is left behind.
  Treatment.—Cicatrices and infiltrated glands must be removed.
Caries of the temporal bone requires the assistance of the aurist.

                Paralysis of the Serratus.
  Etiology.—The paralysis may  be peripheral, resulting  from
various traumatic  causes,  or  cold, affecting  the  course  of the
nervus  thoracicus  longus, to which  alone the serratus anticus
major owes its innervation. When  the causes are peripheral, the
paralysis is unilateral, and more often over the right side, but when
the causes are central, the  paralysis is bilateral, and is often com-
bined with atrophy and paralyses of other muscles.
  Symptoms.—After  transient  pains  in the  supra-clavicular 
DISEASES OF THE NERVOUS SYSTEM.
141
region, the arm can be raised only to a horizontal position, and at
the same time it is observed that the shoulder blade has so twisted
itself that its inner edge projects from the thorax, like a wing, with
curvature of the spinal column ; but if the shoulder blade is  held
fixed  in its proper position, the arm can be raised and the spinal
column straightened.  Later, the  muscle becomes  greatly  atro-
phied.
  Prognosis.—Seldom favorable.
  Treatment.—Stimulating liniments or cupping to the supra-
clavicular region, with massage and the battery,  comprise all that
can be done for such cases.  Strapping may give temporary relief.

               The Organs of Special Sense.
                         (a) Smell.
  The sense of smell is sometimes  wanting from  a congenital
absence of the olfactory bulb, but more often its defects arise from
chronic catarrh acquired early in life.

                        (b) Hearing.
  i. Congenital deafness, often  combined   with  absence  of
speech—deaf and dumbness—proceeds either from malformations
of the inner ear or  from  central  disturbances.   The  intellectual
functions of the deaf and dumb are often preserved intact, and by
instruction in the  appropriate institutions become brilliantly culti-
vated.
  2. Malformations of the Ear.—There may be complete or
partial absence of the pinna of the ear—defectus  auricula—which
can only be  corrected by ^wearing an artificial  ear;  usually not
necessary for defective hearing.  Furthermore, the ears may lie flat
on the cranium—auriculce adpressce—or stand directly out like the
ears of a bat—auriculce vespertilionis.   These require to be bound
down with  bands of adhesive plaster for several  weeks.   Finally,
there  may be closure of the ear— atresia seu imperforatio meatus
auditorii—generally only on one side.  This closure may be either
membranous or osseous, the latter of which occurs only with other
malformations—hemicephalia, etc. Membranous closure may be
safely  removed  by  an operation;  but in the treatment  after 
142
DISEASES OF CHILDREN.
the removal of the obstructing  membrane, it is most important
that  the canal  should  not be allowed  to  close itself again.  As
regards the  treatment of the auditory organs, we  must refer the
reader to the special works on the subject.

                         (c) Sight.
  i.  Malformations  of the Eyelids and surroundings.  Colo-
boma of the  cartilage of the upper lid, without fissure of the skin,
is of no significance.  Epicanthus is a semilunar  fold of skin in
both of the inner angles (canthi) of the eyes, whereby the root of
the nose is  abnormally  flattened,  and the  integument cover-
ing the same  encroaches upon the  epicanthal folds, and may
even reach the inner border of the cornea, but does not interfere with
sight.  Epicanthus sometimes disappears by a spontaneous  cessa-
tion of its growth ; when it persists for a long time, it can only be
cured by cutting out of a fold of skin from the base of the nose, and
closing the edges of the wound with fine sutures.
  2.  Malformations  of the Inner Eye.—(a) Coloboma iridis,
seu iridoschisma, is a fissure of the iris from below or sideways in
different directions.  Sometimes the pupil preserves its normal
shape, and the fissure  is separated from  the pupil by cross-bars
of iris tissue in the pupil.  Coloboma  iridis is rare and is more
often double than single.  The cause  of  coloboma, both  of the
cartilage of  the upper  lid and of the iris, is unknown ; sometimes
it is hereditary.  The action of the fissured iris is very imperfect.
  (b) Irideremia, partial or entire absence of the  iris, is always
double.  Here, as in very marked coloboma, we can always see the
fundus of the  eye  when it is  illuminated by the  proper light.
These unfortunate children are always ^hort-sighted, and are com-
pelled to blink through the lids.  Later,  inflammation and haziness
of the lens are very frequent, whence nystagmus arises.
  Treatment.—Protection from the light by means of blue glasses
and an artificial diaphragm.
   3. Atresia Pupillae Congenita.—The pupillary membrane,
which should atrophy at  the seventh  month of pregnancy, per-
sists either as an entire and transparent membrane, with few or no
vessels, or it may be perforated or ragged.   It weakens the power
of sight and impedes the action of the iris.  Through the traction 
DISEASES OF THE RESPIRATORY SYSTEM.        143
of the iris sometimes  a sort of spontaneous cure occurs,  the
membrane being ruptured and the fragments atrophy.
  Treatment.—Dropping in of a solution of atropin.
  4.  Cataract—centralis seu  neuclearis—appears as  a white,
round  opacity  in  the  center  of  the  lens,  often complicated
with  some of the  previous  malformations.  The lens  is never
entirely opaque, and the ability to see is greatly interfered with,
but never entirely lost.   Requires an operation.
  Discussion  of diseases of ear  and eye, except as complications
or malformations, is not attempted in this volume.
                     SECTION  VIII.

 DISEASES OF THE RESPIRATORY  SYSTEM.

               1. ACUTE  NASAL  CATARRH.
  Synonyms.—Acute rhinitis, cold in the head, coryza.
  Definition.—A self-limited catarrhal inflammation of the mu-
cous membrane of the nose and frontal sinuses.
  Etiology.—Often, if not generally, produced  by a  lithemic
condition  of  the  system.   Sharp cold, a dusty atmosphere, the
powdering of certain drugs, specific microbes, pollen, and other
local irritants may produce nasal catarrh, which is also a symptom
of measles, rubella, hereditary  syphilis, rachitis, and may replace
the sweating stage of malaria in children.
  Symptoms.—Fever (ioi°), restlessness, malaise, and general
aching often  attend the  lithemic form of rhinitis, which some
consider closely allied to a mild rheumatic attack.  The amount
of discomfort depends largely upon the amoupt of swelling of the
turbinated bodies, which, if great, produces loss of smell, head-
ache, and general discomfort.  The usual method of relief is by a
profuse mucous discharge from this hyperemic mucous membrane,
often so profuse  as to keep a  handkerchief  nearly constantly in
use for a day or two.  Within forty-eight hours the discharge grows 
144
DISEASES OF CHILDREN.
thicker and yellow, and in a properly cared for case, entire resolu-
tion and return to a normal condition of affairs ought to take place
within a week.
  Treatment.—According to the writer's ideas,  the essential
things in the treatment of acute coryza are an equable atmosphere,
restriction of diet, and the large  use of  fluids to flush out the sys-
tem.   The value of warm air may be enhanced by the inhalation
of the vapor of hot water containing either spirits of camphor or
menthol.   Homeopathic tincture of camphor has a well-deserved
reputation for the relief of incipient colds, but it should be remem-
bered that it has three times the strength of the officinal spirits and
must be  used with caution, as eclamptic attacks have more than
once resulted from its  careless use.  Except with young children,
a small dose of Dover's powder may be used with advantage at
bedtime to give a night's sleep, and aconite and  phytolacca may
be used during the day to reduce the fever and stimulate glandu-
lar  activity.  Lemonade containing, a little  liq. ammon. acetatis
can be given freely, and, if the child is old enough to tolerate it,
warm alkaline sprays  afford  much relief.  Dilute Dobell's solu-
tion  (i 14) or Seller's tablets furnish a convenient method of use.
Such tepid solutions are to be used in a  hand-bulb spray, or with
very young children to be dropped into the nose with a dropping
tube.  Liquid vaselin containing one to two drops of oil of winter-
green to the ounce should be used after the aqueous spray, and, if
continued for a week or so after the subsidence of an acute attack,
will  do much to  produce entire recovery.
  Prophylaxis.—Regulation of diet and salt baths, lithia.


          2.  ACUTE  CATARRHAL LARYNGITIS.  •
  Synonyms.—Pseudo-croup, spasmodic croup, angina stridu-
losa.
  Varieties.—Illoway divides  catarrhal  laryngitis into three
varieties, viz.: the mild (1. supraglottica), the severe (1. stridulosa),
and the grave form (1. hypoglottica gravis).
  Differentiation.—It should be remembered that syphilitic lar-
yngitis causes chronic stridulousness, and that fibrinous exudates
and edema of the larynx may produce attacks of croup, only to be 
DISEASES OF THE RESPIRATORY SYSTEM.         145
differentiated from the acute catarrhal form by the history of the
case.   Hence, we may find these so-called croupy attacks in any
disease which may lead to edematous swelling of the larynx, e. g.,
struma, papilloma of the larynx, etc.
  Etiology.—Acute  rhinitis is, next  to chronic pharyngitis, the
most frequent exciting cause of these attacks, which are common
between  two and four years, and have  a marked tendency  to
repeat themselves.  As the child grows older, pseudo-croup,  as a
rule, grows more infrequent, and is replaced by hoarseness and
dry cough after fifteen years.
  Pathology.—Hyperemia  and  tumefaction of the  laryngeal
mucous membrane, which is covered with muco-purulent secretion.
Epithelium exfoliated, and in  severe cases the epiglottis is deep
red and swollen, hyperemic.
  Symptoms.—During  the  course  of  a  nasal  or  bronchial
catarrh hoarseness, accompanied with a  sharp  metallic cough,
suddenly appears.   Grave cases begin suddenly in the middle of
the night, with spasm of the glottis and  labored inspiration,  con-
stituting the well-known attacks of croup.  Children thus attacked
sit up in bed, gasping and breathing with  great difficulty.  Their
cough is stridulous and the pulse is quickened and there may be
a mild grade of fever.   After a little while these symptoms become
intensified  until  the  child  breaks into  perspiration, with whose
appearance the fever sinks.  As a rule there follow one or more
lighter paroxysms, terminating in sleep. Generally this is followed
the next day by  a loose  cough,  and  the  hoarseness  disap-
pears in two or three days.  In such children the appetite is  only
slightly diminished and it is impossible to keep them long in  bed,
for the whole attack ought to be concluded within a week, unless
capillary  bronchitis follow.
  Differentiation at the time of the attack  is often impossible,
but we presume that the  attack  is pseudo-croup if it is sudden  in
its onset and paroxysmal in character.   Diphtheritic  croup is pro-
gressive,  and in 50 per cent, of  the cases membrane can be seen
in the throat.
  Prognosis.—Exceedingly good, although  relapses may be ex-
pected for the succeeding night  or two.
  Treatment.—Occasionally the use of an  alcohol  and  cold 
146
DISEASES OF CHILDREN.
water compress may abort a threatening attack of pseudo-croup,
especially if to this may be conjoined the use of a steam atomizer,
whose vapor contains a few drops of wine of ipecac, or paregoric.
When these fail, prompt resort should be  made  to emetics, e.g.,
wine of ipecac, 3j every twenty minutes  ; turpeth mineral.gr. j, or
the domestic remedies of alum and molasses, goose  grease, etc.,
any of which will cut short the paroxysm as  soon as emesis takes
place, and sleep usually follows.  The child usually requires some
mild  expectorant the next  day (R.  No. 33), and  the writer  has
much confidence in the use of quinin  and calomel (gr. j and ^ gr.)
three or four times in the day as a prophylactic to prevent the re-
turn of the paroxysms on succeeding nights.  Subsequent attacks
are usually milder  and yield more  promptly to treatment,  and
children never die from pseudo-croup, your professional  rivals to
the contrary.


        3. LARYNGITIS CATARRHALIS  CHRONICA.
  Etiology and Pathology.—Acute  laryngeal  catarrhs, espe-
cially in children with consumptive parents, or in those where there
has been undue use put upon the voice  in singing, shouting,  etc.,
often run into a chronic condition.  Furthermore, actual morbid
conditions of the larynx, such as are met with in true croup,  per-
tussis, or from the passive hyperemia, produced by pressure upon
the cervical vessels (tumors, caseous  glands, etc.), lead to chronic
laryngeal catarrh  with  consequent  thickening of the laryngeal
mucous membrane and varicose enlargement of  its vessels.
  Differentiation can be  made certain by the use of the laryn-
geal  mirror, by whose  aid  a diagnosis  of the congestion of the
vocal cords, or their paralysis, or the presence of foreign  growths,
etc., can be made.
  Symptoms.—Hoarseness naturally results from the chronic
congestion of  the vocal cords, and this  congestion is aggravated
if the use of the voice is persisted in, hence the hoarseness is worse
at night.  The mucus expectorated,  chiefly early in the morning,
is liquid, grayish white, apt to come in small, roundish bits, and is
easily raised.
  Treatment should be  especially directed to the detection  of 
DISEASES OF THE RESPIRATORY  SYSTEM.        147
the exciting cause and its removal if possible, as in case of undue
use of the voice.  Astringent  sprays  or insufflations are also of
value, and some writers advise the application of nitrate of silver
by means of the probang or brush.  Far more successful than any
of these is the removal  of the child  to a warm, equable climate,
preference being given to a pine forest, when possible. Of internal
remedies, the hydrate of terpene can  be highly recommended
either in capsules or tablets, or in a  mixture like  the one here
given:—
                      Terpene Mixture.
      R.  Hydrate terpene,  ..........3 ss
          Glycerinse,
          Syr. lactucarii......aa.....^ss
          Syr. yerb. sant. aromat.,    .......Elll-  ^.
      Half a teaspoonful to a teaspoonful four times a day.

  When removal is impossible, extra care must be taken to guard
against  chilling the surface  of the  body.


                 4. SPASMUS GLOTTIDIS.
  Synonyms.—Spasm  of the glottis; laryngospasmus, Stimm-
ritzenkrampf; laryngismus  stridulus;   spasm of the thyroid and
crico-arytenoid muscles, thymic asthma.
  Etiology.—Rachitis and hereditary influence undoubtedly play
the most important parts, but teething, poor nourishment, over-
crowding, and bad hygiene  act as exciting causes.  More boys than
girls are attacked (K.).  It has been  experimentally proven that
craniotabes, not so much from the increased compressibility of the
softened occiput as from the secondary hyperemia of the cerebral
membrane, is a frequent cause of spasm of the glottis.  Indigestion
and dyspeptic complications frequently bring on  single  attacks,
which are easily reproduced by coughing, fright, or continued fret-
ting.  But here we must make a careful distinction between the
voluntary " holding of the breath " of spoiled children, who often
scream  until they become blue in  the face, and true spasm  of the
glottis.  The differentiation is easily  made by means of a brisk
spanking or throwing a little water in the face of the unruly child. 
148
DISEASES OF CHILDREN.
  Symptoms.—The   first  onset  generally  appears  without
warning; subsequent  ones are noticed  to  be preceded by short,
whistling inspirations, followed  by a suffocative  attack, during
which the child holds its breath, clutches at its throat, and  bends
its  head backward until the eyeballs  protrude and the jugulars
swell.  The face becomes  suffused, the  mouth  half opens, and
the whole expression one of great alarm.  Such an attack usually
lasts about  a minute, and probably never more than one, though
unless timed it appears much longer.  It terminates in a series of
short, whistling inspirations, followed at  first by noiseless superfi-
cial expirations, which latter grow deeper until  normal breathing
is resumed or another attack appears.  These attacks are often
followed by an  involuntary discharge of urine, or feces, and for a
time the pulse is irregular, but in the intervals between the attacks
the child appears perfectly well; or this is  true  until  the attacks
become very frequent and leave the child at last peevish,  weak,
sleeping badly, without  appetite, and, in consequence, gradually
losing flesh.
  Prognosis.—Fair, although  the  child  may die in the first or
any subsequent attack.  Nevertheless, unless the child is very
young, it somehow manages to pull through except when broncho-
pneumonia intervenes, as not infrequently happens.  Increase in
the number of attacks per diem is an unfavorable  sign, for they
may reach  forty or more in a day, and such increase generally
joins a true eclampsia to the spasm of the  glottis.  Twitching of
the facial muscles, balling the thumbs, flexion of the upper ex-
tremities,  and  rigidity of the lower,  opisthotonos,  etc.,  betoken
these mixed forms, which  are far more dangerous than simple
spasm of the glottis.
  Treatment.—Prophylactic.   Children  in  neurotic  families
should,  if possible, be nursed until their first  six teeth are  cut.
Craniotabes always require anti-rachitic treatment (see page 63)
and cod-liver oil.  Medicinal.  Almost everything in  the way of
antispasmodics and neurotics has been tried for the relief of these
attacks with very little gain, unless it may be from a combination
of bromids  and chloral hydrate, such as is advised in  eclampsia.
German physicians and  negroes advise  the hanging of a bag of
camphor about the child's neck.  Nearly two hundred years ago 
            DISEASES OF THE RESPIRATORY SYSTEM.         149

Underwood discovered the great value of fresh  air in the treat-
ment of these cases.  Tobacco smoke may be used as advised by
him as a last resource for the relief of these spasms, and the writer
bears cheerful testimony to the great value of keeping the child
out-of-doors as much as possible, for the overheated foul air of a
tenement house acts as rank poison upon laryngospasmic children.
Tight clothing should, of course, be removed, a warm bath is often
of service, and whiffs of chloroform may be cautiously used when
absolutely necessary.


         5. FOREIGN  BODIES IN THE LARYNX.
  Etiology.—It not infrequently comes to  pass that children,
from the same reasons that impel them to place various things in
their noses, eyes, or vagina, place similar articles in their mouths,
and then by aspiration draw them into the trachea instead of swal-
lowing them, as was purposed.  Such accidents are not infrequent
with beans, peas, cherry  pits,  almonds, candies,  pennies, tacks,
corks, etc.
  Symptoms.—Violent coughing and suffocation with  cyanosis
attend  the  entrance of a foreign  body into the larynx, and if  it
remains, an irritating cough persists with subsequent inflammation
and  ulceration of the trachea.  Should the substance be carried
deeper, we may be  able to perceive its irritating motion  as an
audible gurgling sound, to and fro with each respiration.   Or if it is
lodged fast, as might happen with a sharp bit of bone, it produces
localized ulceration, indicated by a cough attended with bloody or
purulent sputa.  Should the body be drawn still  lower down into
the  smaller bronchioles, it may lead either to atelectasis of that
portion of the  lung (page 20) or to pneumonia.
  Course.—Some  of these foreign  bodies, as  needles,  may
migrate to other parts of the body, or they may result in abscesses,
or more rarely become encapsulated.  Small,  soft bodies, like bits
of meat, may be thrown out by violent coughing, or if soluble, like
candy, may be dissolved.
  Prognosis.—Generally unfavorable if the foreign body has
passed within  the vocal cords,  or if the body is too large  to  be
coughed out or dissolved.   An insoluble foreign body inspired into 
150
DISEASES OF CHILDREN.
one of the lesser bronchioles leads almost inevitably to death, as
there is no operative or medicinal measure that can be safely used
for its removal.
  Treatment.—If the foreign body lies above the vocal cords,
its extraction should be attempted as speedily as possible with the
aid of the appropriate instruments, or if these are not at hand, by
holding the child by its heels, head_ downward, and encouraging
coughing by slapping its back or  tickling its fauces.  When  the
offending substance has gone deeper, we must resort first to forci-
ble expiration following long-drawn  inspirations (forced coughing)
and emetics, the promptest of which is apomorphia (j1^) or turpeth
mineral (gr.j pro dosi).  Tracheotomy is called for when the object
can be localized, and is usually successful.


                  6. EDEMA GLOTTIDIS.
  Synonym.—Edema of the glottis.
  Etiology.—A symptom attending various lesions of the larynx,
such as burning with hot steam, etc., or as a dropsical complication
occurring in phthisis, nephritis, typhoid, cancer, or other tumors
in the neighborhood of the larynx.  The laryngoscope shows in
such cases an inflammatory edema of the mucous membrane of
the glottis and of the false and true vocal cords.
  Symptoms.—In the first class of cases, after the initial pain of
the lesions inflicted  upon the mouth, pharynx, and larynx have
been  assuaged, increased hoarseness  and painful breathing be-
token  oncoming laryngeal  stenosis.   Dyspnea  soon  becomes
frightful and often produces death  unless help is speedily rendered.
  Treatment.—Intubation is clearly indicated in the first class
of cases, tracheotomy in the latter is justifiable.   Puncture of the
edematous tissue is possible in the hands of an expert, but cannot
be recommended ordinarily for the larynx of an unruly child.


           7.  NEW GROWTH  IN THE LARYNX.
  Varieties.—Pedunculated papillomata, more rarely cysts, con-
genital syphilitic lesions (congenital hoarseness), adenoid growths,
as sequelae of true croup, pertussis, measles.  Differentiation is 
            DISEASES OF THE RESPIRATORY SYSTEM.        151

only possible by the use of the laryngoscope, with infinite patience
on the part of the expert.
  Symptoms.—Hoarseness is absent only when the papilloma
is located elsewhere than near the vocal cords, e.g., on the glottis,
which rarely occurs.  This hoarseness often increases until there is
complete aphonia.  As  the growth  increases in size there  is in-
creased  difficulty of breathing, and if the growth becomes caught
between the  cords there are attacks of  suffocation, resembling
those of croup, which may terminate in death.   Tumors which are
located higher may often be detected by pressing down the root of
the tongue with a spatula, or tongue  depressor.
  Adenoid growths are not  infrequently coughed up in broken
bits, though such are more frequently swallowed by young chil-
dren.
  The progress of these growths, of course, varies greatly with their
nature, sometimes a couple of years elapsing between the begin-
ning of  the hoarseness and the symptoms of suffocation.
  Prognosis.—Never very  good.  The older the child the better
its outlook.   Some of these  children by the aid of cauterization
and the help of intubation  tubes make a fight for  existence for
years, and possibly finally recover.
  Treatment.—Entirely surgical  and local.  Desperate  cases
demand the opening of the trachea and the removal of the growth
after tracheotomy.  Less pressing ones will admit of local cauteri-
zation (galvano) and the use of the intubation tubes p. r. n.


                 8. PARALYSIS GLOTTIDIS.
  Synonyms.—Paresis of the glottis ; Stimmbandlahmung.
  Etiology.—Its origin may be either central,  e.g., tumor at the
base of  the brain, when the  paresis  is always bilateral, or it may
arise from peripheral nerve pressure on the vagus,  or recurrens,
etc., which  not infrequently occurs from caseous glands and is
only bilateral when the cause is located on both sides of the  neck.
Again, this form of paralysis may follow diphtheria.
 .Symptoms.—The first thing  usually to attract attention is a
feverless, noisy respiration, not unlike that of croup, but without
difficulty and more rattling.   Deep breathing,  crying, laughing, 
152
DISEASES OF  CHILDREN.
etc., provoke attacks of violent coughing.  The voice is always
hoarse, or if there  is bilateral  paralysis, aphonic.  The laryngo-
scope makes the diagnosis sure according as one or both of the
vocal cords fail to recede during inspiration, or to approach during
phonation.  During  deep inspiration the chink of the glottis  is
lessened by  atmospheric pressure, and hence the irritative cough.
  Prognosis.—If due to caseous glands  or pressure, unfavor-
able.  The same is even more so with the  brain tumors.   Diph-
theritic paralysis is more hopeful.
  Treatment.—Treat the complicating  scrofula if present, and
use externally  tincture of iodin and electrotherapy.  The intro-
duction of sounds and the insufflation of powders into the larynx
are also helpful in skilled hands.
  If after several  weeks there is no improvement under general
treatment, we must extirpate the bunches of diseased glands, avoid-
ing carefully the vagus, which has more than once been cut during
such  operations.   After diphtheria, use tonics, as iron, and espe-
cially strychnia.

                 9. STENOSIS  TRACHEAE.
  Synonyms.—Tracheal stenosis;  Verengerung der Luftrbhre.
  Etiology.—May be  congenital,  or  follow  as  the result  of
struma.  More  rarely it results from  tumors of the thyroid or  in-
filtration of  neighboring lymphatic glands.   Again it results from
change  in form, or atrophy of the windpipe, not infrequently due
to suppurating lymphatic glands.  Or there  may have been a pre-
vious perichondritis—often of syphilitic  origin.  Or chronic con-
gestion  of  the  tracheal mucous membrane  by extension from
similar affections of the  larynx,  catarrh, croup, diphtheria, etc.,
may  produce this lesion.  Sometimes it is  due to the introduc-
tion of foreign  bodies  into the trachea, more rarely to tracheal
polypi.  Strangulation  of the windpipe with narrowing at the point
of the angle may result from a pleuritic exudate, and  contraction
of the lung on the affected side.
  Symptoms.—The congenital form shows itself by the impeded
respiration and  difficult nursing arising therefrom.  No cyanosis,
but weak and hoarse voice.  The acquired variety manifests itself
by croupy breathing.   Sometimes the narrowing, or strangulation, 
DISEASES OF THE RESPIRATORY SYSTEM.        153
 may be felt just above the sternum, and when such  deformity re-
 sults the  respiratory sounds  on the affected side will be found
 diminished.
   Treatment must be directed to the  cause;  if due to swollen
 lymphatics, syphilis, or scrofula, our main reliance must be placed
 on the internal  and external use of iodin, conjoined in the first
 case with  cod-liver  oil.  Compressed air has  at times been  of
 value.  Polypi must, of course, be removed.


         10.  DISEASES OF THE  THYMUS  GLAND
 are rare in children, and if confined to one side  have no influence
 on respiration, hence the so-called thymic asthma is  a misnomer.
   Caseation of the thymus is its most frequent disease  in child-
 hood,  usually with  similar implication of neighboring bronchial
 glands.  Abscess of the thymus is occasionally met with in syph-
 ilitic children, in whom the disease produces a change in the secre-
 tion of the thymus  from acid to alkaline reaction.   Even more
 rarely cysts  or  carcinoma of the thymus have been noted, but
 usually their  nature has not been recognized before the autopsy.
   Treatment.—Operative only.


             u. DISEASES OF THE THYROID.
   Hypertrophy of the thyroid is usually acquired, and manifests
 itself after the second dentition.   When it reaches its  highest man-
 ifestation  it produces the so-called thyroid  asthma,  caused by
 tracheal stenosis, resulting from the pressure of a cystic or adenoid
 thyroid gland, and  differing in  none of its symptoms from those
 observed in the adult from a similar cause.
   Congenital  bronchocele appears endemic in  certain localities
 and  among certain  families, reference  being made  here only to
the adenoid variety, in which the gland embraces nearly the entire
trachea like  a ring.   These children are often  born  apparently
dead, and when they can be resuscitated, breathe  superficially,
irregularly, and without noise.  Death from asphyxia often follows
quickly after  birth in such cases.
   Treatment  in  congenital forms must be directed to the relief of
      K 
154
DISEASES OF CHILDREN.
asphyxia, for it is possible thus we may obtain relief in the course
of a few weeks by the aid of forced inspiration, good wine, fresh
air, and warmth.
  Other forms of bronchocele have been helped by painting with
tincture  of iodin once or twice  a week,  the possibility of  later
phthisis being always kept in mind in the treatment of these cases.
  Latterly the attempt has been made to  prove that cretinism is
due  to torpor or atrophy of the   thyroid.   Hence in such casesif
we follow Horsely's advice we shall endeavor to restore the loss of
function of the thyroid body.  Schiff suggests that this may be done
by transplantation of a thyroid from  one of the  lower animals.
Desiccated thyroid glands from  the sheep or a glycerin extract
of the same  are just now the popular fads in the treatment of
myxedema and cachexia strumipriva, but more time is required
for certainty as to their beneficial results.


               DISEASES OF  THE LUNGS.

                  i. ACUTE BRONCHITIS.
  Synonyms.—Bronchitis catarrhalis; Luftrohrenkatarrh.
  Varieties.—Acute, subacute, or chronic;  due to a general or
localized hyperemia, with all degrees of secretion  resulting there-
from, even deficient, giving rise to the  so-called bronchitis sicca.
  Pathology.—According to Hamilton, the anatomical changes
of acute  bronchitis are always the same whatever may have been
its cause. The first microscopic  change evident is a relaxation
and  distention of the abundant network of blood-vessels distrib-
uted through  the inner fibrous coats of the bronchioles.  Following
this the basement membrane becomes thickened and  edematous,
though not uniformly so, for its inflammation occurs  in patches,
limited in extent, often confined to the tubes of large caliber only.
In twenty-four to  thirty-six hours the columnar  epithelium  be-
comes loosened and desquamates in  patches, this desquamation
constituting part of the early catarrhal discharge in the stage known
as tight, which is  followed by more profuse secretion from the
deeper epithelium so soon as they are freed from the overlying
columnar.  This with mucus constitute the sputa. 
DISEASES OF  THE RESPIRATORY SYSTEM.         155
  Etiology.—The usual effect of extreme cold, excessively dry
or dusty air, is to produce hyperemia of the bronchi, hence bron-
chial catarrhs are especially frequent in winter, also in summer in
large  cities  from the dust flying  at that time in the streets or
squares which have not been properly  watered.  The same holds
true of the poorly ventilated rooms in which many of the poor are
compelled to live,  which are  always  provocative of bronchial
catarrh.  Like results are often observed during the dentition of
children (tooth cough),  due to the excessive salivation at that
time and the consequent wetting of  the chest.  The children of
tubercular parents  are  especially  liable to these attacks.  Such
children give early evidence of nasal catarrh (snuffles), whose ex-
tension from the nasal cavities to the pharynx, larynx, and bron-
chial tubes is a matter of frequent occurrence.
  Bronchial catarrh is an invariable accompaniment of measles
and typhus.  In variola, pustules form upon the tracheal and bron-
chial mucous membrane, with resulting bronchial catarrh.  The
etiology of the recently named autogenetic bronchial catarrh is  a
subject well  worthy more extended study than has yet been given
it.  It can, however.be safely stated that many morbid conditions
of the  body produce  within it a toxic substance  or  substances,
whose  excretion  through the bronchial mucous membrane gives
rise to  a specific  catarrh. A case in point  is the so-called  hypo-
stastic  pneumonia  of typhoid, undoubtedly produced by the irri-
tative effect  of typhoid ptomains, or leucomains, excreted in part
through the  bronchial mucous membrane, as it is well known hap-
pens in measles  and asthma.
  Symptoms.—The most invariable  symptom is cough, not in-
creased by lying on the  back as compared with a lateral posture,
but intensified by sitting upright (K.).  At first the attacks of
coughing are violent; but with increased secretion, the sputa be-
come looser and hence easier to cough out, although sleep  is yet
frequently disturbed by  coughing.  Older children complain of a
weight beneath the sternum  and a girdle-like pain across the dia-
phragm, and the disposition of such  children is often changed at
the same  time.  They  become  peevish, unruly, and easily pro-
voked.  Fever is, as  a rule, moderate  (io2°-io3° F.).  The sputa 
156
DISEASES OF  CHILDREN.
with a young child is rarely seen, since it is swallowed as soon as
raised;  but if it is necessary to examine it, sufficient may be ob-
tained by the tip of the doctor's finger carried well back over the
child's tongue during  coughing.   In the early stages the sputum
will be found to be grayish-white and full of air bubbles; later it
becomes thicker, yellowish-white, and  if the coughing has  been
violent may be streaked with blood.  If the larger bronchial  tubes
only are involved, respiration is  not  greatly disturbed, or  only
slightly  quickened (30-40 p. m.), but if all the bronchioles are at-
tacked  (bronchitis  totalis,  capillary bronchitis, catarrhal  pneu-
monia), then respiration becomes very  difficult, and deficient oxi-
dation results.  This is shown by the dilation of the alas, cyanosis,
and other symptoms of approaching death from asphyxia.  Gravi-
tation of the thickened secretions and plugging of groups of air
cells by deep inspiration after violent coughing may produce lob-
ular pneumonia, or secondary atelectasis.
  Examination  by percussion, notwithstanding niceties of differ-
entiation laid down in the text-books, is generally unreliable.  The
best results may be obtained by palpation, which most  children
submit  to with the  best grace, and by which  the examiner may
locate large accumulations of mucus in the larger  bronchial tubes,
the rales produced by thickened secretions in medium-sized tubes,
and the purring crepitation of capillary bronchitis.
  Auscultation always reveals vesicular  breathing, with  large
and fine ronchi,  and if capillary bronchitis be present, crepitation
as well, unless it be masked by larger and coarser rales.  Respira-
tory sounds entirely disappear for the moment, when  a bronchus is
completely filled with tough mucus, but so soon as a  deep inspira-
tion is taken they reappear.
  Prognosis.—Unless there is a persistence of the exciting cause,
in previously well children an acute bronchial catarrh ought not
to last more than a week.  Of course, if the exciting cause persists
the duration of the bronchitis is longer, and with  children of con-
sumptive parentage may persist for months or years with alternate
improvements and relapses until death.
  If extensive caseation of the bronchial glands has taken place,
then no improvement in the bronchial  catarrh can be hoped for, 
DISEASES OF THE RESPIRATORY SYSTEM.        157
 since the  bronchial mucous membrane has  become hypertro-
 phied with  fibroid proliferation and  ectasis; later  pulmonary
 phthisis.
   Hence we may say that in healthy  families the prognosis is
 good ; in consumptives always a source of anxiety, although there
 may  have  been  previously recoveries from  mild  attacks of
 catarrh.
   Prophylaxis is  often more important than other treatment,
 especially in tubercular families.  During dentition such children
 should always be provided with waterproof bibs to prevent wetting
 and chilling the neck and chest.   If possible, these tubercular
 children  should be provided with a healthy wet nurse and should
 always have an abundance of pure, fresh air, and in winter should
 be guarded from the raw, cold northeasters, and not  allowed to
 play upon the floor or on window seats, which are always several
 degrees cooler than the rest of the living rooms.  Repeated attacks
 of bronchitis require that an attempt should  be made to lessen the
 susceptibility of the child by means of tepid salt-baths just before
 sleep, the wearing of flannel next to the skin, and cold sponging
 of the neck and throat on rising,  etc.
   Change of climate is very  desirable  for  many of these cases,
 selection being made of such localities as promise the least varia-
 tions in temperature and the largest opportunity for an out-door
 life, pine forests being especially desirable.
  Treatment.—Whenever possible, there  should be  prompt re-
 moval from all exciting causes, as, for instance, dusty or illy ven-
 tilated rooms.  Expectorants, as  ipecac, with the  citrate of potash
 or bicarbonate of soda, may be employed to liquefy viscid secre-
 tions (see R. page 89), or if there  is great distress for breath, resort
 may be made to emetics, as powdered ipecac, turpeth mineral, fl.
 ext. of quebracho.  To  quiet the hyperesthesic mucous mem-
brane, narcotics, such as codein,  syrup of lactucarium, or cherry
laurel water, may be cautiously  employed  (R. No. 14), or sooth-
ing sprays may be utilized in a steam atomizer.  Recurrent catarrh
in phthisical children should be guarded against as far as possible
by the use of cod-liver oil, syr. ferri iodid (gtt. x t. i. d.) and quinin
(tannate  in chocolate), avoiding with the greatest  possible care all
sudden changes in temperature. 
158
DISEASES OF CHILDREN.
             2.  PNEUMONIA  CATARRHALIS.
  Synonyms.—Catarrhal pneumonia; pneumonia lobularis.
  Definition.—Secondary extension of an  acute bronchitis into
the smaller bronchioles, where it may run  an acute  or  chronic
course.
  Etiology.—In general bronchitis with copious secretion it often
happens that mucus may be drawn into the alveoli, especially upon
deep inspiration, or after violent paroxysms of coughing,  as  in
pertussis.   Persistent lying on the back is a frequent cause of the
same accident, and  hence it happens that catarrhal pneumonia is
usually bilateral  and is an  exceedingly frequent complication  of
measles, pertussis, or of  bronchitis, occurring in rachitic children,
more rarely so in the scrofulous.
  Symptoms.—The onset of this disease  is not usually  well
marked, because acute bronchial catarrh has previously existed
and simultaneously  points of inflammation from the size of  a pea
to a cherry may be found scattered through  the lungs.  With
these all the previous symptoms  become worse, pulse and fever
slowly rise, but never reach the same height that they do in croup-
ous pneumonia.
  Respiration becomes labored, often interrupted with sighing and
followed by general unrest.  Temperature in a few  days reaches
I02°-I03°, or even higher, but with  well-marked morning remis-
sions, and falls just as gradually as it rose (3-10 days) until it again
reaches normal.
  Auscultation,  to the well-trained ear, gives,  in addition  to
the catarrhal sounds which previously existed  at various points,
crepitation  and  rhonchi.  More rarely and less  clearly marked
are bronchial  breathing and  bronchophony, on  account of the
small area of the spaces  affected.
  Percussion  generally yields only a tympanitic note or the
amphoric tone.  Well-marked dullness can only be detected  in
case of large extension of these areas of lobular pneumonia, and
then seldom can be relied upon.
  Prognosis.—In  general is less  favorable and the disease  of
longer duration than croupous pneumonia.   The younger the child
the worse the prognosis.  The mortality of catarrhal  pneumonia 
DISEASES OF THE RESPIRATORY SYSTEM.         159
 after measles is about 33 per cent., that of pertussis below one year
 nearly 50 per cent.  Nurslings  generally succumb from deficient
 oxidation of the blood, as shown by the pale skin, cold sweat, and
 general collapse;  or they die directly from asphyxia.  With chil-
 dren, and  especially after measles,  it runs a more  acute  course,
 but in tuberculous or scrofulous families, or where there is a per-
 sistence of the cause (pertussis), the disease often becomes subacute
 or chronic.   In the latter there is a typical fever which persists for
 weeks, or so long as the infiltration  is  unresolved, which infiltra-
 tion becomes  transformed  into  either fibroid  induration with
 emphysema, or passes into pulmonary phthisis.
  Treatment.—If, in spite  of what has already been directed in
 the way of prophylaxis, fever appears during the course of a sub-
 acute bronchitis, we should  endeavor to reduce temperature by
 means of  safe  antipyretics,  such as phenacetin, cold  baths, or
 packings, and the free use of lithia water.
  When properly managed, large, warm  flaxseed poultices often
 afford  great relief,  but where  the  nursing  cannot  be depended
 upon, we should rely upon cotton-wool, or oil-silk jackets.  Am-
 monia carb. and digitalis are of real value in threatening capillary
 extension,  especially if associated with minute doses of strychnia
 or tinct. nux vomica, e. g.:—

                    Respiratory Stimulant.
                             (5o).
      R.   Ammon. carb.............  4 gm.
           Syr. scillse,.............12 c.c.
           Tinct. digital.,...........4 c.c.
           Aquae camph.,   ...........44 c.c.  M.
      SlG.—One quarter to one teaspoonful as required.—M. P. H.

  Deficient oxidation calls for  the prompt administration  of caf-
fein  or quebracho.  If the disease runs into a chronic condition,
our chief reliance must be put upon good nourishment and country
air.  Tardy resolution may be assisted by the inhalation of medi-
cated vapor and the  internal  use of potassium iodidi (gr. ij. t. i. d.).
Bronchorrhea may be relieved by emetics and irritating cough by
small doses of some  opiate, preferably codeia, or appropriate doses 
160
DISEASES OF CHILDREN.
of the syrup of lactucarium (Aubergier).  Appropriate clothing and
salt bathing will do much to prevent relapses.


        3.  ATELECTASIS PULMONUM ACQUISITA.
  Synonyms.—Acquired atelectasis; apneumatosis.
  Etiology.—Always as a secondary result of the compression
of the lung, and hence most frequently met with  in the rachitic
thorax.   More  rarely  arises from  pleuritic exudates,  scoliosis,
kyphosis, or from any enlargement of the organs of the thorax or
from a foreign growth located therein.  In this connection it should
be  remembered that the  rachitic  chest not only suffers  from
arrested  development, and hence  is smaller than normal, but it
also happens that the weakened ribs are pressed inward by atmos-
pheric pressure during each inspiration, so that the capacity of the
thorax is still further diminished and pari passu the  pulmonary
tissues are  unduly  emptied of their blood and acquire a flesh-like
appearance (carnification)  in place of their normal spongy tissue.
Under a continuance  of  this  pressure the walls  of  the alveoli
disappear and the parts of the lung thus compressed are  trans-
formed  into a rind  or cortex—see Atelectasis  Pulmonum, p.  20,
whose boundaries  are fixed only by the cessation  of  its exciting
causes {e.g., the disappearance of a pleural exudate, etc.).
  Symptoms.—The natural  result of diminished lung  capacity
is quickened respiration, often accompanied by a  mild  degree of
dyspnea.   At  first auscultation gives crepitation,  later on bron-
chial  breathing similar to pneumonia, but from which atelectasis
may be distinguished by its lack of fever.   Percussion rarely yields
a clearly marked dullness, for  the reason that the atelectic area is
generally of very limited extent.
  Prognosis is always unfavorable, though it is  possible that if
causal rachitis  can  be relieved we may hope  for a cure of  the
atelectasis as well.   Its course  is always chronic, like its underlying
causes.  With incurable rachitis, the disease coincidently grows
worse, frequently producing most distressing dyspnea, and death
occurs after weeks of exhausting bronchorrhea.
  Treatment.—Chiefly that of the primary disease, endeavoring
at the same time to provide the most nourishing food in the hope 
DISEASES OF THE  RESPIRATORY SYSTEM.        161
of increasing the activity of the  respiratory muscles.  Mountain
air is of especial value  in  these  cases.  Where pleurisy compli-
cates, aspiration, or an operation  for the  removal of the pleuritic
exudate  is clearly indicated, and  the usual treatment for the relief
of bronchial catarrh.

                     4. NIGHT COUGH.
  Etiology.—Rarely, if ever, except the  malarial  variety,  met
with in  otherwise sound children.  Usually  betokens enlarge-
ment of  the bronchial glands, with  underlying  hereditary tuber-
culosis.
  Symptoms.—Every night, usually about the same time, the
child suffers from one to two hours with a violent, dry cough, from
which it  is exempt during the day. This  condition of affairs lasts
for months and is then  followed  by  the other symptoms of incip-
ient  tuberculosis, page 107.
  Treatment.—According to Vogel, narcotics are  useless in
these cases, though trial should  be  made of chloral.  Kormann
recommends full doses of iron and quinin, with the general treat-
ment already given for suspected tuberculosis.


                5.  PNEUMONIA CROUPOSA.
  Synonyms.—Croupous pneumonia;  pneumonia lobarus.
  Etiology.—More  rarely met  with in  children than in adults,
and much more infrequent than catarrhal or lobular pneumonia
during childhood.   It may, nevertheless, occur in utero as a sepsis
(see p. 23), originating  in the mother or in the new-born  as a
sequela  of pyemia or  sclerema.   In older children it  usually
comes without a sufficiently proven cause  (Friedlander's  micro-
coccus ?), although epidemics are frequent, such epidemic being
accompanied, according to Kormann, with an  unusual  prevalence
of membranous croup.   The  blame  is often laid to cold, and one
attack increases the liability to a second.
  Symptoms.—In nurslings we may expect to find—as in all
other serious interference with respiration—the frequent letting go
of the  nipple  for breath and  rapid  breathing and  groaning.
Convulsions  usually take the place  of the  chill observed at the 
162
DISEASES OF  CHILDREN.
onset of a pneumonia in an adult, and relapses are by no means
rare in infants.
  Older children  present  the  same symptoms as  adults, but the
diagnosis of croupous pneumonia in such is rendered difficult by
the absence of the  characteristic rusty  sputa, and crying  often
marks the physical signs of pneumonia during auscultation.  As
a rule, the  onset is sudden,  beginning in young children with
shivering or convulsions, with  high  temperature, I03°-I05°, in
older children, with a distinct  chill,  and in every case, except
the pneumonia of sclerema, with rapid  elevation  of temperature
and high pulse  rate.  At the  same  time respiration becomes
labored,  the face is slightly cyanosed, and the  alas of the nose
dilate with each respiration.   If at the same time  there are  pleu-
ritic pains, respiration becomes  superficial and  irregular, and in
such cases the child is unwilling to  lie on the affected side,  while
in uncomplicated  pneumonia the child prefers to lie on the affected
side,  and in  order to restrict as far as possible  painful move-
ments of the thorax, the child lies curled up with the spinal column
concave toward the affected side. The cough is  always short and
choppy and generally attended with pain.
  Until the fifth to seventh day the fever keeps at an undeviating
high temperature, and there is continued exudation into the alveoli,
with the production of the so-called red hepatization.  This filling
up of the lung with a croupous exudate, which it is impossible to
expand by inspiration, limits greatly the motion of  the chest walls,
and brings as  a result cyanosis  to a greater or  less degree.  By
auscultation we obtain bronchial breathing during the stage of
hyperemia, but when resolution begins fine vesicular rales.
  Percussion gives,  when  hepatization is complete, marked
dullness  over  the affected spots, unless, as is  rarely  the  case,
the hepatization  is  central only.   More frequently with cen-
tral hepatization  we have at  first  a tympanitic  note  over the
affected spot, but  in from two to  five days later,  dullness in the
same location from the extension of the hepatization to the pleura.
At the commencement of  resolution the  percussion note is  again
tympanitic,  and  sometimes, from  conjoined  partial resolution
and partial infiltration, we may hear the amphoric note (cracked
pot).  Herpes  labialis and facialis  are frequent attendants upon 
            DISEASES OF THE RESPIRATORY SYSTEM.         163

croupous pneumonia, with which we may also have alarming cer-
ebral  symptoms, which may make  the  diagnosis difficult at  first.
These are the  cases in which the apices of the lungs are first at-
tacked and begin with  vomiting, loss of consciousness, delirium,
stupor, convulsion, immobility of the pupils, etc., all largely  due
to the height of the fever, as  croupous  pneumonia is rarely com-
plicated with true meningitis.
  Course.—Croupous pneumonia runs its course more rapidly
with the child  than in the adult.  The fever, at first high with very
slight morning remissions, generally falls with the general declen-
sion of the inflammation on the seventh to eighth day ; or if small
in extent, this  may occur  on the fourth day,  or  we may say on
the fifth as an  average, when within twenty-four hours crisis occurs.
The temperature suddenly  falls to normal, or even subnormal,
though, as with adults, this normal subsidence of the inflammation
may be  interrupted  and the process  delayed for a day or two
longer.   Crisis sometimes  ushers in a collapse in which the patient
expires, the temperature again rising  in the  death  agony, even
though the thermometer may have fallen at the beginning of crisis.
If crisis is complete, the pneumonitis has subsided and resolution
begins partly  by absorption and  partly by expectoration of the
fatty degenerated exudate, now liquid  and in the condition of so-
called yellow hepatization.   But even yet alarming cerebral symp-
toms  may make their appearance  as the result of anemia of the
brain.  These are delirium, hallucinations, coma, and amaurosis,
anemia of the retina, as may be proven by the ophthalmoscope.
  Differentiation.—The  differentiation between catarrhal and
croupous pneumonia in the  child is not always easy from the phy-
sical  signs, but  we may be assisted in this by remembering the
bronchitis which precedes catarrhal pneum.onia as contrasted with
the sudden onset of the croupous variety.  The temperature of the
latter is higher than that of the catarrhal form, which is a disease
without crisis, which occurs in croupous pneumonia on the fifth to
seventh day with a sudden fall in the temperature of from three to
five degrees.
   Prognosis.—Lysis occurs more rarely with children than the
complete crisis  just described. • When the former occurs it is ac-
 companied by  a gradual decline of  fever,  partial resolution of 
164                DISEASES OF CHILDREN.
the exudate, and often a drifting into chronic pneumonia.  Hence
it happens that caseation of the lungs, or fibroid phthisis, is  more
rarely met with in children  after pneumonia  than with adults.
The mortality with children  varies greatly, but may be  said  to
range from 5 to 25  per cent.  In general it may be said to be better
than for the adult,  but  it must be remembered that when  for any
reason resolution is delayed and the exudate is for days  or weeks,
partly expectorated, partly swallowed, partly reabsorbed, intestinal
disorders follow, and in the case of nurslings may ultimately lead
to death from malnutrition.
  Complications, as may  be inferred, are most frequently a
bronchitis of the sound lung, caused by collateral  congestion,  or
lobular pneumonia in addition to the croupous, or  a pleurisy with
exudate, and diarrheas. Death results either from the height of the
fever or from extension of the inflammation and fatal asphyxia,  or
from heart failure.
  Treatment.—It should always be remembered  that croupous
pneumonia is in  the child, as in the adult, a self-limited disease,
not to be aborted  or greatly  shortened  by any medication.  The
fever in  a nervous child  may require control, lest its hyperemia
produce convulsions.   In such children  a temperature above 1030
is very liable to produce an eclamptic attack, and hence it is justifi-
able with such  to reduce the initial fever of pneumonia with  some
safe antipyretic to below the danger  line.  Tepid  baths, cold
packing, or the cautious  use of antipyrin may be necessary  to
accomplish  this.   Expectorants  are   never   of   value  in the
congestive stage of croupous  pneumonia, as they can accomplish
nothing in the way of resolution,  and the fluidity of the pneumonia
secretions can be better preserved by the free use of lemonade  or
cold water without the  nausea and anorexia produced by the ordi-
nary expectorants.  Next to the free use of cooling drinks a large,
well-ventilated room—preferably by means of an  open fireplace
—is a godsend in the treatment of pneumonia in children, which
needs little if any medication. Niemeyer strongly advises the use
of ice bags to chest during the onset of pneumonia, but efficient
as this has proven with German children, they are illy borne by
the American child, with whom  the annoyance of the cold  more
than counterbalances the good attained by its use. 
DISEASES OF THE RESPIRATORY SYSTEM.        165
  For feverishness, restlessness, and hot, dry skin, divided doses
of aconite in tablet form often give relief, and if there is fever small
doses of phenacetin prove a valuable adjuvant.  Purgatives are
depressing and laxatives should be given only as they are posi-
tively required.  Poultices may relieve pleuritic pain and do no
harm if kept warm, but in croupous pneumonia the cotton-wool
and oil-silk jacket is preferable, because it requires less care and is
fully as  efficient.  The great danger in  croupus pneumonia lies
in heart  failure, for the right side  of  the heart is kept con-
stantly surcharged with blood in the ineffectual effort  of the heart
to carry the blood  through  the congested lungs, hence nitrogly-
cerin and  the  preparations of belladonna are theoretically indi-
cated for  this emergency.  For continued use the writer prefers
caffein (gr. ss-j every four hours), remembering that  caffein may
produce a condition resembling delirium tremens in the young
child.  Alcohol, if not given too early, has helped many  a pneu-
monia over crisis, and strychnia is an excellent heart  tonic.
  If bronchitis attacks the sound side apply poultices and use the
treatment elsewhere recommended for acute bronchitis.
  (c) For  the delirium of cerebral  anemia give freely wine, beef
juice, expressed with a lemon  squeezer, and  nourishing soups.
Coffee and cream ad lib.  Alcohol when septic.
  (d) To hasten expectoration nothing has yet been found more
reliable than the free use of the alkaline carbonates, or a  muriate
ammonia  mixture.

      R.   Ammon.  muriat.,........3'J
           Aquse anisi,
           Glycerinoe,.....aa.....J;ss
           Syrup glycyrrhizae,   .......3 iij.      ^.
      Sig.—One-half teaspoonful every two hours.—H.

  (e) For  pleuritic pains sinapisms and  small  doses of morphin.
Large, warm poultices give speedy relief for pain, and phenacetin
will  often  bring sleep when opiates only excite.
  (/) For tardy convalescence change to the country, iron, and
good food.  For the diarrhoea, tannate of quinine or saccharated
ext.  coto can be highly commended.  And every pains should be 
166
DISEASES OF CHILDREN.
taken to bring about entire recovery, for unresolved pneumonic
deposits are a fruitful  source of bronchial adenitis, night cough,
and miliary tuberculosis, which see.


              6. EMPHYSEMA  PULMONUM.
  Synonyms.—Emphysema  of  the  lungs;   Lungenbronchi-
ektasis.
  Varieties.—May be congenital, or be produced during the act
of birth, as, for instance, by too forcible inflation of the lungs of
a child born asphyxiated.  Pulmonary emphysema, as a rule, in
children is only.partial or localized, being vicarious or supple-
mentary ;  hence is a  secondary result of those diseases of the
chest which  diminish its respiratory  capacity, such as unresolved
pneumonias, pleuritic exudates, or those diseases which are accom-
panied by violent cough (pertussis,  etc.),  whose tendency  is to
distend the alveoli in the unaffected  parts of the lung.   (In per-
tussis this pressure is doubled upon both sides, so that air may be
forced into the intercellular  connective  tissue, and thus give rise
to what is known as interlobular emphysema).  It should also be
remembered emphysema may occur in feeble and atrophic  chil-
dren without  previous  pulmonary disease.   Dilatation  of the
bronchioles in children is generally cylindrical instead of pouch-
like.  (K.)
  Symptoms.—So long as the original pulmonary trouble per-
sists, the secondary emphysema presents no noticeable symptoms;
but if after the recovery of the  primary trouble there is persist-
ence for a long time of dyspnea  and pulmonary engorgement,
cyanosis, and dilatation of the right  heart, we may well turn our
attention to the existence of emphysema.
  Prognosis.—Emphysema in a child's lungs may make perfect
recovery if the original disease is  cured or the paroxysms of
coughing can be quieted and the exciting general atrophy removed.
In such cases the alveoli will regain their contractility and the air
spaces return to their original capacity.                      v
  Treatment.—In the main, looking toward a general  support-
ing of strength, cutting short the original disease, and good air,
with inhalations of soothing vapors,  such  as  those containing oil
of Scotch pine in some alkaline liquid. Cream, liquid peptonoids, 
DISEASES OF THE RESPIRATORY SYSTEM.         167
 and cod-liver oil are of great  value in  building up the general
 condition of the  child, while the electric current may assist the
 action of the enfeebled respiratory muscles.  Syrup of lactucarium
 or codeia for cough.

                         7. PLEURITIS.
   Synonyms.—Pleurisy; Rippenfellentziindung.
   Etiology.—A child may be born with septic pleurisy which has
 originated in utero as a result of the transference of puerperal
 poison from its mother during the latter part of pregnancy, or she
 may later infect the new-born (during epidemics of puerperal fever
 in  lying-in wards), or it may occur in the form of pyemic pleu-
 risy as a result of phlebitis umbilicalis, etc.  Intraparietal pleuritis
 may also be met with as a primary affection (rheumatic) or more
 frequently as a secondary complication in various lung dise'ases, as,
 for instance, in catarrhal or croupous pneumonia, or after hemor-
 rhagic infarcts, as  adhesive pleurisies {pleuritis sicca).  Even
 oftener phthisis  produces a pleurisy, where  we find either the
 adhesive  or exudative forms of pleurisy.  Exudative pleurisy in
 phthisis  is very prone to take on the purulent form (empyema)
 and become chronic. Pleurisies also occur, though less frequently,
 during the course of the acute infectious diseases, and pyemia and
 scurvy.
  Differentiation.—Ought not  to  be difficult to the physician
 who is called in time to note the characteristic pain on inspiration,
 and the  friction  sounds of early pleurisy.  Unfortunately, he is
 often not called until this stage has passed, and he has nothing for
 his guidance but an obscure history of pain and localized dullness
 in the chest.  Later the effusion may  be sufficient to give complete
 loss of fremitus, immobility of the affected side, and woody resist-
 ance to the  percussing finger,  making diagnosis easy, though all
 these often escape detection for weeks, if through mistaken kind-
 ness to the child the test of the hypodermic syringe is neglected.
  Symptoms.—Children attacked  with  congenital pleurisy are
either  born  dead  or die, cyanosed,  soon after birth.  All other
forms begin  with fever and pain, which soon makes the breathing
rapid and superficial.  Little children whimper when the affected
side is disturbed  or when they are  set upright.  The pain  dis- 
168
DISEASES OF  CHILDREN.
appears with the appearance of the exudate, but is apt to return a
few days later, similarly to disappear.  So long as the  pain lasts,
the child lies on the sound side ;  after the  exudate appears it de-
sires to lie  only on the affected side.  In adhesive pleurisy it  is
often possible both to hear and feel  friction between the pleural
walls.  Percussion  gives  negative results,  except when phthisis
pulmonalis has formed a thickened cortical  layer, and then dull-
ness is readily detected over the pleuritic areas.
  Inspection gives  us  various methods of detecting  larger or
smaller amounts of pleuritic exudate.   If the quantity is large, we
shall find bulging in the intercostal spaces and deficient respiratory
motion caused by pressure upon  the lung.  If  the  exudate  is
located upon the left side, the heart will be found displaced to the
right, and generally with children  the measurement of the affected
side will be found to be greater than the sound one.  Clear up to
the upper border of the exudate there are  no respiratory sounds
and no fremitus, but on  the border  bronchial breathing may be
heard, and in some rare cases this  may also happen, even if there
be exudate, if the lung is bound down by earlier pleuritic adhe-
sions which prevent displacement of the compressed lung. Fric-
tion sounds often reappear on the edge of the exudate as it begins
to be reabsorbed.
  Course.—Adhesive pleurisy leads to a union of the  two walls
of the pleura, either as a whole  or by fibrinous bands.  The pleural
exudate,  whether sero-fibrinous or purulent, may be absorbed in
from one to three  months, and recovery take place with a fibrin-
ous deposit left behind.  Retraction of the thorax with dropping  of
the affected shoulder, due  to scoliosis of the spinal column with
convexity to the affected side, and compensatory lumbar distortion,
is a frequent result  of pleurisy,  best seen when standing.   This de-
formity often brings with it permanent atelectasis.   In  other cases
there is  an external discharge> of pus through the walls of the
thorax, usually below the nipple, through a spot previously swollen
and reddened before the breaking through of a copious empyema.
This is prone to leave  a fistulous opening through which pus dis-
charges  for years ; or  it may  quickly heal  and  soon  break out
afresh.   More  rarely the empyema discharges into the lung or
forms a  pulmonary cavity, constituting a pneumothorax, or the 
             DISEASES OF THE RESPIRATORY SYSTEM.         169

 pleural exudate—especially with children—may remain as a thick,
 caseous layer, which may prove the starting point for future tuber-
 culosis, usually of the acute miliary form.
   Treatment.—Allay pain by means of warm poultices, opiates,
 and, if necessary, cupping.   If there is constipation, as is usually
 the case, give a free dose of calomel and combat fever with cold
 spongings and appropriate antipyretics.  For  the removal of the
 exudate local applications of tincture of iodin—or, better, pig-
 mentum tiglii (see R  below), and in obstinate cases conjoin the use
 of diuretics (infusion digitalis, cream of tartar, spir. juniper, etc.).

         Corson's Pigmentum  Tiglii.—Modified for children.
       R-  Ol. tiglii,............3ss
           Glycerinse............3'ijss
           Tinct. iodinii,..........^ iv
           Ether sulph.,..........^j.        M.
       Sig.—To be applied  with a brush  to the chest night and morning
         until  pustules appear.                             H.

   If convalescence is tardy, in otherwise favorable cases, recourse
 must be taken to good air and the best of nourishment, such  as
 fresh milk, beef juice, eggs, and cream, etc.   An assured diagnosis
 of empyema or pressing  dyspnea in any pleurisy justify resort to
 aspiration, and if need be to paracentesis thoracis, or even a simple
 incision, if the empyema threatens to break through the chest walls,
 always tapping first with a clean  hypodermic syringe to make cer-
 tain  your diagnosis.
  Prognosis of primary pleurisy is fairly  good, even then we
 must expect tedious recovery.   Secondary pleurisy less hopeful, as
 there is  usually  an  underlying  tuberculosis.  Septic pleuritis is
 very fatal.

                8. PNEUMONIA CHRONICA.
  Synonyms.—Scrofulous or chronic pneumonia;  phthisis pul-
monum; Lungenverkasung.   (See Tuberculosis.)
  Definition.—One of the manifestations of hereditary tubercu-
losis, where its description properly belongs.
  Etiology.—Hereditary, often manifesting itself in the first year
of life either as a chronic  pneumonia, or it may  develop from a
       L 
170
DISEASES OF  CHILDREN.
scrofula due to poor nourishment and the bad air of great cities.
Again, measles, pertussis, or syphilis frequently precede this affec-
tion.  In general, it does not make its appearance until  after the
first  year,—in fact, much less  frequently in the first year than
after the twenty-fifth  year.
  Whether in any individual case the disease begins as a miliary
tuberculosis, originating from an embolism due to previously exist-
ing suppurating points and terminating in pulmonary tuberculosis,
or whether we have to do in the beginning with a case of caseat-
ing pneumonia, is often a very difficult question to answer.
  Pathology.—The autopsy in such cases shows either miliary
tuberculosis of the lungs or their caseation,  both of which may be
diagnosed by means of the tubercular bacilli or bits of caseous lung
found in the sputa.
  Symptoms.—Usually immediately  after  a  catarrhal pneu-
monia, or more frequently after measles or pertussis in scrofulous
children, we  fail  to get desired resolution.   Either the infiltration
remains unchanged or increased in extent, or fresh deposits take
place, and finally these exudates become transformed into a thick,
cheesy mass, or suppurate, breaking down with them the infiltrated
lung tissue.  At these points of  infiltration we may find the evi-
dence of localized pneumonia with coincident pleuritis, often  with
adhesions.  If, however, the infiltration is  centrally located  and
the physical signs fail, we must rely for our diagnosis upon general
symptoms, such as the blanched skin, bluish conjunctivae, wasting
and  chronic cough, hectics and sweating.
  It  should be remembered that  scrofulous pneumonia in children
may begin anywhere  in the lungs.   There are, of course, a small
number of children  with whom, as with the adult,  the process
begins with an induration, caseation, and the formation of a cavity
at the apices of the lungs.   (These are usually sequelae to apical
croupous pneumonia.)  Cough  is a marked and  persistent symp-
tom, such children becoming used to coughing, and expector-
ating freely and hopefully.  Only rarely streaks of blood are mixed
with the expectoration, but very frequently elastic fibers and pus
corpuscles may be found with the  microscope in the sputa.  At
this stage of the disease the bronchial glands are  always enlarged,
and frequently infiltrated and caseated. 
DISEASES OF THE RESPIRATORY SYSTEM.        171
   Prognosis.—So long in chronic pneumonia as the fever does
 not reach a high point  and the strength is not greatly prostrated,
 we are not justified  in  making a fatal prognosis, for even a pro-
 tracted pneumonitis may  recover, though  a tendency to  relapse
 will persist thereafter.  The disease, however, usually runs a slow
 course, with variable, daily alternations of temperature—afternoon
 hectic, and  early morning sweatings, and  progressive emaciation
 and death ; but it is possible that very gradual gain in weight may
 take  place, as relative recovery takes place  by fibroid induration
 of the diseased  points,  one after another.   Autopsies made upon
 such cases, dying suddenly from other causes, as cholera, dysen-
 tery,  etc., show not  infrequently such cicatrized points accompa-
 nied  by a moderate bronchiectasis.  The majority of these cases,
 however, develop hydremia as the result of amyloid degeneration
 of the vessels of kidneys, lymphatic glands, liver, or intestines.
 More rarely hemoptysis occurs from the perforation of a blood-
 vessel during the erosion of a pleural  exudate  or the  breaking
 down of the lung into a pulmonary cavity.
   Death usually  results from septicemia, being preceded by hectic
 with  fever and chill, announcing the ravages of the tuberculosis
 bacilli in the lungs or throughout the body (general tubercu-
 losis).
   Treatment.—Fever is to be controlled as usual by antipyretics,
 cold  baths, and  packings, and  especially  valuable  here are full
 doses of quinin when they are well borne.   Such children should
 have  the very  best nourishment possible, to which should be added
 cod-liver oil, or cream when the first causes indigestion.   Above
 all, careful provision should be made for an ample supply of good,
 pure air, preferably in the  pine woods  or at a moderate  altitude
 when this is possible, but no locality should ever be chosen unless
it is possible there to guard against sudden changes of temperature
by means of properly warmed living apartments.
  Astringent sprays  and the internal use of small doses of alum
or the terpene hydrate mixture will do much to diminish excessive
secretions.   Hyperemia  without secretion, but tormenting  cough,
will be greatly  relieved by  alkalies  and  narcotics,  preferably
chloral or codeia—enough of  the latter being used to insure good
sleep.  Forced respiration and out-door life might save many 
172
DISEASES OF CHILDREN.
of these children, too little attention being given in these cases to
pulmonary gymnastics in the hands of a competent teacher, early
in the disease.


     9. PHTHISIS GLANDULARUM PULMONALIUM.
  Synonyms.—Glandular phthisis; Brustdriisenverkasung.
  Definition.—A localized tuberculosis originating in the bron-
chial lymphatic glands.   (See Tuberculosis?)
  Etiology, etc.—Is generally an hereditary affection which can
be  traced back directly to tubercular  parents  or grandparents.
Caseation of the bronchial glands is never a primary disease,  but
is due to either a primary scrofulosis or to previous inflammation
of other organs whose lymphatic current would be  carried through
the bronchial lymphatics, hence it may arise after chronic pneu-
monia, chronic  bronchitis, broncho-pneumonia,  especially that of
pertussis, measles, or rachitis, where  it  often comes to pass that
notwithstanding the exciting bronchial catarrh has  long ago appar-
ently been cured, inflammation, suppuration, and caseation of the
lymphatics have just begun their course.
  Symptoms are those usually met with in pulmonary phthisis,
with no recognizable pulmonary lesions other than mild bronchial
catarrh with  slight evening rise of temperature.  Sometimes chains
of infiltrated lymphatic glands may be detected  in the fossa supra
clavicularis.   These glands and those lying deeper may attain the
size of a hen's egg, and  thus  displace contiguous  organs, as  the
trachea or bronchi, causing in this way dyspnea.  Pressure upon
the esophagus gives us the symptoms of esophageal stenosis, or if
upon the vena cava superior we find turgescence  of the veins of
the neck, blueness of the face, and slight edema of the lids.
   Pressure upon  the recurrent nerve increases  the  attacks of
dyspnea,  even  to  orthopnea,  cyanoses  the  face, and  produces
a rapid, feeble  pulse, hoarseness, sometimes aphonia, and even
fames  canina, though rarely.   Continued pressure of these  en-
larged glands may produce atrophy in the organs thus pressed upon.
At last the enlarged gland projects like a ball valve into the lumen
of the trachea, bronchus, or esophagus, vena cava, or aorta, and
may thus  perforate one of these organs, and even such a thing 
DISEASES OF THE RESPIRATORY SYSTEM.        173
 as double perforation of two organs by the same gland has been
 known,  manifested,  for  instance, by cough and dyspnea after
 swallowing, as might happen from a perforation of both esophagus
 and trachea or bronchus by an  excavating caseous gland.   In
 addition to pus in the sputa, we may often find the debris of case-
 ous glands.  If they are sufficiently large they may be detected by
 percussion, most easily between the shoulder blades or directly
 behind the manubrium.  Eustace Smith claims that  enlargement
 of the bronchial glands  gives rise to a characteristic bruit to be
 heard over the trachea  if the head is held slightly retracted during
 auscultation.   The duration of bronchial adenitis is  usually very
 tedious unless there arise some dangerous pulmonary complication,
 such  as a perforating pleurisy.  The final result is usually either
 death from pulmonary  phthisis or miliary tuberculosis.  Goodhart
 believes recovery takes place more often than is generally believed
 is possible.
   Treatment.—Prophylactic:  Scrofulous  children should   be
 guarded from taking cold by means of proper clothes  and equable
 temperature  (respirators,  when obliged to  be out-of-doors  during
 the winter).  Not less important than good air is nourishing food—
 cream, eggs, rare beef,  and meat juice.
   Therapy :  Cod-liver oil, either pure or in some agreeable emul-
 sion, as with syrup  of the iodid of iron, gtt. x-xx, t. i.  d., stands at
 the head of all remedies for these children.  Other forms of iron
 are highly spoken of by others, and the writer has obtained some
 remarkable results  in  the  disappearance of chronic glandular
 swellings by the continued use of calcium chlorid (crystallized).
  Hygienic : Salt baths and friction,  either at home or at the sea-
 shore, when possible, are  valuable adjuvants to other treatment for
 these children if they react nicely after their use, not otherwise.


                    10. HYDROTHORAX.
  Synonym.—Dropsy of the pleura.
  Etiology.—Like other dropsies, this is not a primary disease,
but a symptom common to many causes, perhaps most frequently
of scarlatinal nephritis,  where it is usually associated  with ascites
and anasarca.  Hydrothorax is also, though much more rarely, met 
174                DISEASES OF CHILDREN.
with in heart disease and the cachexia of malaria when conjoined
to enlargement of the spleen.   Hydrothorax  is always  bilateral
except in those rare cases where one pleural  cavity has previous
adhesions over its entire extent.
  Symptoms.—The same in  children as in adults; pain and
friction sounds are  always wanting, and thus  make probable the
diagnosis from the earlier stages of pleurisy.  Dyspnea and cyan-
osis  are in children commensurate with the amount of the drop-
sical  effusion, which in  scarlatinal  nephritis  may necessitate
orthopnea.
  Prognosis is never favorable ; somewhat better after scarlatina
and worst of all  in heart disease, where hydrothorax is soon fol-
lowed by death.   Pulmonary edema betokens  speedy death.
  Treatment.—The anuria of post-scarlatinal  nephritis should
be combated by hot or vapor baths and  the free use of diuretics—
infusion digitalis, liquor ammonia acetatis, or the following:—

      R .  Sol. pot. citratis,
          Syr. acidi citrici,  . .  . aa......^ij
          Cocain. hydrochl............gr. j.   M.
      Sig.—Teaspoonful every two hours in water.

or cream of tartar lemonade (^ss to  Oj), or diuretin, gr. xv. per
diem, which  often produces an  excessive diuresis.  Such  choice
of food  should also be made as to  throw the  least tax  upon the
kidneys, while at the same time  it should be nourishing.  If diar-
rhea appears, although conservative, it should be checked if clearly
weakening the strength of the child.  Iron in some agreeable form
is indicated after the disappearance of the dropsy. 
DISEASES OF THE DIGESTIVE APPARATUS.        175
                       SECTION  IX.

DISEASES  OF THE  DIGESTIVE  APPARATUS.

    I. MALFORMATIONS OF MOUTH  AND TONGUE.

                        (a)  Harelip.
  Synonyms.—Labium leporinum ; Wolfsrachen ; bee de lievre.
  Definition.—Is an  arrest  of development of the embryonic
inter-maxillary and superior maxillary bones, whereby they fail to
unite.
  Varieties.—Harelip may occur on one  or both  sides, either
single or double, and also implicate the soft palate.   In the worst
cases the fissure extends from the outer third of one lip into the
corresponding nostril,  while  in the mildest  cases the lip is  cleft
only one-third to one-half of  its width.
  Fissures of Hard Palate.—The fissures  of the  hard palate,
palatum fissum, are generally only unilateral, and  may be  so
broad as  to allow one readily to look into the cavity of the nose.
Double  uvula, or simple fissure of the uvula without fissure of the
palate, or harelip, is to  be  regarded as an arrest of development
in its simplest form, while the most marked disfigurement of the
face may result from fissure of the palate complicated with double
harelip.  In such cases the intermaxillary bone has not united on
either side with the maxillary bones and projects forward like an iso-
lated knob or snout.  The nostrils are widely and irregularly dilated
and the central part of the upper lip is almost entirely wanting.
  Consequences are in proportion to the degree of the deformity.
In the milder cases nursing is not  difficult, but in severe ones the
children are unable to  seize  upon the nipple with their lips, but
quickly  learn how to nurse if the  nipple is placed in  the fissure.
When the palate is cleft, nursing is always considerably more diffi-
cult, and especially so when the milk runs out of the nostrils, though
this may  be lessened  by holding the head high.  Later in  life
speech  always becomes indistinct; in harelip  the labials, and in
fissured palate the palatals, cannot be enunciated.   If harelip is 
176
DISEASES OF CHILDREN.
not operated upon, a part of the teeth always grow in a faulty
direction, but if harelip is successfully  operated  upon,  it lessens
the cleft of the palate.
  Treatment.—If the cleft lip renders nursing difficult, the fissure
should be operated upon during the first days of life, and on no
account ought we to wait until the child has become enfeebled. On
the other hand, when sucking is not difficult and the child is thriv-
ing, we may defer the operation until the fifth month.  The opera-
tion should be performed on the child after it has been awake  for
a few hours and has previously taken a  good quantity of nourish-
ment.  (For the particulars of this operation we refer the student
to works on  surgery, as  we do for the operation of staphylor-
rhaphy for cleft palate, which, however, need not to be performed
before the tenth year.)
                      (b) Microstoma.
  Definition.—Any lessening of the size of the mouth even to
complete imperforation  of the lips.
  Etiology.—Congenital, or traumatic arising from  burns or
syphilitic ulcers, etc.
  Occurrence.—Very rarely seen, except as result of an accident.
  Treatment.—If there is complete imperforation, or if the mouth
is so small  that the child  is unable to seize hold upon the nipple,
the operation of stomatopoesis must be immediately performed.

                      (c) Macrostoma.
  Synonym.—Congenital fissure of the angle of the mouth.
  Treatment.—On the same principles as harelip.
  Congenital fissure of the lower lip,  according to Ashhurst, is also
occasionally met with and requires the same kind of treatment.

                 (d) Hypertrophia Labium.
  Etiology.—May depend upon the existence of the scrofulous
diathesis, or from the irritation produced by fissures or ulcers, and
in some rare cases hypertrophy exists without any apparent cause.
  Operation consists in making two transverse incisions so as to
remove a sufficient slip from the thickness of the lip  and then
approximating the edges with delicate sutures.
  Congenital tumors, cystic, erectile, etc., of the lips are occasionally 
DISEASES OF THE DIGESTIVE APPARATUS.        177
met with and should be treated as such tumors are when found
elsewhere upon the body.

         (e) Anchyloglottis et Elongatio Frenuli.
  Synonym.—" Tongue-tie."
  Definition.—The frenum of the tongue is found as a membrane
extending to the tip of the tongue.  This may appear either as a
thin or thickened membrane, which if too short ties down the tip
of the tongue.
  Symptoms.—This occasionally renders  nursing difficult and
the protrusion of the tongue beyond the lips impossible.  Possibly
it may later render speech indistinct and is popularly believed to
make children dumb.
  Treatment.—An operation is indicated only when nursing is
difficult, but it is often performed for the peace of mind of those
parents who are frightened over their "tongue-tied" children.
May  be  easily performed as follows: Lift up the tongue with an
index finger, thus making  the frenum  tense.  Draw down  the
lower lip and snip with a pair of round-pointed scissors the offend-
ing frenum, but refuse to operate when the tongue can be made to
pass the vermilion of the lips.

                   (f) Atrophia Lingua.
  Occurrence.—Atrophy affecting only one side of the tongue
has been observed.
  Etiology.—In Ashhurst's case was due to necrosis of the occi-
pital,  and recovered upon extraction of the sequestra.

             (g) Fissura Seu Defectus LiNGUiE.
  Etiology.—When  the two halves of the visceral layers fail to
coalesce, or unite too late, the tongue remains cleft with a longitu-
dinal  fissure sometimes confined to its tip.

                (h) True  Defectus Linguae.
  Definition.—Occurs when there is  a failure to develop the
tongue and it appears only as two wart-like bodies lying on the
floor of the mouth.
  Treatment.—None possible. 
178
diseases of children.
        (i) Hypertrophy and Prolapse of Tongue.
  Etiology.—Any part of the tongue may be hypertrophied, so
that after birth instead of lying, as usual, close to the hard palate,
the tongue protrudes between the lips.  It is swollen, with enlarged
papillae, and becomes purplish or brown  and dry from exposure
to the air.  As the hypertrophy increases,  not only in length but
also  in breadth  and thickness, the prolapse  also increases and
nursing becomes difficult.   The incisors project horizontally for-
ward  and excoriate the tongue, and by their irritation still further
augment  its hypertrophy.   The saliva constantly dribbles  out of
the mouth, decomposes, and produces a disgusting odor.  Articula-
tion is always very difficult.  Such hypertrophy is especially apt
to be found in cretins, but it can  also be acquired after convul-
sions, etc.
  Treatment.—The projecting portion of the tongue should be
removed  by the galvano-cautery, or a wedge-shaped piece may be
cut from the tongue.

                        2. RANULA.
  Definition.—A semi-transparent, fluctuating, encysted  tumor
lying  beneath the tongue.
  Varieties.—(a) True ranula, found in the floor of the mouth,
from the size of a walnut to a pigeon egg,  and containing glairy,
tenacious contents.
  (b)  Mylohyoid, found between the mylohyoid and buccal mucous
membrane, often as  large  as an orange, and filled with  cheesy
contents.
  Etiology.—The common form  of ranula has thin walls, and
contains  a  fluid  somewhat resembling saliva, whence it was for-
merly supposed to be a dilatation of the duct of the  submaxillary
gland. May be  so in those instances where the duct is occluded
by a  salivary  calculus, but the majority of ranulas appear to be
distinct cysts.  (Ashhurst.)
  Symptoms.—If the ranula has attained some size before it is
noticed, it may be large enough to  crowd  the tongue against the
hard palate, so that nursing and swallowing are interfered with,
and sometimes even breathing also becomes difficult, especially 
            DISEASES OF THE DIGESTIVE  APPARATUS.        179

 if there is concomitant coryza, or there may be convulsive attacks
 of dyspnea, simulating croup.
   Prognosis.—Favorable, though disease is prone to recur; rarely
 spontaneous cures have been known to follow suppuration.
   Treatment.—If complicated with croupy attacks, operate im-
 mediately, as follows:—
   Open  sack sufficiently to thoroughly cauterize its inner walls,
 which must be repeated often enough to" prevent  union, except
 from the bottom of the sack.  If this is not obtained, relapses will
 occur.

              3. STOMATITIS CATARRHALIS.
   Definition.—Simple hyperemia with increased secretion by the
 mucous membrane of the mouth.
   Etiology.—Too  hot, or otherwise irritating food or drink, den-
 tition, or symptomatic after the use of mercury, arsenic, etc., or as
 a sequela  of measles, scarlatina, typhoid, or acid dyspepsia with
 gastric catarrh.
   Symptoms.—At first unnatural heat, redness and dryness, and
 then profuse flow of saliva, which soon becomes acid and excori-
 ates.  Slight fever, considerable restlessness and pain, and conse-
 quent unwillingness to eat.
  Prognosis.—Always favorable on the removal of the cause.
  Treatment.—Addition of lime-water to milk, and feeding with
 a spoon, if necessary, on account of pain in nursing.  The bowels
 should be  kept  free (^ gr. calomel), and the mouth  thoroughly
 washed, hourly,  with a solution  of borax or potass, chlorat. (gr. x
 to fjj rose  water), preferable on a  bit of absorbent cotton twisted
 around the end of a  probe.  If  gastric catarrh complicates, this is
 to be treated according to the methods hereafter to be detailed.
  Complications.—Other and more serious forms of stomatitis,
 especially thrush, or

                   4. STOMATOMYCOSIS.
  Synonyms.—Thrush; sprue; soor; muguet; milnet; Mehlmund.
  Definition.—A specific, yellowish-white parasitic growth upon
the mucous membrane of the mouth, which has  been previously
irritated by acid secretions or ingesta.  Exceedingly frequent. 
180                DISEASES OF CHILDREN.

  Pathological Anatomy shows no destruction of the mucous
membrane, which is merely inflamed and serves as a nidus for the
growth of the fungus, oidium albicans.
  Etiology.—During the first weeks of infancy the buccal secre-
tions are acid, and hence this  disease is very  common  among
young  infants.   Also  especially apt to occur from sour food.  A
spoiled " sugar tit," an  unclean rubber  nipple, a dirty nursing
bottle,  or sour milk (oidium lactis), lead to the development of the
thrush  fungi upon  the  mucous membrane, whenceK possibly, it
may be transferred to other persons.  Thrush is  very prevalent in
foundling asylums  and among bottle-fed babies, where it is almost
invariably associated with impaired nutrition as well.   More rarely
met with in the last stages of wasting  diseases, as phthisis, tuber-
culosis, and glandular degeneration with malnutrition.
  Symptoms.—First a severe catarrh of the mucous membrane
of the mouth and tongue, with a great hyperemia and tenderness of
the parts, extending over the whole mucous membrane except that
of the  hard palate.  The buccal secretion becomes viscid and has
an acid reaction.  After these conditions have lasted a varying
length of time numerous white specks are found upon the reddened
mucous membrane.  These enlarge rapidly and may coat the
whole  cavity of  the mouth with a thin, white membrane.  At first
these white specks can  be separated  from the  underlying  mem-
brane  only with  difficulty, but after a few  days they become loose
and can easily be removed, and show under the microscope that
they consist in part of epithelial cells and in part of a growth consist-
ing of roots, branches, and sporules. This fungus may spread from
the cavity  of the mouth into the pharynx, esophagus, or produce
hoarseness by extending into the larynx wherever cylindrical and
ciliated epithelium are absent.  Thrush may be communicated to
any raw surface which is not kept  scrupulously clean, and hence
we may find it about the anus, though rarely so, of a child suffer-
ing from intertrigo.  Infants having thrush cannot nurse well,
hence often let go of the breast or  refuse to take the bottle, and
 pass into a drowsy, marasmic state.
   Prognosis.—If the children are strong and the cause  is re-
 moved, thrush lasts about eight days.  Its most frequent compli-
 cation is intestinal catarrh, arising from the soured ingesta.   As a 
DISEASES OF THE DIGESTIVE APPARATUS.        181
 rule, when there has  been a persistent diarrhea we fear a fatal
 result.   Though the prognosis  in general is  good, when there  is
 complicating diarrhea, or when the thrush  is  of long  duration,
 the result is always doubtful; in the latter case because the oidium
 may extend into the blood-vessels and send  an embolus to the
 brain—thrush emboli.  The prognosis for thrush in the esophagus
 is  always bad.  In phthisis, etc., always bad.  Statistics  vastly
 differ, but in private practice  it need not be dreaded; often fear-
 fully prevalent in orphan asylums.
   Treatment.—(i) Change  the  acid reactions of  the buccal
 secretions to  alkali, by means  of borax or bicarbonate of soda
 solution 1-20,  penciled every half hour over the whole mucous
 membrane of the mouth.  (2)  Avoid the use  of all substances
 which  favor the growth  of fungi, as  sugar  or  saccharine fluids,
 honey or syrup, etc., sugar tits, or milk.  Unsweetened bouillon or
 oatmeal gruel with eggs are the  best foods until  the fungus has
 disappeared.   (3) If the  thrush extends into the  esophagus and
 produces vomiting, paint the inside of the  mouth  with a solution
 of sulphurous  acid in  glycerin. Jenne  prefers sulphite  soda
 (3j-Jj).  Pay  most careful  attention to nutrition,  employing  a
 wet-nurse if necessary.
   In  bad cases may use nitrate of silver solution (gr. ij-^j t. i. d.),
 or  better, swabbing with  peroxid of  hydrogen;  ordinarily the fol-
 lowing  is efficient:—
                             (52)
      R .  Pulv. borax,...........5 ss
           Glycerinoe,...........gj
           Aquae cin.,...........3 ij.

  Prophylaxis.—Sugar-teats are always to be  prohibited, and if
the child has become accustomed to  their use we  must substitute
in their place a rubber  nipple, which should be cleansed frequently
and thoroughly.  The  nipples of the nursing bottles  and  the bot-
tles themselves must always be cleansed with the greatest care lest
any milk should be left adherent and turn sour.   Rubber nipples
must be turned  inside  out and cleaned daily with  a brush.   The
bottles must also be cleaned daily with a brush  and sand, and
when not in use they ought to  be kept filled with  water  to which 
182
DISEASES OF CHILDREN.
a little bicarbonate of soda has been  added.  The rubber nip-
ples ought also to be kept in the same solution, and the  mouth of
the child and the nipples of the wet-nurse should also be carefully
cleansed with R No.  52, or warm water, after  every feeding,
with a bit of soft rag or absorbent cotton twisted about the finger
of the nurse.

               5.  APHTHOUS STOMATITIS.
  Synonyms.—Aphthae ;  stomatitis vesiculosa.
  Definition.—addai, as used by Hippocrates, clearly denoted a
breach of substance.
  Symptoms.—After a  few days of simple  catarrhal  stomatitis
(see page 179) subepithelial exudates  occur in the form of small
vesicles which soon leave a shallow, painful ulcer behind.  These
are without odor, have a yellowish base  and excavated edges, as if
cut out from the mucous membrane of the  mouth with a circular
or ovoid  punch, and heal within four to six days from their first
appearance.
  Prognosis.—Good,  if the exciting cause is removed.
  Treatment.—Sugar teats and injurious medicines must be dis-
continued.  The roots of decayed teeth should  always be removed.
Liquids, and these  cool, must alone be given.   If during dentition
nourishment is refused by the  infant  for  several days, in such
cases  a few  nourishing enemata  must be given.  Solutions of
bicarbonate of soda or borax (1-20 of water)  should be penciled
over the  mouth every half hour, to neutralize its acid secretions.
Keep the mouth scrupulously clean, and use potass, chlorat freely,
as Henoch regards it a specific in this disease,  and it is very nearly
so.  Small doses of calomel night and morning are also helpful.


               6.  STOMATITIS  ULCEROSA.
  Synonyms.—Ulcerative stomatitis ; Mundfaule.
  Definition.—Ulceration of the gums, found  only in children
who have cut some of their teeth.
  Etiology.—Transmission is  possible, but can only take place
from direct contact, or by means of children's toys, spoons, etc.
Non-contagious  sporadic  cases  may  also occur  from  carious 
DISEASES OF THE  DIGESTIVE APPARATUS.        183
teeth, calomel (stomatitis mercurialis), improper food, bad air, and
during convalescence from serious diseases, especially measles.
  Symptoms.—After a transient erythema of the mucous mem-
brane of the mouth and gums, ulcers form on the latter about  the
teeth, accompanied sometimes with high fever.  The floor of these
ulcers is covered with a yellow  coating and bleeds at the slightest
touch.   The  secretion of  saliva is increased while an  intoler-
able odor, like that from  rotting flesh, always accompanies this
variety  of stomatitis.  Then the whole  of the  buccal mucous
membrane becomes swollen, and marks of the teeth appear upon
the mucous membrane of the  tongue and cheeks.  Later, upon
the lips appear like painful  ulcers, with  sharply-defined, jagged
edges and little inclination to heal.  The lymphatic glands of the
neck are always somewhat swollen. The mouth cannot be closed,
but  allows the copious,  fetid, sero-sanguineous saliva to trickle
over the chin and  erode it.
  Prognosis.—If the cause persists, the  stomatitis may last for
months ;  the  teeth dropping out, the  child  becoming despond-
ent and atrophic ;  since mastication and deglutition are extremely
painful and  difficult, thirst  alone  compels the  child at last to
drink, and then it  takes a great deal at once.  Recovery, however,
generally takes place ultimately.
  Treatment.—First of  all,  good air  and nourishment must
always  be provided, with  the  most scrupulous  cleanliness, by
means of rinsing out the  mouth with antiseptic  solutions, and  the
removal of necrosed tissues by cutting or scraping.  Older children
may use a gargle,  but whatever method is adopted, cleansing must
be frequent and complete.  Painting the  ulcers with a solution of
permanganate of  potash or peroxid of hydrogen is also of value,
as is also fluid extract  of golden seal  and  glycerinas.   Inter-
nally,  Starr  speaks highly  of  potass, chlorat, in the following
mixture :—
                             (53)
      R.   Pot. chlorat.,............gr. xlviij
           Acid, muriat., dil.,.........f 3J
           Syrupi,............   .  3 ss
           Aquae,...........q. s. ad f 3 iij.   M.
      SiG.— 3 j diluted for child of 3 years.—Starr. 
184
DISEASES OF CHILDREN.
                   7. GANGR^ENA ORIS.
  Synonyms.—Noma ;  Wangenbrand ; oral gangrene.
  Etiology.—Nearly always occurs in children about two years
of age, and generally after some severe  constitutional disease, as
typhoid, scarlatina, measles, dysentery,  etc., or in children who
have become greatly reduced, especially when living in  foul air.
It generally attacks but one cheek and is more frequently observed
in girls than boys.  Noma of the genitals, under similar circum-
stances, occurs much more rarely, also gangrene of the anus, vulva,
or external meatus.  This perhaps occasionally follows the admin-
istration of mercury, and one  attack, if survived, predisposes to
another (Gerhardt).
  Symptoms.—During apparent convalescence, or in atrophic
children, without any clearly marked premonitory symptoms, a
circumscribed  induration of a  portion of the cheek is  noticed.
This takes place painlessly and is generally found in the neighbor-
hood  of  one  of the angles  of the  mouth;  on the underlying
mucous membrane appears first an ichorous vesicle, which very
soon becomes  a gangrenous ulcer, of a dark reddish-brown hue.
Great edema of the affected cheek and  side of the neck imme-
diately ensues, with infiltration of the lymphatic glands.  The skin
of the cheek, which has previously been pale, now becomes bluish
over the primary induration, and the epidermis blisters and peels
off.   As a rule, no line of demarcation is established, but the gan-
grene spreads rapidly,  both outward  and  inward, sometimes
extending to the eyelids or neck.  The gum and superior maxilla
necrose with surprising rapidity, the teeth fall  out,  and there is a
sanious discharge with horrible fetor.
  Course.—The entire  process generally reaches its  acme in
four to seven days ;  then pyemia ensues from absorption of infec-
tious matters.  Sopor and delirium follow, and  usually death takes
place within two weeks, with the symptoms of hydremia. Very
rarely has recovery been known to take place, then only with
great deformity, on account  of the  destruction  of tissue, sec-
ondary affections of the respiratory organs, e.g., pneumonias or
gangrene of the lungs may complicate.
  Prognosis.—Very bad.   Ninety to ninety-five per cent. die. 
           DISEASES  OF THE DIGESTIVE APPARATUS.         185

   Treatment.—(i)  Strengthen  the  constitution  by  means of
 wine, coffee, milk, meat, eggs, quinin,  and good, pure  air.   (2) If
 possible, prevent the spreading of the gangrene by means of effi-
 cient cauterization of its boundaries with caustic potash, or fuming
 nitric acid two or three times a day.  (3) Lessen the fetor by thor-
 ough application of a solution of permanganate of potash, iodoform
 and bismuth, carbolic acid, or peroxid of hydrogen.  Older chil-
 dren can also use gargles of the same, and daily baths and change
 of clothing should be  insisted upon.


           8. PHARYNGITIS CUM  TONSILLITIS.
   Synonyms.—Inflammation of the pharynx and tonsils ; amyg-
 dalitis follicularis ; tonsillitis.
   Etiology.—Scrofulous children are  peculiarly predisposed,
 hereditarily, to this  affection  with  each cold or  other exciting
 cause.  Rheumatic children the same.
   Symptoms are the same as in adults.  Difficulty in breathing
 and a sense of suffocation  occur rarely, as there  sometimes  are
 also delirium and convulsions with high fever.
   Prognosis.—Good.
   Treatment.—Small children are unable to gargle, and conse-
 quently their necks should be rubbed  with warm camphorated oil
 and covered with cotton batting.  Warm  drinks  may be given
 frequently, and the steam atomizer used.  Larger children should
 gargle their throats with  warm  mucilaginous decoctions, oatmeal
 gruel, etc.  Their bowels should be carefully looked after, and dia-
 phoresis  should be promoted.  Hoadley's gargle (p. 103) is very
 valuable in these cases, with the internal use of tincture of iron.


  9. TONSILLITIS PARENCHYMATOSA SUPPURATIVA.
  Synonym.—Abscess of the tonsils,
  Etiology.—Frequently follows diphtheria or a follicular inflam-
mation of the  tonsils, which leaves their surface roughened and
predisposed to the formation of an abscess from the accumulation
in the lacunas of foreign matters.  Sometimes occasioned by cold,
in a child predisposed to rheumatism.
      M 
186
DISEASES OF CHILDREN.
  Symptoms are the same as in adults, except the  dyspnea is
greater, and there is greater liability to attacks of suffocation.
  Course.—The abscess generally breaks  spontaneously about
the end of the second week, discharging offensive pus, with imme-
diate relief from dyspnea and pain.  The formation of an abscess
on one tonsil is often followed  by a like process in the other;  but
simultaneous suppuration of both tonsils has not yet been  ob-
served.
  Prophylaxis.—Excision of the ragged tonsil, and subsequent
gargling of the throat with cold green tea after each meal.
  Treatment.—If the physician is  early called, as is rarely the
case, he must endeavor to remove the bits  of food which have been
lodged in the ragged surface of the tonsil, and  the incipient in-
flammation must be combated by cold gargles and like applications
about the  neck.  But if the abscess has already formed, then warm
gargles are to be preferred.  When there is great pain or dyspnea,
the tonsil should be  incised, and timely incisions are always to be
made when fluctuation can be detected.   Should the incision  fail
to reach the abscess when it is deeply seated, and as  all cutting
here must be  done cautiously on account of the internal carotid
artery, which lies behind and to the outward of the tonsil,  we
must rest  satisfied with a single incision into the tonsil, and  en-
deavor to  relieve the pain with cocain spray  (four per cent.) until
the abscess spontaneously  discharges.  Where there  is  a rheu-
matic diathesis, an initial dose of calomel, followed by salicylate
of soda, will abort or greatly mitigate the attack.


          10. HYPERTROPHIA TONSILLARUM.
  Synonym.—Enlarged tonsils.
  Occurrence, Etc.—Very  frequently  met with in children,
especially scrofulous, and hence hereditary.   Met with often as
early as the second year, without acute inflammation ; or this  hy-
pertrophy may follow repeated attacks of pharyngitis.  In either
case the uvula is pushed forward and upward ; the isthmus of the
fauces as well as the posterior opening of the nares are narrowed,
and hence result  a snuffling  voice,  mouth-breathing,  and, from
relaxation of  the uvula, snoring during sleep.  If the Eustachian 
DISEASES OF  THE DIGESTIVE APPARATUS.        187
tube is  obstructed,  it interferes with  hearing.  In severe cases,
breathing becomes difficult and quickened, and the child wears an
anxious expression upon its face.  Especial danger to the child is
always to be feared when an attack of acute angina or diphtheritis
supervenes, because then  the  already narrowed  air-passages will
be still further obstructed.
  Treatment.—As long as respiration is not rendered difficult,
treatment of the scrofula with  cod-liver oil, syr. ferri  iodid, etc.,
is sufficient; but when breathing becomes labored, the pharyngeal
cavity must be  increased  by  lessening the size of the tonsils.
This can be done by means of (i)  puncturing them repeatedly,
e.g., twice a week, and afterward cauterizing the wound.  (2) Ex-
tirpating at least one tonsil by means  of a tonsillotome, which is
the best and most  rapid method, because in  this way the whole
operation is over before the child  knows what  the physician is
about, and to this end the child should never be informed before-
hand what is about to be done.  The  same operation may be per-
formed later on the other tonsil. Sometimes one sitting for each
tonsil is sufficient, but frequently the children are unruly, and we
are often obliged to repeat the operation later in life, as it is often
urgently required to improve articulation.


  11. RETROPHARYNGEAL AND RETROESOPHAGEAL
                          ABSCESS.
  Definition.—Abscess behind the pharynx or esophagus.
  Etiology.—Caries of the  cervical vertebras, or more rarely
suppuration of the retropharyngeal  lymphatic glands.   Again, it
may have an idiopathic  origin, as is the case with scrofulous, tuber-
culous, and rachitic children.
  Symptoms.—At first there is difficulty in swallowing, and to
this are soon joined stiff neck,  tenderness of the cervical vertebras,
and the voice becomes snuffling.  Later, the head is bent strongly
backward as far as possible to prevent dyspnea; nevertheless,
respiration becomes difficult and stertorous, but not whistling, as
in croup,  while  the  facial muscles twitch and  speech is  unin-
telligible.   The  posterior  wall of the pharynx at  first only red-
dened and somewhat swollen, soon  evidently protrudes  as a 
188
DISEASES OF CHILDREN.
fluctuating  tumor, which  sometimes crowds  forward the  uvula.
Finally, the abscess opens and an enormous quantity of  pus is
poured forth into the mouth, and if this happens during sleep, the
pus may flow down  into the larynx and result  possibly in suffoca-
tion.
  Prognosis.—Bad, though not necessarily fatal.
  Treatment.—Quiet and bits of ice.  Timely incision must be
employed after the abscess forms  in consequence of suppuration
of the lymphatic glands; but if the abscess arises from caries of
the cervical vertebra, we must delay incising it until there  is real
danger  from  suffocation.  After opening, lying on the back for
months and iodid of iron are to be prescribed.


   DISEASES OF THE ESOPHAGUS AND STOMACH.

        i.  MALFORMATIONS OF THE ESOPHAGUS,
Such as fistula colli congenita, stenosis of  the esophagus,  and
diverticular pouches of the same,  are sometimes met with,  but are
very rare, and can be remedied only by the aid of the surgeon.


                      2.  ESOPHAGITIS
Has been described by Brush as a separate disease, characterized
by heat, redness, pain in swallowing and between the shoulder
blades, etc.;  but when it exists it is probably merely an extension
of catarrhal stomatitis,  and requires the same  treatment.


        3. INFANTILE VOMITING  AND DYSPEPSIA.
  Vomiting is  the  natural and easiest method of relieving the
child of injurious ingesta. Hence, unless associated with gastric
catarrh, so long as the child  does not waste, it is not a matter  of
serious import.  But when a symptom of gastric catarrh, or symp-
tomatic of other troubles than gastric, it deserves the careful atten-
tion of the physician.  More cases of death result from neglected
dyspepsia than from all other preventable causes of children's dis-
ease.   Hence the importance of the subject.   The reader's atten- 
            DISEASES OF THE DIGESTIVE APPARATUS.         189

tion is called to the subject of artificial feeding (page 53), and he
is again reminded that all foods may be divided into—
  {a) Inorganic salts, or those which, having served their purpose
in the economy, are excreted unchanged.
  (b) Albuminoids, converted into peptones by gastric juice (pep-
sin), and by trypsin in alkaline media.
  (c) Fats,  mainly digested by pancreatin in smaller intestine ;
also assisted by bile and Brunner's glands.
  {d) Saccharine and starchy carbohydrates, changed into glu-
cose by saliva and intestinal juices (invertin).
  Chemically,  we  may have a  dyspepsia of any of these,  but
clinically, it  is  convenient  to divide the dyspepsias of childhood
into—
   1. Mucous dyspepsia (Apeptic dyspepsia).
  2. Acid dyspepsia (Putrid dyspepsia).
  3. Intestinal dyspepsia, or that of fats, starch, etc.,  in the lower
part of the alimentary canal.
  Apeptic Dyspepsia should be limited to those cases in which
there is failure on the part of the child's stomach  to secrete a
proper quantity or quality of pepsin.  This is characterized by the
frequent ejection of undigested milk,  either by vomiting or in  the
feces.  Otherwise the passages may be natural, and  the appetite
excellent, nevertheless the  child wastes and passes into a marasmic
condition,  not from  a lack of food,  but from  failure  to assimi-
late sufficient  to keep up the  nourishment  of the  body.  The
mother's milk  may be good, perhaps  too good,  and yet the child
does not thrive, and is very apt to fall a prey to  some intercurrent
disease, which  a better nourished child would have  successfully
resisted.
  Prophylaxis and Treatment.—The very name of this dis-
ease suggests its only successful  treatment, viz., the addition of
sufficient artificial digestants to supply the stomach's lack.  These
are the cases in which a reliable pepsin yields the most gratifying
results.  This form of dyspepsia is not as frequently met with as
the others, but  it is  the one most amenable to treatment of them
all.  Apeptic dyspepsia is,  as a rule, attended  with gastric catarrh.
Perhaps it is its most frequent cause, the abundant alkaline mucus
undoubtedly neutralizing and rendering inert  the peptic juices of 
190
DISEASES OF CHILDREN.
the stomach.  In these cases the gastric catarrh requires treatment
fully as much  as the apepsia, which improves pari passu  with the
catarrh.  Of all remedies for this we much prefer the subcarbon-
ate or subnitrate of bismuth in  ordinary cases.  This is  usually
sufficient, but  occasionally we have  hastened  convalescence by
substituting pyrophosphate of iron for the bismuth for awhile, or
when there is  considerable gastric torpor trying  minute  doses of
Fowler's solution or tinct. of nux vomica.  German authors and
teachers speak very highly of a tincture of the malate of iron in
such cases, but that to be obtained in this country has no appa-
rent advantage  over  the ordinary tincture of the chlorid or the
lactate of iron.  And,  of course, all treatment is useless unless you
can regulate the number and kind of feedings the child receives.
  Acid Dyspepsia  is that  arising from an excess of acid in the
stomach, either lactic or hydrochloric, which unduly clots the
casein and produces  thus, in addition, gastric catarrh, enteritis,
entero-colitis, etc.  This form of dyspepsia differs from that first
mentioned in the acid eructations, sour vomit,  and colicky pains
of acid dyspepsia.  The passages are too frequent, at  first hard,
sour, and curdy, and later, loose,  copious, and inclined to become
colorless.
  Prophylaxis is more satisfactory than later treatment, for at
first we have to  do only with a chemical problem, but later with
pathological changes  as well.  The earliest symptoms call for the
free use of barley water  as  a  diluent, or the  use of Meigs' cream
mixture  (page 53), or  the entire  disuse of milk for a day or two,
and the substitution  of peptonized beef or mutton broth in its
stead.   For later complications, see Entero-colitis.
  Fat Dyspepsia is occasionally seen, and in such cases pancre-
atic extract, or pancrobilin, is valuable.  For other forms  of intes-
tinal dyspepsia, see Gastro-duodenal Catarrh and Affections of the
Intestinal Canal.


   4. CATARRHUS  GASTRO-INTESTINALIS ACUTUS.
  Synonyms.—Cholera infantum ;   epidemic cholera ; acuter
magendarmcatarrh  ; entero-colitis choleriforme.
  Etiology.—Faulty nutrition  of the child,  especially apt to 
DISEASES OF THE DIGESTIVE APPARATUS.         191
occur in summer from sour milk, or from bad, improper fodder-
ing of the cows, or it may arise from abnormal irritation  caused
by  fermenting food,  teething,  colds,  or emotional excitement.
Vaughan thinks all cases due to the production of tyrotoxicon, a
poisonous alkaloid formed by the  decomposition of milk.  Dr.
Brush believes it a poison produced in cow's milk by over-heating,
and Dr. Brunton states that the alkaloids resulting from the decom-
position of albumin cause diarrhea (toxemic)  with  the nervous
symptoms of summer diarrhea (Holt).
  Symptoms.—Frequently we learn  that for some time the
child's food, generally  cow's milk,  has been vomited at  times,
after one or two days of prodromal restlessness.  Or there may
suddenly occur at the onset of the  disease an  alteration  in the
stools, which may still be  normal, for the first  few, but are
passed rapidly one after another, and contain  either undigested,
curdled milk, or consist of frothy masses of a strongly acidulous
and penetrating odor.  After this condition has lasted for  several
hours, or without any premonition, yellowish-green, watery stools,
with a stale or sour smell, occur in great number, twenty to thirty ;
"rice-watery" at first and very profuse, running through napkins,
and often the bed-clothes also;  at last stools are tinged with blood,
with simultaneous  vomiting of all ingesta.  As the supply of fluids
discharged from the intestines, can only be procured from those of
the body, viz., those contained in  the blood,  areolar and mus-
cular tissue, and even the brain, whose fluids must be reabsorbed
to supply the drain, this  serous hemorrhage  produces disturb-
ance of circulation everywhere.  The pulse  becomes  small and
frequent, the  nose and the extremities become  cool, the skin
and the urine scanty.   The child  becomes blue  and pinched
looking.   The  features  become  senile, the  eyes hollow, the
great fontanelle sinks in, and  the  borders  of  the cranial bones
override each other.  Very  rarely,  even now, a  reactive  fever
occurs, with cure or a transformation into chronic gastro-intestinal
catarrh.  Generally, however,  death occurs  in  from two to six
days, with  the  symptoms  of spurious hydrocephalus, charac-
terized  by  moaning,  restlessness,  eyes dilated,  immobility of
the pupils,  convulsions, dyspnea from anemia of  the medulla
oblongata, and marantic thrombosis of the cerebral sinuses.  Or 
192
DISEASES OF CHILDREN.
death may result from pneumonia, which frequently arises from
the passage  of part of the food  down the trachea (Schluck-
pneumonia).
  Prognosis.—Generally bad.   May die in six to twelve hours,
usually not for twenty-four to thirty-six.   Statistics  show improve-
ment in mortality of late years or better diagnoses.
  Treatment  of cholera infantum,   (i)  Keep  child  in tem-
perature below 8o°, better below 700 (F.); in open  air, if possible.
Watch carefully diet and guard  against initial diarrhea.   During
stages of  evacuation  give aromatic spirits of am. with calcined
magnesia, teaspoonful every thirty minutes.

                             (54)
      R.  Sp. am.  aromatici,..........4  c.c.
          Magnesii exsiccatae,.........2  gm.
          Aquae anisi.............5°  c,c-
          Tr. opii  camph.,..........4  c.c.

  Might substitute bismuth for the magnesia, if much vomiting.
Rectal injections of chloral hydrate, giving one grain for each year
of child's age, and collodion over abdomen, or hot  pack, mustard,
or red pepper in the bath.  If this does not produce reaction, then
give quinin hypodermically, with T^j grain morphin.
  Gaslro-duodenal catarrh, the  so-called bilious diarrhea, is one
of the symptoms  of  hepatic incompetence,  " biliousness," and
needs treatment more by regulation of diet than by checking the
diarrhea.  This  and the vomiting  may be so annoying as to re-
quire immediate relief,  which  can be  usually most  promptly
attained by the  use of minute doses  of  calomel (^ to -fo) com-
bined with bicarbonate of soda and bismuth.  The  after-treat-
ment consists in the regulation of the duodenal dyspepsia and the
use of such  foods as will least tax  this part of  digestion.   If
this is not done, the  child soon  regains its appetite, eats inordi-
nately, overtaxes its hepatic secretions, and culminates matters be-
fore long with another bilious attack.  The indications then are :
(1)  Relieve hepatic incompetence and catarrh.  (2) Keep bowels
regularly emptied  of  fermentable and undigested food.  Both are
well accomplished by the use of phosphate of soda or chlorid  of
ammonium in some such mixture as the following:— 
DISEASES OF THE  DIGESTIVE APPARATUS.        193
      R.   Sodii sulphat ,...........2 gm.
           Phosphate soda,..........8 gm.
           Cascara cordial,..........6o c.c.    M.
      Sig.— 3J-ij night and morning, as required.—H..

With regulation  of the  diet as before indicated—cocoa, chops,
steak, toast, oysters and soups being the foods best adapted for
such cases.

                   5. SEROUS DIARRHEA.
  Synonyms.—Intestinal  catarrh, without anatomical changes ;
acuter darmkatarrh; diarrhee catarrhale;  diarrhee idiopathique.
  Varieties.—Lienteric (irritative), dentition (reflex), idiopathic,
symptomatic, diarrhea ablactatorum, "lienteric laiteuse " (B).
  Etiology.—Nervous  excitement of the  muscles of intestines
(Bouchut), either simply from mental  impressions, reflexly,  or
from irritation within the tube itself (worms, curds, etc.) ; also criti-
cal in certain diseases, as measles, etc.
  Exciting Causes.—Cold, bad hygienic surroundings, fear,
anger, rachitis, suffering  of protracted dentition, intestinal worms,
impressions made  upon  nurse, eruptive fevers, wrong foods, poor
nurse, weaning, suppressed  eruptions, fruit, etc.
  Predisposing.—Bad air, hospitals, foundling  and other asy-
lums, uncleanliness, hot  weather continued for several days.
  Principal oi  these  in young children is unsuitable quantity or
quality of their food conjoined with hot weather, producing, accord-
ing to modern theories, a good breeding-place for bacteria in and
outside of the body.
  Complications.—Emaciation, if diarrhea is  persistent; the
skin becomes leaden, face pinched, and muscles soft, and in aggra-
vated  cases the  nose becomes cool  and  symptoms of anemia of
the brain supervene.
  Symptoms with a very young child are most marked at night,
and consist of  light  sleep,  frequently interrupted  by cries and
colic, which leads it to twist and turn and flex its thighs  on abdo-
men. During the day the child is peevish and fretful, and appears
from time to time to  actually be in suffering, as the face changes
in expression. 
194
DISEASES OF CHILDREN.
  At first there is no fever, and the child nurses less eagerly but
well, although it swallows less easily and often regurgitates bits of
curds, while the intestinal discharges may be  thin and mucous,
or firm, mixed with undigested food, bits of meat, vegetables,  or
lumps of casein, etc. At first they are of a normal color and homo-
geneous, later they become greenish and thin, or gray, rice-water
stools of summer diarrhea, in which case  the stools are odorless,
of neutral or alkaline reaction, and often  ejected with great force,
after which the colic generally ceases.   In addition there are mod-
erate  distention  of  the  abdomen  with tenesmus and  intestinal
gurgling (borborygmi).
  Course.—Recovery takes place more frequently than in cholera
infantum ; in one or two days the stools generally become more  con-
sistent, though still mixed with mucus.  With others, constipation
follows  and the appetite improves, but if the nutrition  is  faulty,
relapses are very prone  to take place.  These,  at last, transform
themselves  into a chronic intestinal catarrh with tabes, but this
may also develop itself  directly from  an acute  diarrhea without
the  intervention  of relapses.  In such cases the mesenteric glands
are  never infiltrated and  enlarged, or at most they are hyperemic.
  Prognosis.—Favorable, if checked in two or three days ; after
that very prone  to run into inflammatory form, so never safe  to
make an absolute prognosis.
  Treatment.—The indications in general for the treatment of
serous diarrhea in infancy are these, viz., (i) To empty the bow-
els.   (2) Stop decomposition.   (3)  Restore  healthy action of the
intestinal canal.   (4) Treat complicating lesions.
  1. To remove curds  and  undigested food,  nothing  is better
than castor oil (3j  in hot milk, Jacobi), or  small and repeated
doses of calomel, if the  stomach  be  very irritable,  or  by warm
water enemata (Oj  for  child of six months, or  enough to reach
the  ileo-cecal valve).
  2. To arrest decomposition a large number of antiseptics have
been proposed, and of these, according to Starr, the best are  sali-
cylate of soda,  or  naphthalin ;  one to three grains  of  the  first
every two hours (readily soluble).  Naphthalin  is insoluble, and
has a strong odor, but can be given rubbed up with sugar of milk
(gr. j-v, p. r. n.). Resorcin and bichlorid of mercury are recom- 
DISEASES OF THE DIGESTIVE APPARATUS.        195
mended by others.   (One of the  best is salol (gr. ij-v) combined
with five to ten grains of bismuth).

                               (56)
      R.   Subnit. bismuth.,..........gr. ij-iij
           Pulv. Dover's,...........gr- K-     M-
      Sig.—Every two to four hours for young infants.
Or-
                               CS?)
      R.   Salol,..............gr.j
           Bismuth, subnit.,..........gr. iv-vj.
Or—
                               (58)
      R.  Bismuth, subnitrat...........gr. j-iij
           Tinct. opii camph...........gtt. iv
           Mist, cretae,
           Aquae anisi,.......aa .  .  .  . 3 ss.      M.
      Sig.—Every two hours.

   Hutchinson prefers salicylate  of bismuth or chalk, gr. ij-v.
Germans speak well of benzoate of soda, gr. ij—iv, pro dosi in sim-
ple elixir.  A favorite prescription is—

                               (59)
      R.  Sodii bicarb.,...........£ss
           Syr. rhei aromat.,.........^ ss
           Aquae menth. pip.,.........giiss.     M.
      Sig.— 3J every two hours.—(Starr.)
Or—
                               (60)
      R.  Sod. bromid.,...........4
           Syr. rhei aromat.,
           Tinct. opii camph., .... aa ...  .   8 c.c.
           Aquae anisi,...........ad 60 c.c.   M.
      Sig.— 3J every two to four hours.—H.

   Prophylaxis.—The  intestinal discharges must  be carefully
examined, especially in the summer time, and their  least depart-
ure from a normal condition should at once be  promptly rectified
by change of milk, or, at least, by the addition of a little soda bicar- 
196
DISEASES OF CHILDREN.
bonate.  Health and habits of mothers and wet-nurses must also
be carefully looked after, and changed if necessary.
  Hayem thinks  the  green  passages are  contagious  from the
presence of bacteria, which flourish only in an alkaline or neutral
medium.  Experiments seem to show that lactic acid is very de-
structive to them, hence Hayem prescribes :—

                             (61)
      R.  Lactic acid,   .....
          Simple syrup......
          Lemon juice,.....
      SlG.— 3 j every three hours.

          6. CHRONIC INTESTINAL CATARRH.
  Synonyms.—Enteritis follicularis ; chronic diarrhea; summer
complaint;  atrophia lactantium (Cheyne) ; entero-colitis.
  Symptoms.—An acute diarrhea or an attack of cholera in-
fantum,  ending  neither in  death nor cure, leaves  the  physical
forces  of the body in an  unsettled  condition, while  the dis-
charges remain peristently thin, acrid, and gradually acquire the
penetrating  odor of decomposition.   The anus and thighs become
excoriated by the acrid discharges, and the abdomen  is markedly
distended and meteorismic.  At the same time there is high, con-
tinuous fever and great thirst.   Sometimes, after giving too much
drink,  vomiting results, and sometimes the appetite  is very good,
at times abnormally so (bulimia, polyphagia,  or fames canina.
The same is often observed  in children suffering from intestinal
worms and chronic cerebral disease).   But notwithstanding this
voracious appetite the child atrophies rapidly, if it has not already
done so, until it looks like a skeleton with a  distended, tympanitic
belly.   The lymphatic vessels,  with their valve-like nodules about
the size of the head of a pin, may often be recognized in the skin.
In  the atrophy  the  brain participates, and, in consequence, the
bones  of the skull override each other, i. <?.,  the  parietals overlap
the occipital and  frontal, so that in the further progress of the dis-
ease, besides the  carrion odor of the stools, the symptoms of brain
atrophy and anemia (see page 50) present  themselves, and, as a
rule, almost without an exception, death follows soon  after the
 2 c.c.
98 c.c.
q. s.      M. 
           DISEASES OF THE  DIGESTIVE APPARATUS.        197

coating of the tongue with thrush, although  in a few rare cases
it may not take place until several weeks later.
  Pathological Anatomy.—" Cut-beard " follicles, and  infil-
tration of the submucous cellular tissue of the whole colon and a
portion of the  small intestines, the  superficial surface of which
shows signs  of  an acute catarrh in the loss of its  cylindrical epi-
thelium with abundant secretion of mucus.  Moreover, many of
the solitary glands and Peyer's patches are swollen and infiltrated,
or have degenerated into ragged ulcers.   The mesenteric glands
form  enlarged  and infiltrated patches—red-grayish white—and
show  injected lacteals and chyle stains.   If tuberculous, they are
seen as gray or yellow granulations under the microscope. Many
slough out and show actual ulceration.
  Differentiation lies between incipient tuberculosis and chronic
follicular enteritis; but, remember, that the former has an evening
rise of temperature, while the latter may show exactly the reverse.
  Treatment.—Successful treatment is more a matter of the
regulation of diet  and hygiene than medication, though the  latter
is necessary.  Cleanliness is a sine qua non to recovery, hence an
abundance of clean napkins and bathing must be insisted upon.
  Diet Hints.—Cocoa is constipating in its effects and nutritious.
A little fresh butter will sometimes be assimilated.   Cod-liver oil
is usually not well borne, hence rub it on externally.   Koumiss is
valuable for an irritable stomach.  Beef-tea—do not  give it—only
stimulant, and  whisky is much  better.   Beef-tea is  a laxative,
and hence do not use it, except as an occasional change.  Raw
or pounded  beef is good. Hash finely, rub through  a grater, put
a little sugar on it, and a child will take it eagerly, but it (i)  gives
horrible fecal passages ;  (2)  may produce tapeworms.
  Prognosis.—Always serious; generally fatal.  Apparent cessa-
tion of diarrhea not always hopeful, but hope on if without  com-
plications.   Secondary  less hopeful than primary.  Worst stools
are fetid, chopped spinach,  with  dirty-brown  fluid;  more   con-
sistent passages the better prognosis.    If  intercurrent  disease
appears prognosis is hopeless.
  Medication.—The initiatory acute diarrhea must be quieted
as quickly as possible, for if it has passed into  the chronic  state,
only few cases can be saved, even with a wet-nurse.  If a wet- 
198
DISEASES OF  CHILDREN.
nurse is not to be had,  then  try substitutes (see page  53), but
remember that " one lump of indigestible food does more hurt than
all medicines help."  Antacids as long as sour smell.  Underwood
says add aromatic astringents, like rhubarb, fld. ext.  coto, tinct.
catechu, or, if the progress is very slow, quinin (tannate, gr. ij, p. d.),
scraped raw beef, yelk of eggs, cocoa, soups, and good old rum.
Don't forget the importance of good air, for dampness is almost as
bad as sudden changes to these children.   As a last resource, use
rectal injections of nitrate of silver or bismuth subnitrate and tinct.
of opium suspended in starch water.

                       ILEO-COLITIS.
  Definition.—Inflammation of the colon and rectum attended
with bloody stools and tenesmus.  (See page 113.)
  Etiology.—Epidemic and  sporadic, the former  clearly infec-
tious, possibly contagious.  Most common between two and three
years of age.
  Symptoms.—Nausea, vomiting, high fever, and abdominal
pains.  Passages are frequent, painful, and soon mixed with pus
and blood.   Face anxious, tongue dry and brownish, loss of appe-
tite and great thirst, abdomen  distended, and tenesmus more and
more distressing.
  Prognosis.—None too favorable, even in the sporadic  forms.
  Treatment.—Absolute rest must be insisted upon, and the child
fed on  browned flour and scalded milk with cracked ice  or toast
water for thirst.  Of remedies, the best are—
                             (62)
      R .  Olei ricini,.............3 ijss
          Tinct. opii deod.,..........Tf\/vuJ
          Pulv. acacia?,
          Sacch. alb.........aa.....gij
          Aq. menth. pip,..........ad 3 ij.   M.
      SlG.— 3J every three hours.—(Starr.)

or rectal injections  containing gr. iv-v of chloral hydrate with fl.
ext. ipecac suspended in  starch water immediately after a passage.
Others claim the very best results from minute doses of corrosive
sublimate given every one or two hours with the food. 
DISEASES OF THE DIGESTIVE APPARATUS.        199
DISEASES OF THE LIVER, PERITONEUM, AND LOWER
                  INTESTINAL CANAL.

      i.  INSUFFICIENT FORMATION OF BILIARY
                       SECRETIONS
Is perhaps rather a symptom than a  distinct disease, but it is so
frequently met with in nurslings that it requires a word or two of
description.
  Etiology.—Artificial nourishment,  especially when  there is
coincident dyspepsia and malassimilation of albuminoids.
  Symptoms.—Without icterus.  The feces are like crumbling,
soft, gray, grayish brown or yellow clay, often being discharged
with great exertion, and can be shaken out of the diaper without
leaving a mark behind.  Generally the nutrition of the child falls
away.
  Treatment.—Gr. ij pulv. rhei with as much mag. usta or phos-
phate soda in small doses twice a day.  Sometimes a change of food
alone will produce an improvement; or, if a more efficient remedy
is required, try
                            (°3)
      R.  Podophyllin,............gr. j
          Alcoholis,.............3J.

gtt. iv-v  on lump sugar as required, or podophyllin granules, p.
r. n.,or the free use of lithia water and an occasional laxative dose
of phosphate of soda, will work wonders in these cases.


  2. MALFORMATION OF LIVER AND GALL-BLADDER.
  Of the malformation or arrest of development  of the  liver, we
may note that it may be entirely absent,  especially in acephalic
children.  Again it may be variously modified in form ; e.g., there
may be no separation into lobes, or there may be supernumerary
ones.  The same may be true of the gall-bladder.  In a case of
congenital cleft diaphragm the liver may be found in the thoracic
cavity, more rarely on the right side.  In umbilical hernia—exom-
phalus—it lies outside of the abdomen, and where there is situs 
200
DISEASES OF  CHILDREN.
transversus viscerum the liver, of course, lies on the left side, and it
should always be remembered that the liver is relatively larger in
children than in adults.

                       ■
                   3. HEPAR ADIPOSUM.
  Definition.—Fatty liver, either from infiltration or degenera-
tion.
  Pathological Anatomy.—Cell-walls uninjured, surface oily
and glistening, margins rounded,  doughy, and of a yellowish tint.
  Occurrence.—A mild degree is always met with in the infant
liver, where it is the physiological result of the child's milk diet,
which has a superabundance of hydrocarbons, or  after cod-liver
oil given medicinally.
  Etiology.—Pathologically, is  always  a  secondary  result in
certain diseases tending to  emaciation, as scrofulosis,  pernicious
anemia;  fatty infiltration more frequent than fatty degeneration,
and  is found after tuberculosis  of the various organs,  rachitis,
protracted diarrhea, enteritis  follicularis, typhoid, syphilis,  etc.,
its cause in these cases being a faulty assimilation of food, whereby
the fat normally deposited  in the subcutaneous cellular tissue is
absorbed, accumulates in the blood, and is subsequently deposited.
The liver is enlarged and can be detected by percussion, unless
covered by inflated loops of intestine, but fatty liver never gives
rise to ascites.
  Symptoms.—The edges are  blunted and its  upper surfaces
smooth.  If the ramifications of the portal vein are affected by the
atheromatous  degeneration, we then find the familiar reticulated
appearance, known as  nutmeg liver.  If the hepatic veins have
also become implicated, a cross-section covers  the blade  of the
knife with fat and shows a uniform, pale yellow surface.
  Course.—If  recovery from the  primary  disease takes place,
absorption of the  deposited  fat occurs  and the corresponding
enlargement of the liver  disappears.
  Prognosis is really that of the primary disease, for if that is
curable, the fatty liver is also.
  Treatment is that of the primary disease. 
DISEASES OF THE DIGESTIVE APPARATUS.         201
     4. AMYLOID  DEGENERATION OF THE  LIVER.
  Synonyms.—Waxy liver ; lardaceous liver ;  speck-leber.
  Definition.—Albuminoid infiltration of  the substance of the
liver, causing increase in its size.   This infiltrate  gives with an
aqueous solution of iodin a bright brownish-red reaction, the color
becoming blue upon the addition of dilute sulphuric acid.
  Occurrence.—Not a very infrequent disease of the liver, being
found chiefly between the ages of four and fourteen years, and is
always accompanied with marked increase in the size of the  liver.
It has been met with as early as the fifth week (Steiner), but is most
frequently observed about the fifth year, and boys are  apparently
more subject  to this disease than are girls.  It is seldom confined
to the liver alone, but affects the spleen,  kidneys, intestinal and
lymphatic glands as well.
  Etiology.—According to Lawrence Johnson, amyloid degen-
eration  of the liver is always preceded by chronic suppuration or
caseous degeneration elsewhere in the body.  Steiner insists that
amyloid disease of the liver may exist independently, but is usually
found associated with chronic  suppuration.   Others claim that it
may result from syphilis, rachitis, or even eczema of the scalp,
though the diseases that it most frequently follows are bone caries,
tuberculosis, chronic pneumonia,  abscess, variola,  and pleurisy.
In short, it may be  said that whenever there is  caseous degen-
eration  or chronic suppuration  in any of the organs of the body,
amyloid degeneration of the liver, kidneys, or spleen is a later
possible complication.
  Symptoms.—Amyloid  degeneration has  no  characteristic
symptoms in its beginning other than those  of preceding diseases
already noted. After protracted illness from any of these causes,
the patient is observed to become pale and his complexion waxy.
At the same time there is emaciation, and the appetite is greatly
impaired,  especially as regards  animal food.   There is diminished
secretion  of the bile, and the stools  in  consequence are light-
colored and very offensive.  The  liver can be felt as a smooth,
hard tumor, sometimes  extending to the  crest of the  ilium, with
bluntly-rounded edges,  distending the  abdomen  and making its
cutaneous veins prominent.   If there is concomitant disease of the
      N 
202
DISEASES OF CHILDREN.
kidneys,  there may be edema or albuminuria.  If the spleen is
affected, it  will be found enlarged, and intestinal complications
produce diarrhea and hydremia.   Death  usually preceded by
ascites, which invariably accompanies sufficient enlargement of
the liver, whose weight has been known to reach  one-eighth that
of the entire body.
  Pathological Anatomy.—The liver is always increased in
size ; at times greatly so (7 lbs. 10 ozs., Steiner), and is firmer than
normal in texture. Its edges are rounded, the color grayish-yellow
to light brown, and its cut surface smooth and shining, and bathed
with a small quantity of viscid bile.  The  microscope shows that
the smaller blood-vessels and liver acini are filled with a trans-
parent albuminoid substance which gives a reaction with iodin
similar in appearance to that produced by adding iodin to starchy
substances, whence the improper naming of this disease, amyloid
degeneration. A more delicate reaction is that obtained by stain-
ing the tissues with an iodo-aniline methyl solution, which colors
the amyloid infiltrate a ruby or reddish violet tint, and colors the
healthy tissues bluish violet.
  Treatment.—Cure, if possible,  the primary disease as speedily
as may be, lest amyloid degeneration appear in other organs.  To
this  end take especial care  of  nutrition, employing,  in addition,
such drugs  as potassium iodid, syrup of the iodid of  iron, ammo-
nium chlorid, or dilute muriatic acid.   Quinin, iron, and  country
air are all valuable in improving the general nutrition.
  Prognosis.—Generally unfavorable, the disease being almost
always fatal, especially if dropsy has appeared.  Initial  amyloid
degeneration accompanying diseases which are curable  may dis-
appear upon the removal of  such diseases.


                  5. CIRRHOSIS HEPATIS
Occurs rarely in  childhood, although it has been observed in the
newborn.   Its etiology is usually unknown, though sometimes it is
due to the early use of alcohol,  or malarial intoxication.
  Symptoms, Prognosis, and Treatment same as in the adult.
  Hepatitis Interstitialis Syphilitica.—See Syphilis.
  Tuberculosis of the Liver.—See Tuberculosis. 
           DISEASES OF THE DIGESTIVE APPARATUS.        203

6.  DISEASES AND MALFORMATIONS OF THE SPLEEN.
  Amyloid degeneration of the spleen is observed concomi-
tantly and as a consequent of the causes which produce like degen-
eration of the liver and kidneys.  Either the small arteries of the
Malpighian tufts may be attacked and we have what is known as
sago spleen, or the whole organ may be uniformly affected, pro-
ducing the lardaceous spleen,  in which the  spleen becomes
enlarged to a hard, smooth tumor easily felt.   At the same time
diarrhea  and albuminuria are present, due to similar affections of
the intestines and kidneys.
  Infarctions  of the spleen leading to inflammation of the
same (splenitis), are certainly often  of embolic origin.
  Neomata (new formations) are observed in the spleen, as is
miliary tuberculosis, and the very rare  cases of splenic echino-
cocci.
  Splenic  Lymphomata are met with in  leucocythemia, in
which  there is an  increase of white  blood-corpuscles, and  in
pseudo-leucocythemia, with swelling of various lymphatic glands—
especially cervical.  Both  of these conditions  give an enlarged
spleen with a perceptibly uneven surface.  Lymphomata appear at
autopsies as whitish or grayish-red tumors about the size of a pea.
  "Wandering spleen has been  observed by Steiner in a two-
year-old  rachitic child ; in  this case the spleen at times was found
in the left inguinal region  and again between the umbilicus and
symphysis.

          7. PERITONITIS AND APPENDICITIS.
  Occurrence.—Even in utero.  Not infrequent with children,
especially traumatic peritonitis.
  Etiology.—Fetal peritonitis is due either to secondary syphilis
or to septic infection  from the mother in  the later stages  of
pregnancy.
  Peritonitis in infants is due to the same causes as in adults, or
to umbilical phlebitis, or gangrene, which are  especially prone to
occur simultaneously with puerperal fever in lying-in hospitals and
foundling asylums.   The peritonitis of larger children arises, usu-
ally, from traumatic influences, colds, pyemia, acute exanthemata 
204
DISEASES OF CHILDREN.
(especially scarlet fever), intussusception, strangulated hernia, or
very rarely from perforation of the stomach or intestine.  Rarely
also worms penetrate the intestine and pass into the peritoneum,
and produce what is known as worm abscess.  Gonorrhea may
also produce peritonitis in the female child.
  Symptoms.—Vomiting is usually one of the most marked
and the earliest  symptoms in  acute peritonitis.  The abdomen  is
tense and distended with meteorismus, and  is painful to the touch
and to all respiratory movements.  Hence  the patient endeavors
to avoid every motion and assumes a crouching position.  The
feet are usually outstretched  and breathing very superficial and
short, in order to prevent,  as far as possible, all motions of the
diaphragm, which are painful.  Hence breathing  is very imperfect
and with  a short cry whenever a deep breath is taken.  At the
same time fever and a rapid pulse are present, while later collapse
occurs.  Infants refuse the breast.   Their facial muscles are pain-
fully distorted and the countenance is often  cyanotic.  In circum-
scribed, or chronic, peritonitis the pain is less, often  occurring
only on pressure.
  Prognosis.—Fetal peritonitis frequently leads to  angulation,
or stenosis,  of the intestine, and  likewise  to  secondary  ascites.
Peritonitis of the newborn generally ends fatally in 1-3 days ; very
rarely the sero-purulent exudate finds exit via the still patulous
canalis vaginalis testiculi, or by way of the umbilicus.   Death may
occur in older children from  pyemia,  tuberculosis  of the peri-
toneum, or pneumonia.  Cures have been known to result after a
discharge  of the  purulent or  sero-purulent fluid externally, or a
purulent discharge  may persist for years  through the  fistulous
opening thus established, but it may be said that, in general, the
prognosis of peritonitis is unfavorable. When the case is compli-
cated with pyemia,  septic infection, or  intussusception, death  is
certain.  The circumscribed peritonitis  of older children,  which
points and discharges externally, may result in recovery.
  Treatment.—Traumatic peritonitis, if the child is robust, will
permit local abstraction  of blood,  but generally, in acute periton-
itis, cold is especially indicated.   As it is difficult to  use ice blad-
ders,  as their pressure is painful, we  must generally be content
with cold applications ; frozen cloths in winter.  Calomel is called 
DISEASES OF THE  DIGESTIVE APPARATUS.        205
for if  the attack is ushered in with constipation, while opium and
morphin are our main reliance against the pain and diarrhea.
If vomiting  supervenes, opiates can be administered by enema or
subcutaneously.  When  the  pain has somewhat  diminished,  but
the meteorismus is still great, the whole abdomen may be coated
thickly with collodion.  Bits of ice for vomiting and stimulants for
collapse.  If it is probable that the pus will discharge externally,
try to assist  by cataplasms, and as soon as an  accurate diagnosis
of the position of the pus can be made, give exit to it by means of
an incision, or, better, by antiseptic laparotomy.
  The  after treatment consists of warm baths  and  nourishing,
easily-digested food, and if an incision has been made, in keeping
the pus cavity well drained and  frequently cleansed with some
non-poisonous antiseptic solution, best,  peroxid of hydrogen.
   Chronic Peritonitis is sometimes met  with in children, the
first symptom that attracts the physician being usually ascites, for
which see following section.


           8. ASCITES,  OR ABDOMINAL DROPSY.
   Definition.—This is the name given to any dropsical transuda-
 tion into the peritoneal  sack.  It is not a disease, but a symptom
 common to several, e.g., disordered  circulation, hydremia, or a
 diseased peritoneum.
   Etiology.—Very frequently due to affections of (ist) the heart,
 especially  of the tricuspid valve ; (2d) of the lungs—atelectasis,
 emphysema; (3) of  the  liver—syphilitic gummata, pylephlebitis ;
 (4th) of the spleen—malaria ; or (5th) of the kidneys—as in Bright's
 disease,  after scarlatina, with edema and  hydrothorax, in  con-
 sequence of hydremia.  Furthermore, the  pressure of the infil-
 trated or waxy lymphatic glands  upon the inferior vena cava or
 portal vein may lead to the same condition, and more rarely ascites
 is found  as a symptom  of tuberculosis of the peritoneum and its
 resulting chronic peritonitis.
   Symptoms of ascites are the same in the child as in the adult.
 Small effusions are better detected sitting or reclining than lying on
 the back.  Death usually results from  exhaustion or complicating
 diarrhea, peritonitis, or pleurisy. 
200
DISEASES OF CHILDREN.
  Prognosis.—Not necessarily hopeless, though, as a rule, dis-
couraging, unless the primary cause of the disease is removable.
Goodhart believes that the prognosis in tubercular peritonitis is far
better for the child than  the adult.
  Treatment.—While the effusion is small, our main reliance is
to be placed in  diuretics, such as  acetate of potash, infusion  of
digitalis, or fluid extract of apocynum cannab.  As soon as ana-
sarca appears, we must apply vapor baths and cathartics, the most
reliable of which is elaterium, with tonics and iron  to preserve the
general health.   So soon as the  action of the diaphragm is inter-
fered with, tapping should be resorted to and repeated as required,
or permanent drainage, as advised by A. Caille, employed.

     9. DISEASES OF THE MESENTERIC  GLANDS.
  Etiology.—The mesenteric glands always become secondarily
implicated in all protracted intestinal troubles, e.g., may become
enlarged'm typhoid, follicular enteritis, but rarely can be recognized
by palpation on  account of the meteorismus generally accompany-
ing these diseases.  Moreover, these glands may  undergo casea-
tion with a  simultaneous deposition of tubercle  (see Scrofulosis
and Tuberculosis), especially when previous morbid conditions—
typhoid, repeated intestinal catarrh—have  enlarged them,  and,
moreover, when they do not diminish in size with the cessation  of
the disease.   Lastly, amyloid degeneration of the mesenteric gland
has also been observed.
  Treatment.—See Tuberculosis.

                     10. KOPROSTASIS.
  Etiology.—Lead poisoning (from licking cards or leaden toys),
or when the rectum is diseased, as from polypus or fissures.  Con-
stipation also occurs as a marked symptom in tubercular menin-
gitis, in atrophic children—or if there is atrophy of the abdominal
and intestinal musculature,—also in peritonitis (early).  Constipa-
tion, found in feverish conditions, is due either to too tenacious or
too scanty intestinal secretions, or from a deficient supply of fluids.
  Symptoms.—A nursling ought to have two or  three passages,
and a child  at least one daily,  or the abdomen becomes distended 
           DISEASES  OF THE DIGESTIVE APPARATUS.        207

and the appetite impaired.  At first there is meteorismus to a great
degree, and if the constipation persists, the abdomen becomes tym-
panitic and sensitive to touch.  Belching, vomiting, loss of appetite,
and, in small children, convulsions are the natural consequences of
habitual constipation.  Nutrition always suffers.  Often from pres-
sure upon the intestinal veins a venous collateral circulation is set
up in the abdominal coats.  When, at last, by the strenuous exer-
tions of the child, a passage is obtained, the stool is a hard mass,
from want of intestinal secretions,  or  appears as clayey, grayish
or light-yellow bits in the diaper.
  Prognosis.—Favorable  except  in  cases of meningeal tuber-
culosis, twisting or intussusception of the intestine.
  Treatment.—(i)  Examine  for  mechanical interferences.
Strangulated hernia can generally be reduced by taxis.  (2) Tran-
sient aid may usually be  obtained  by  the use of lukewarm water,
enemata of soap water, or cold vinegar clysters, or by soap supposi-
tories (one inch long).  To give a clyster  successfully, the child
must lie  on its  right side, so that the  water injected into the sig-
moid flexure may by  its own weight pass  into the right side of the
abdomen.  When the enema proves useless, either  the feces are
situated too high up, when the enema does not return, or if it does,
without the stool, or on the other hand the  feces may be impacted
so low down that the enema immediately flows back.  In this
case the removal of  the  first hardened scybalas by the finger or
spoon handle can hardly be avoided;  in the former, laxatives only
are of use, e.g., -^ gr. calomel hourly, or milk of magnesia.  (3)
Endeavor  by all means to discover and  remove  the  cause  of
habitual constipation, since it usually lies in faulty nutrition, a
change in which generally produces a  successful  result.   Give
amylaceous food as  little as  possible, in its stead giving beef-tea
or meat, or when the children are  older, baked or ripe fruit, and
allow them laxative  food;  permit  the use  of fresh  water, which,
unfortunately, is forbidden in too many families.   Medicinally try
the following :—
                             (64)
      R.   Cascara cordial,........^ ij
           Tinct. bellad.,..........gtt.xv.      M.
  Sig.—C. p. nocte. 
208                DISEASES OF CHILDREN.

                            (65)
      R.  Podophyllin,'  .  .  ........gr. j
          Alcoholis,...........3J.        M.
  Sig.—5 to 10 drops on sugar.


                  11. INTUSSUSCEPTION.
  Synonyms.—Invagination, volvulus; darmknoten.
  Definition.—Spontaneous slipping  down of a portion of in-
testine (intussusceptum)  into the adjacent and lower portion of the
same (intussuscipiens), as a finger of a glove may be pushed down
into itself.
  Occurrence.—Most  frequent in infants  under  one  year,
though, fortunately, rare.  More  frequent in boys  than girls, and
very frequently cadaveric (8-20 in a single abdomen).
  Location.—Almost invariably confined to the small intestine,
at the ileo-cecal valve, though it  may occur elsewhere.
  Etiology.—Unequal innervation of the muscular structure of
the intestine, or disproportionate width and mobility  of  the two
portions of the intestinal tube connected at the ileo-cecal valve.
A strong peristaltic movement of a  tightly contracted portion of
intestine may drive it into another relaxed part, as often occurs
during the death agony, and hence frequently  found in autopsies,
especially in those  cases  where the  intestines have remained
healthy, e. g., brain diseases,  etc.   After protracted diarrhea  it
may be met with in children under a year.
  Symptoms are about the same as in the adult; the onset being
always abrupt, with constipation, abdominal pains, intestinal hem-
orrhage, and vomiting,  which at last may be  fecal in  character.
At last comes collapse.  In consequence of stenosis and  the dis-
turbance of circulation in the mesentery, edema and inflammation
of the peritoneum appear, beginning at the point where one part
of the intestine has slipped down into  the  other.  Generally,
if meteorismus is absent, a cylindrical,  smooth  tumor may be felt;
if, however, it is the lower portion of the colon which has slipped
into  the  rectum, no  tumor can  be felt externally, but it may be
detected by the anus.
  Prognosis.—In rare cases recovery results  from gangrene and 
           DISEASES OF THE DIGESTIVE APPARATUS.        209

sloughing off of the intussusceptum and a complete union of the
rest of the intestine where it enters into the volvulus.   Or the con-
tracted canal of the invaginated portion  becomes gradually dis-
tended—wide enough to allow the passage of thin, fecal masses.
Whereupon, a partial cure may take place, leaving behind chronic
inflammation and stenosis of the intestines, which is a source of
trouble whenever the stools become harder.   On the  other  hand,
death often occurs in  3-4 days from exhaustion, less frequently
from peritonitis, inflammation of the intestine, or gangrene with-
out adhesions.
  Treatment.—Absolute rest, opium  pushed to  narcosis, ice
applications to the abdomen, large enemata of  water to free, if
possible, the volvulus.  Laparotomy, or the making of an artifi-
cial anus,  has  often led to good results,  as a  last resource.   If
recovery takes  place, food must be administered for some time by
enemata.   Inflation by means of seltzer and rectal tube or seidlitz
powders has given good results.


                     12.  APPENDICITIS.
  Synonym.—Typhlitis cum  perityphlitis.
  Definition.—An  inflammation of the  cecum and vermiform
appendage, due to a stoppage of feces there, or  from other causes.
  Varieties.—(a) With  or  without  ulceration  of  the mucous
membrane,  (b) Complicated with localized peritonitis.
  Etiology.—Foreign bodies, such as  cherry-pits, grape-stones,
etc., may enter the vermiform appendage and remain there, or
hardened feces may there accumulate  and form local scybalas.
Any of these may cause ulceration of the  mucous membrane and
sometimes perforation of the vermiform appendage. In other cases
an arrest of feces takes place in the cecum without participation of
the vermiform  appendage, or the ulceration of the  same, termi-
nating in perforation, which latter occurs frequently after traumatic
injuries, as a fall, blow, etc.  It is more frequent in larger children,
and in boys rather than  girls, and relapses are frequent in the
same person.
  Symptoms usually begin with sudden acute pain, located in
the right  iliac  region.  This  pain is increased upon pressure, 
210
DISEASES OF CHILDREN.
change of position, or moving the right foot.   Obstruction of the
bowels, as a rule, occurs  from the very beginning; later  there is
frequently vomiting, which is  a sign of commencing ulceration, or
of perforation having taken place.  At  first a  distinct tumor, dull
on percussion, may be mapped out in the right hypogastric region,
but after perforation it disappears and tenderness extends  over the
abdomen.  The whole abdomen becomes dreadfully painful, vom-
iting  and great meteorismus  supervene, and  in  consequence of
general peritonitis death usually takes place on the third to fifth day.
If, however, the intestines early form adhesions  with the abdominal
parietes, the contents  of the tumor (feces, worms, foreign bodies,
etc.) may  be discharged externally.
  Prognosis generally unfavorable, though a cure is possible if
treatment is prompt.
  Treatment.—If the case  is recent, the tenderness moderate,
and a distinct tumor can be felt, a prompt purgative may be given.
If, on the  other hand, the tenderness is  already great, purgatives
are contraindicated.  The peritonitis must be  combated  by abso-
lute rest, liquid food (lemonade, etc.), ice bags, and opium in large
doses, but if perforation of the appendage and general peritonitis
occur,  nothing generally is of any avail.  Should,  however, re-
covery take  place, the diet  must  be confined  to liquid food and
careful  diet adhered to for a long time, and the bowels kept open
lest a relapse occur.


          13.  CONGENITAL INGUINAL HERNIA.
  Definition.—Although called congenital it is seldom present at
birth, .but  produced soon after by coughing, straining, or crying,
and is often associated with phimosis.
  Etiology.—Due to a patulous canalis vaginalis  testiculi,  or
more  rarely of the canalis ligamenti  rotundi,  which allows of a
forcing  downward of  an intestinal loop from the action of the
abdominal muscles.
  Symptoms.—With boys a toughish, round, soft tumor is seen
extending from the internal abdominal ring into the scrotum.  This
tumor can be easily returned  to the abdomen  by pressure, being
reduced with a gurgling sound.   The limits of the testicle are hard 
           DISEASES OF THE  DIGESTIVE APPARATUS.        211

to define, but it generally lies behind and above the tumor, which
consists, usually, of intestine alone, though very rarely it also con-
tains  peritoneum.   With girls one labia majora is  swollen, and
here also the hernia can be easily reduced if retained during the
interval with a proper truss.
  Course.—As a rule, as the child grows older, the  hernia cures
itself  spontaneously, if retained  during the interval with a proper
truss, though inflammation  may bring about such adhesions be-
tween the peritoneum, intestine, and canal as to render the hernia
irreducible.  Strangulation is rarer than with the adult. (Guersant.)
  Treatment.—(i) Prevent  intertrigo, which is very  prone to
occur if the hernia be large, by washing  the parts with extreme
care after urination, and dusting with starch  powder  and talc.
(2) The child must not be allowed  to become constipated.  (3) In
small children the hernia must be kept reduced during sleep, and
after they are a year old they should wear a truss, several of which
should be kept on  hand on account of their becoming wet.  Wash
daily with alcohol those parts which come in contact with the truss,
to prevent their  becoming chafed.  (4) The best of nourishment
always, in the hope that with  the increase  of adipose tissue the
inguinal ring may  close.


                   14. PROLAPSUS  RECTI.
  Synonyms.—Prolapse of rectum ;  mastdarmfall.
  Etiology.—Protracted diarrhea with atrophy ; dysentery, espe-
cially when it follows obstinate constipation, and, indeed, the latter
alone may lead  to  prolapsus recti.  Furthermore, long-continued
tenesmus, due to stone in the bladder or persistent coughing (per-
tussis, etc.),  always lead to relaxation  of the rectum.
  Symptoms.—In the place of the normal anus we find a bluish-
red tumor, into whose central aperture the finger can be introduced
for a longer or shorter distance before meeting with the sphincter.
  Prolapse of the  rectum may be partial, i. e.,  affect only the
mucous membrane of the anal border, or involve a larger section.
In the latter case it simulates  an intussusception or invagination
of the middle portion of the rectum into the lower portion, or  into
the anus itself. 
212
DISEASES OF CHILDREN.
  Prophylaxis.—If prolapse has once occurred, guard against
its  return by  prevention  of diarrhea, constipation, or tenesmus
(opium enemata).  The chamber should  be placed so high that
the child's feet cannot reach the floor, for straining by abdominal
muscles is thus kept within safe limits.
  Ice water clysters are often valuable, and if all else fail we may
use rectaltampons saturated  with some such astringent as rhatany,
tannin,  alum,  or vinegar.   Jacobi advises an ointment of ext.
nucis vomica (gr. x to 3J).
  Prognosis.—Good.
  Treatment.—In  atrophic  children, above  all other things,
care should be had  for good nourishment, for  this alone assures
the success of any local treatment.  A reposition of the prolapsed
mucous membrane  of the anal border should  be made  immedi-
ately after each passage.  This should be performed on the child
in the knee-elbow position, gently pushing back the prolapsed por-
tion through  the central opening by means of a bit of greased
cloth until  the  finger has passed through the sphincter, where-
upon the finger  must be withdrawn by carefully rotating it as it
is withdrawn.  If there is  intussusception  of the  middle portion
of the rectum, we must try to set it free by the careful  use of a
cotton tampon, or the colpeurynter, but cauterization is only per-
missible when the rectal wall is extremely relaxed.


                    15.  RECTAL POLYPI.
  Definition.—Pedunculated,  hypertrophic  growths  of  rectal
mucous membrane.
  Occurrence.—After third year, and not so rarely as generally
believed, as they are often mistaken for partial prolapse of rectum.
  Symptoms are like those of prolapse of the rectum, viz. : pain
and hemorrhage with each passage, and sometimes persisting for
a while after, if the  feces have  been  hard.  Deep-seated  polypi
make their appearance at the  anus  with each passage, at  first,
quickly  slipping back  to  their places.  Later, when they have
grown larger, they remain longer at  the anal  opening and their
reposition causes pain.
  Prognosis.—Good.  Spontaneous cures, by the rupture of the 
           DISEASES OF THE DIGESTIVE APPARATUS.        213

pedicle by a hard  stool, seem  to  be frequent.  The return of a
polypus is not known, but the  simultaneous presence of several
sometimes occurs.
  Treatment.—Application of a double silk thread about the
pedicle immediately after a free passage is produced by means  of
a laxative.


             16. RHAGADES  ET FISSURE ANI.
  Definition.—Fissuras ani are small  fissures of the mucous
membrane of the anus in the vicinity of the sphincter ani externus.
  Etiology.—Hard stools, or anal syphilis.
  Symptoms.—Acute pain with every passage from the bowels,
sometimes sufficient  to  cause  convulsions  before  the  passage.
The stool is generally hard and is either coated with a little blood,
or a little hemorrhage follows it, or both may occur at the same
time.  By pulling apart the folds of the mucous membrane about
the anus, a wound, or  a  deeply hidden  ulcer with  more or less
redness, can be discovered.
  Treatment.—(i) Removal  of  the  constipation  by  means  of
clysters,  etc.  (2) Cauterization of the denuded spot  of mucous
membrane with  nitric acid or  nitrate of silver.  (3) In obstinate
cases only, the forcible  dilatation of the anus while under the in-
fluence of chloroform is to be recommended, with powdered iodo-
form as a local application to the ulcer.


       17. CONGENITAL  MALFORMATIONS IN THE
                   INTESTINAL TRACT.
  1. Stenosis  et  atresia, or  narrowing  or closure  of the
intestine,  is not very infrequent in  children,  and may  occur  at
various points, e. g.
  2. Entero-stenosis—seu Atresia interna—is either congenital
or acquired.  Most frequently seen as a congenital deformity.
  3. Stenosis ani.—See Imperforatio ani.
  Etiology.—These congenital cases of narrowing or closure  of
the  intestines can only be referred to interuterine cicatrices  result-
ing  from interuterine ulcers, or  from the formation  of peritoneal 
214
DISEASES OF CHILDREN.
bands or tumors of the intestine in utero.  The  stenosis is most
frequently located  in the duodenum at the  point of junction be-
tween the ilium and colon, or at the sigmoid flexure or rectum, a
few centimeters above the anus.
  Symptoms consist in a failure to pass the meconium, because
when the stenosis  or atresia is situated high up, none is formed,
and  when  low down the meconium cannot pass off.  Soon the
abdomen distends  and fluids taken are rejected;  if the stenosis or
atresia is located high up, the ingesta.are  rejected as they were
swallowed, but if the  trouble is  low down,  they are  thrown  up
mixed with meconium.  Death, sometimes with convulsions, early
takes place from atresia, but if it is a case  of stenosis, it may be
deferred up to the tenth to eleventh day.
  The acquired forms may arise from these  same causes or from
closure of the intestinal tube by means of indigestible food, seeds,
accumulation  of ascarides, etc.  Stenosis ani frequently escapes
detection until the  soft, pap-like stools of the newborn are replaced
by harder,  when the symptoms of narrowing of the intestinal tube
make their appearance, though  they can  usually be  obviated
by means of enemata and laxatives.   More rarely, however, the
stenosis is so great that there is no passage at all  of meconium, or
only after a very great effort.
  Treatment.—The rectum must be dilated, preferably by means
of a couple of sounds, as in fissure  of  the anus, or by nicking the
same with a bistoury and a grooved director.
  Imperforation.—Under the name of atresia  seu imperforatio
ani, seu recti, we understand various conditions, all of which have
the same termination, viz.: occlusion of the  rectum.
  Etiology.—(a)  Rectum ending as a blind pouch with the anus
in same condition,  their  floors forming the  membrane which  oc-
cludes the rectum.
  (b) The rectum may terminate at any point below the sigmoid
flexure and above the  internal sphincter  without  a blind anal
pouch, the  rectum  being attached directly to the  floor of the peri-
neum, which gives a roundish swelling when the blind end of the
rectum dilates with meconium.
  {c) A blind pouch may be  (normally)  formed, but fail entirely
to coincide with that of the  intestines, of which the entire lower 
DISEASES OF  THE DIGESTIVE APPARATUS.         215
colon may be  wanting.  There may be a narrow canal, large
enough,  perhaps,  to admit  a  goose-quill,  extending  upward
from  the anus 1-3 inches, the intestinal canal terminating in a
similar blind  pouch a short distance  above, leaving an interme-
diate, tolerably firm fibro-cellular  diaphragm.   The  anus and
lower rectum may be altogether absent and the gut end in a small
fistulous  orifice upon the inner  side  of bladder, urethra, vagina,
anywhere in  the perineum, or in the side or upon the anterior or
lateral walls  of the abdomen, or lead into the ductus omphalo-
entericus.  (Anus preternaturalis, ectopia ani.)
  Prognosis.—Only favorable in the first variety, bad as a rule
in the others, even after a successful operation for artificial anus.
  Treatment.—If the rectum is clearly not the seat of the sten-
osis or atresia—diagnosed by passing elastic  catheter to  sigmoid
flexure—then help can only be obtained by making an artificial
anus. 
 
INDEX.
Abscess of tonsil, 185
    retropharyngeal, 187
    retroesophageal, 187
Acephalia, 115
Acid dyspepsia, 189
Acute catarrhal laryngitis, 144
Adenitis, scrofulous, 66
Albuminoids, 189
    digestion of, 189
Albuminuria, 84
    diphtheritic, 100
Amygdalitis simplex, 185
Amyloid liver, 68
Anemia cerebri, 120
Anchyloglottis, 177
Anuria, 47
Apeptic dyspepsia, 189
Aphthous stomatitis, 182
Apnea neonatorum, 18
Apoplexia neonatorum, 35
Apoplexy of the lungs, 37
Appendicitis, 209
Aneria umbilicales, 10
Arthrogryposes, 137
Ascites, 83
Asphyxia neonatorum, 18
Atelectasis pulmonum, 20
Atelectasis pulmonum acquisita, 160
Atresia ani, 213
    pupillae, 142
Atrophia cerebri, 119
    linguae, 177
    infantum, 49
    lactantium, 196
    musculorum lipomatosa, 139
Atrophy, facial, 137
    simple, 50
Auriculae adpressse, 141
    vespertilionis, 141
Bacterium lactis aerogenes,  11
Bacteria, intestinal, 11
Bathing, 4,
Bilious diarrhea, 192
Bladder, lateral ligaments 10
Blind pouch of rectum, 214
Bow-legs, 61
Bronchitis, acute, 154
Bulimia, 196

        O
   Cadaveric invagination, 208
   Caput succedaneum, 33
   Carbon dioxid, excretion, 11
   Cardialgia, 128
   Cataract, congenital, 143
   Catarrh, nasal, 143
   Catarrhal diarrhea, 196
   Catarrhus, gastro-intcst., 190
   Cerebro spinal meningitis, 109
   Chicken pox, 80
   Cholera infantum, 190
   Chorea, minor, 133
       major, 135
   Chronic  diarrhea, 196
   Colitis, epidemic, 113
   Coloboma iridis, 142
   Colostrom, 51
   Condensed milk, 52
   Constipation,  48
   Convulsions, 128
   Coryza diphtheritica, 97
   Coxarthrocace, 68
   Cranial fractures, 32
   Craniotabes, 60
   Cyanosis, 21
   Cyclopia, 142

   Deafness, congenital, 141
   Defectus auriculae, 141
       linguae, 177
   Dentition, 13
   Desiccation of cord, 40
   Diarrhea, catarrhal, 193
       divisions of, 193
       serous,  193
    Digestion, 189
   Diphtheritis, 97
   Diphtheria, latent, 97
   Dislocations congenital, 32
    Dropsy, abdominal, 205
   Ductus Arantii, 10
       arteriosus, 10
       Botalli, 10
       venosus, 9, 10
    Dysentery, epidemic,  113
    Dyspepsia, infantile, 188
       varieties, 189

    Ear malformations, 141
  I  Eclampsia, 128

217 
21S
INDEX.
Eclampsia, temperature, 12
Eczema, scrofulous, 65
Edema glottidis, 150
    neonatorum, 28
Embolism, cerebral, 124
Emphysema pulmonum, 166
Encephalocele, 115
Encephalitis, 124
Enteritis choleriform, 190
    follicularis, 196
Entero-colitis, 190
Entero-stenosis, 213
Epicanthus, 142
Epilepsy, 130
Erysipelas, 24
Esophagus, malformation of, if 8
    diverticular pouches, 188
    stenosis, 188
Eustachian valve, 9
Exomphalus, 39
Eye, malformations of,  142
Eyelids, malformations of, 142
Facial paralysis, 140
Fames canina, 196
Fat dyspepsia,  190
Fats, digestion of, 189
Fatty degeneration, 200
    liver, 200
Feces, of milk diet, n
Fetal circulation, 9
Fissurae ani, 213
Fissura linguae, 177
Fissured lip, 177
Fistula colli congenita, 188
F'latulence, 47
Fontanelles, closure of, 14
Foods, digestion of, 189
    division of, 189
Foramen ovale, 9, 10
Foreign bodies in larynx, 149
Fractures at birth, 32


Gall-bladder, malformation of, 199
Gastro-duodenal  catarrh, 192
Gangrena oris,  184
    umbilici, 42
German  St. Vitus* dance, 135
Growth of the child, 14
    head, 15
Harelip, 175
Harrison's groove, 60
Hematocele, 38
Hemicephalia, 115
Hemorrhage, cerebral, 124
Hemorrhagia infantum, 31
Hepar adiposum, 200
Hepatic incompetence, 192, 199
Hernia, congenital, 39, 210
Herpes conjunctivitae, 66
Hexenmilch, 13, 30
Hordeolum, 66
Hyperemia cerebri, 121
Hypertrophia cerebri, 118
    tonsiliaruni, 186
    labium, 176
Hydrocephalus,  116
Hydrorrachis, 126
Hydrothorax, 173
  Icterus neonatorum, 22
  Idiocy, 119
  Ileocolitis, 198
  Indigestion, acute, 54
  Influenza,90
  Insolatio, 120
  Interuterine traumatism, 32
  Intermittent fever, 111
  Intestinal catarrh, 193
      dyspepsia, 189
j  Intussusception, 208
  Irideremia,  142
Jacobi's mixture, 33
Keating's blanc mange, 53
Keratitis, scrofulous, 66
Kephalhematoma, 34
Koprostasis, 206
Knock-knees, 61
Kyphosis, 61
 Lachrymal glands, 14
 La grippe, 90
 Lardaceous  liver, 201
     spleen, 203
 Laryngitis catarrhalis chronica, 146
     diphtheritica, 99
 Laryngismus stridulus, 147
 Ligamentum teres, 7, 10
 Lips, hypertrophy, 176
 Liver,amyloid, 201
     cirrhosis, 202
     malformations of, 199
 Lymphomata, 203


 Macrostoma, 176
 Malarial fever, 111
 Mastitis,  30
 Measles,  87
      German, 8g
 Meconium, 11
 Melena neonatorum, 31
 Meningitis, 121
      tubercular, 122
 Mesenteric glands,  167
 Microcephalia, 115
 Microstoma, 176
 Milk digestion, 11
  Morbilli, 87
  Morbus Werlhofii,  71
      Winckelii, 21
I  Mucous disease, 56 
219
Mucous dyspepsia, 189
Meigs' mixture, 53
Mumps, 105


Nasal catarrh, 143
Navel malformations, 41
    gangrene, 42
    care of, 40
    inflammation, 41
Neomata of spleen, 203
Nervous system, 16
Neuralgia, 127
New growth in the larynx, 150
Neuropathic facial atrophy, 137
Night cough, 161
Noma, 84
Nutmeg liver, 202


Omphalitis, 41
    diphtheritic, 41
Ophthalmia neonatorum, 28
Osteu-porosis, 68
Otitis, scrofulous, 66
Ozena, scrofulous, 66


Pachymeningitis, 124
Pancreatic digestion, 11
Paralysis, diptheritic,  101
    essential, 138
    motor, 138
    myoscleroica, 139
    nervi facialis, 38
    of sterno-cleido mastoid, 38
Parotitis epidemica, 105
Paralysis, glottidis, 151
Peptones, 189
Peptonized milk, 54
Peiiostitis, scrofulous, 67
Peritonitis, 203
    chronic, 205
    fetal,  203
Perityphlitis, 204
Pertussis, 92
Pharyngitis cum tonsillitis, 185
Phlebitis umbilicalis, 43
Phthisis glandularum, 67
Pigeon breast, 60
Pleuritis, 167
Pleurodynia, 128
Pneumonia catarrhalis, 158
    chronica, 169
    crouposa, 162
Poliomyelitis, anterior, 138
Prolapsus recti, 95, 211
Prolapse of tongue, 178
Purpura, 71
Pulse in infancy, 10
Pulmonary blood pressure, 10
    excretion, 11
Putrid dyspepsia, 189
Rachitis, 59
Raspberry tongue, 82
Ranula, 178
Rectal polypi, 212
Respiration, 10, 11
Retroesophageal abscess,
Rhagades ani, 213
Rheumatism, 72
Rotheln, 89
Rubeola, 89
Sago spleen, 203
Saliva, 13
Salt rheum, 66
Scarlatina, 81
    nephritis, 84
Sclerema neonatorum, 27
Sclerosis, cerebral, 118
Scorbutus, 75
Scrofulosis, 65
Scurvy,75
Scoliosis, 61
Septic infection, 23
Serous diarrhea, 193
Serratus paralysis, 140
Skeer's line,  123
Skin of new born, 13
Sleep, 46
Small intestine, n
Smallpox, 77
Smell, 141
Sore mouth, aphthous, 182
    ulcerative, 182       »
Spastic hemiplegia, 36
Spasmus nutans, 132
    glottidis, 147
Spleen, amyloid, 203
    infarcts, 203
    neomata, 203
Splenic lymphomata, 203
Spina bifida, 126
Stenosis ani, 213
    of esophagus, 188
    tracheae, 152
Stomatitis aphthous,  182
    ulcerosa, 182
    catarrhalis, 179
Stomatomycosis, 179
Stomach, infantile, 11
St. Vitus' dance, 133
Substitutes for breast-milk, 53
Sudoriferous glands, 13
Sweat glands, 13
Sugars, digestion of,  189
Summer complaint, 196
Sunstroke, 120
Temperature variations, 12
Tetanus, 25
    traumatica, 128
Thyroid, diseases of, 153
Thrombosis, umbilical, 10
    cerebral, 124
Thrush, 179
Thymus gland, 14
Tongue hypertrophy,  178 
220
INDEX.
Tongue-tie, 177
Tonsils, hypertrophy, 186
Tonsillitis  parenchymatosa  suppurativa.
    185
Traumatic accidents of birth, 32
True defectus linguae,  177
Tuberculosis, 106
    of liver, 202
Tumor, cerebral, 125
    spinal, 127
Tumors of lip, 176
Typhoid fever, 108
Typhlitis, 209
Tyrotoxicon, 191
Ulcerative sore mouth, 182
Umbilical arteries, 10
    hernia, 43
    polypus, 41
    veins, 10
Urine, amount of, 12
    of infancy, 11
Uric acid infarct, 11
Vaccination, 78
Varicella, 80
Variola vera, 77
Ventilation, 46
Vernix caseosa, 13
Vomiting, infantile, li
Wandt ring spleen, 203
Waxy liver, 201
Weight of child, 15
White swelling,68
Whooping cough, 92
Worm abscess, 204
Wounds during birth, 39 
Catalogue No. 8.
March, 1896.
      CLASSIFIED  SUBJECT
            CATALOGUE
                    OF

MEDICAL BOOKS
                    AND
   Books on Medicine, Dentistry, Pharmacy,
        Chemistry, Hygiene, Etc., Etc.,
                PUBLISHED BY

 P.  Blakiston, Son & Co.,
         Medical Publishers and Booksellers,
   1012 WALNUT STREET, PHILADELPHIA.
  SPECIAL NOTE.—The prices given in this catalogue are
absolutely net, no discount will be allowed retail purchasers
under any consideration.  This rule has been established in
order that everyone will be treated alike, a general reduction
in former prices having been male lo meet previous retail dis-
counts.   Upon receipt of the advertised price any book will
be forwarded by mail or express, all charges prepaid.
  We keep a large stock of Miscellaneous Books, not on this
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application.
    «5=-SEE NEXT PAGE FOR SUBJECT INDEX. 
SUBJECT   INDEX.
  «S- Any books not on this Catalogue we will furnish a price
for upon application.
SUBJECT.                 PAGE
Anatomy..............................  3
Anesthetics........................  3
Autopsies (see Pathology)..... 16
Bandaging (see Surgery)........ 19
Biology (see Miscellaneous) ... 14
Brain ..................................  4
Chemistry............................  4
Children, Diseases of............  6
Clinical Charts......................  6
Consumption (see Lungs)....... 12
Deformities..........................  7
Dentistry.............................  7
Diagnosis............................. 17
Diagrams (see Anatomy, page
  3, and Obstetrics, page 16).
Dictionaries.........................  8
Diet and Food  (see Miscella-
  neous) .............................. 14
Dissectors............................  3
Domestic Medicine............... 10
Ear.....................................  8
Electricity ...........................  9
Emergencies (see Surgery)..... 19
Eye....................................  9
Fevers................................  9
Gout .................................. 10
Gynecology ......................... 21
Headaches.......................... 10
Heart.................................. 10
Histology............................ 10
Hospitals (see Hygiene)........ 11
Hygiene............................... 11
Insanity ..............................  4
Journals .............................. 11
Kidneys .............................. 12
Lungs.................................. 12
Massage..............................  12
Materia Medica................... 12
Medical Jurisprudence.......... 13
Microscopy  ........................ 13
Milk Analysis (see Chemistry)   4
Miscellaneous ...................... 14
Nervous Diseases ................ 14
SUBJECT.                 PAGB
Nose.................................... 20
Nursing............................... 15
Obstetrics.....................a..... 16
Ophthalmology.....................  9
Osteology (see Anatomy).......  3
Pathology............................ 16
Pharmacy............................ 16
Physical Diagnosis............... 17
Physical Training (see Miscel-
  laneous) ........................... 14
Physiology .......................... 18
Poisons (see Toxicology)....... 13
Popular Medicine.................. 10
Practice of Medicine............. 18
Prescription  Books................ 18
Railroad Injuries (see Nervous
  Diseases)........................... 14
Refraction (see Eye).............  9
Rheumatism ........................ 10
Sanitary Science................... 11
Skin.................................... 19
Spectacles (see Eye) ............  g
Spine (see Nervous Diseases) 14
Students' Compends..........22, 23
Surgery  and  Surgical  Dis-
  eases................................. 19
Syphilis............................... 21
Technological  Books............   4
Temperature Charts..............  6
Therapeutics........................ 12
Throat ................................ 20
Toxicology.......................... 13
U. S.  Pharmacopoeia............. 16
Urinary Organs...................  20
Urine................................... 20
Venereal Diseases................. 21
Veterinary Medicine.............. 21
Visiting Lists, Physicians'.
  (Sendfor Special Circular.)
Water Analysis (see  Chemis-
  try)................................... 11
Women, Diseases of.............. 21
        'The prices as given in this Catalogue are net.   Cloth
 binding,  tinless otherwise specified.    No discount can  be
 allowed under any circumstances.   Any book will be sent
postpaid, upon receipt of advertised price. 
SUBJECT CATALOGUE  OF MEDICAL BOOKS.      3
  4®~ All books are bound in cloth, unless otherwise speci-
fied,.  All prices are net.

                       ANATOMY.

MORRIS.   Text-Book of Anatomy.   791 Illus., 214 of which are
  printed in colors.     Clo., $6.00; Lea., $7.00; Half Russia, $8.00.
  " Taken  as a  whole, we  have no hesitation in according very  high
praise to this work.  It will rank, we believe, with the leading Anato-
mies.  The illustrations are handsome and the printing is good."—
Boston Medical and Surgical Journal.
  Handsome Circular of Morris, with sample pages and colored  illus-
trations, will be sent free to any address.
CAMPBELL.   Outlines for  Dissection.  Prepared for Use with
  " Morris's Anatomy" by the Demonstrator of Anatomy at the  Uni-
  versity of Michigan.  Just Ready.                          $1.00
HEATH.  Practical Anatomy.   A Manual  of  Dissections.   8th
  Edition.   300  Illustrations.                                  $4.25
HOLDEN.   Anatomy.  A Manual of the Dissections of the Human
  Body. 6th  Edition.   Carefully Revised by A. Hewson, m.d.,  De-
  monstrator  of Anatomy, Jefferson Medical College,  Philadelphia.
  311 Illustrations.     Cloth, $2.50; Oil-Cloth, $2.50; Leather, $3.00
HOLDEN.  Human Osteology. Comprising a Description of the
  Bones, with Colored Delineations of the Attachments of the Muscles.
  The General and Microscopical Structure of Bone and its Develop-
  ment.  With Lithographic Plates and numerous Illus.  7th Ed.  $5.25
HOLDEN.  Landmarks.   Medical and Surgical.  4th Ed.   $1.00
MACALISTER. Human Anatomy.  Systematic and Topograph-
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  With Special Reference to the Requirements of Practical Surgery and
  Medicine.   816 Illustrations, 400 of which are original.
                                       Cloth, $5.00; Leather, $6.00
MARSHALL.   Physiological Diagrams.   Life Size,  Colored.
  Eleven  Life-Size Diagrams (each seven  feet by three feet seven
  inches).  Designed for Demonstration before the Class.
     In Sheets, Unmounted, $40.00;  Backed with Muslin and Mounted
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  lar upon application.
POTTER.   Compend of Anatomy,  Including Visceral Anatomy.
  5th Edition.  16 Lithographed Plates  and 117 other Illustrations.
                                             .80; Interleaved, $1.23
WILSON.   Human Anatomy,   nth  Edition.  429 Illustrations, 26
  Colored Plates, and a Glossary of Terms.                     $5.°°
OBERSTEINER.  Anatomy of the Central Nervous  Organs.
  198 Illustrations.                                          $5-5°
                  ANESTHETICS.
BUXTON.  On Anesthetics.  2d Edition.  Illustrated.      $1.25
TURNBULL.  Artificial   Anesthesia.  The  Advantages  and
  Accidents of; Its Employment in the Treatment of Disease ; Modes
  of Administration;  Considering  their Relative  Risks;  Tests  of
  Purity; Treatment of Asphyxia; Spasms of the Glottis; Syncope,
  etc.  3d Edition, Revised.  40 Illustrations.                  $3.00

                                t. 
1
SUBJECT CATALOGUE.
           BRAIN  AND  INSANITY.

BLACKBURN.  A Manual of Autopsies.  Designed for the Use
  of Hospitals for the Insane and other Public  Institutions.   Ten full-
  page Plates and other Illustrations.                          $'.25
GOWERS.   Diagnosis of Diseases of the  Brain.  2d Edition.
  Illustrated.                                               $1-5°
HORSLEY.  The Brain and Spinal  Cord.  The Structure and
  Functions of.  Numerous Illustrations.                       $2.50
HYSLOP.  Mental  Physiology.  Especially in Relation to Men-
  tal Disorders.   With Illustrations.  Just Ready.             $4.25
LEWIS  (BEVAN).   Mental Diseases.   A  Text-Book Having
  Special Reference to the Pathological Aspects of Insanity.   18 Litho-
  graphic Plates  and other Illustrations.
MANN.   Manual  of  Psychological  Medicine  and Allied
  Nervous Diseases.  Their  Diagnosis, Pathology, Prognosis, and
  Treatment, including their Medico-Legal  Aspects ;  with chapter on
  Expert  Testimony,  and an Abstract of the Laws  Relating  to  the
  Insane in all the States of the Union. Illustrations of Typical Faces
  of the  Insane,  Handwriting of the Insane, and  Micro-photographic
  Sections oi the Brain and Spinal Cord.                       $3.00
REGIS.  Mental Medicine.   Authorized  Translation by H.  M.
  Bannister, m.d.                                          $2.00
STEARNS.  Mental Diseases.  Designed especially for Medical
  Students and General Practitioners.  With a Digest  of Laws of the
  various States Relating to Care of Insane.  Illustrated.
                                        Cloth, $2.75; Sheep, $3.25
TUKE.   Dictionary  of  Psychological  Medicine.  Giving the
  Definition, Etymology, and Symptoms of the Terms  used in Medical
  Psychology, with the Symptoms, Pathology, and Treatment of the
  Recognized  Forms of Mental  Disorders, together with the Law of
  Lunacy in Great Britain and  Ireland.  Two volumes.        $10.00
WOOD,  H. C.   Brain and Overwork.                      .40
  CHEMISTRY AND  TECHNOLOGY.

Special Catalogue of Chemical Books sent  free  upon application.
ALLEN.  Commercial  Organic  Analysis.  A  Treatise on  the
  Modes of Assaying the Various Organic Chemicals and  Products
  Employed in the  Arts, Manufactures, Medicine, etc., with concise
  methods for the Detection of Impurities, Adulterations, etc.  2d Ed.
  Vol.  I, Vol.  II, Vol. Ill, Part I.   These volumes  cannot be had.
  Vol.  Ill, Part II.  The Amins.  Pyridin  and its  Hydrozins and
    Derivatives.  The Antipyretics, etc.  Vegetable  Alkaloids, Tea,
    Coffee, Cocoa, etc.                                       $4 c0
  Vol.  Ill,  Part III.                                     In Press.
ALLEN.  Chemical  Analysis  of  Albuminous  and  Diabetic
  Urine.   Illustrated.  Just Ready.                           $2.23
BARTLEY.  Medical  and  Pharmaceutical  Chemistry.   A
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  Illustrations, Glossary, and Complete Index.   4th Edition, carefully
  Revised.  Just Ready.                  Cloth, $2.75 ; Sheep, $3.25
BLOXAM.  Chemistry, Inorganic and Organic.  With Experi-
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MEDICAL  BOOKS.
5
CALDWELL.  Elements of  Qualitative  and  Quantitative
  Chemical Analysis.  3d Edition, Revised.                 $I-5°
CAMERON.   Oils and  Varnishes.  With Illustrations, Formula?,
  Tables, etc.                                               $225
CAMERON.   Soap and Candles.  54 Illustrations.         $2.00
CLOWES AND  COLEMAN.  Elementary Qualitative An-
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  Illustrated.                                                $i-°o
GARDNER.   The  Brewer,  Distiller,  and Wine  Manufac-
  turer.   A  Hand-Book  for all  Interested  in  the Manufacture and
  Trade of Alcohol and Its Compounds.  Illustrated.           $1.50
GARDNER.   Bleaching, Dyeing, and Calico  Printing.  With
  Formula.  Illustrated.                                    $1-5°
GROVES AND THORP.  Chemical  Technology.  The Appli-
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  with numerous Illustrations.
  Vol. I. Fuel and Its Applications.   607 Illustrations and 4 Plates.
                                 Cloth, $5.00; Half Morocco, $6.50
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HOLLAND.  The  Urine, the  Gastric Contents, the Common
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  cal, fur Laboratory Use.  5th Ed.   Illustrated and interleaved, $1.00
LEFFMANN.  Compend  of  Medical  Chemistry,  Inorganic
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                                           .80;  Interleaved, $1.25
LEFFMANN.  Progressive Exercises  in  Practical Chemis-
  try.  Illustrated.  2d Edition.                              $1.00
LEFFMANN.  Analysis of Milk and Milk  Products.  Arranged
  to Suit the Needs of Analytical Chemists, Dairymen, and Milk Inspec-
  tors.                                                     $'-25
LEFFMANN.  Water Analysis.  Illustrated.  3d Edition.  $1.25
MUTER.  Practical  and Analytical Chemistry.  4th  Edition.
  Revised to meei the requirements ot American Medical Colleges by
  Claude C.  Hamilton, m.d.   51 Illustrations.              $125
OVERMAN.  Practical Mineralogy, Assaying, and Mining.
  With a Description of the Useful  Minerals, etc.  nth Edition.   $t.oo

RAMSAY.  A System of Inorganic Chemistry.  Illus.     $4.00
RICHTER.  Inorganic Chemistry.  4th  American, from 6th Ger-
  man Edition.  Authoiized  translation by Edgar F.  Smith, m.a.,
  ph.d.  89 Illustrations and a Colored Plaie.                  $i-7S
RICHTER.  Organic Chemistry.  3d American Edition.   Trans.
  from the last German by Edgar F. Smith.  Illustrated.  In Press.
SMITH.  Electro-Chemical Analysis.  2d  Edition, Revised.  28
  Illustrations.                                             $1.25
SMITH AND KELLER.  Experiments.  Arranged for Students
  in General Chemistry.  3d Edition.  Illustrated.  Just Ready.   .60
STAMMER.  Chemical Problems.  With  Explanations and An-
  swers.                                                     '5°
SUTTON.  Volumetric Analysis.  A Systematic Handbook for
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  Applied to Liquids, Solids, and Gases.  7th Edition, Revised. With
  Illustrations.                                         In Press. 
6                 SUBJECT CATALOGUE.
SYMONDS.   Manual of Chemistry,  for  Medical  Students.
  2d Edition.                                              $2.00
TRIMBLE.   Practical and Analytical  Chemistry.  Being a
  Complete Course in Chemical Analysis.  4th Ed.  Illus.       $'-5o
WATTS.  Organic Chemistry.  2d Edition. By Wm. A. Tilden,
  d.sc.p.r.s.   (Being the 13th Edition of Fowne's Organic Chemistry.)
  Illustrated.                                              $2.00
WATTS.  Inorganic Chemistry.  Physical and Inorganic.  (Being
  the 14th  Edition of Fowne's Physical and Inorganic Chemistry.)
  With Colored Plate of Spectra and other Illustrations.        $2.00
WOODY. Essentials of  Chemistry  and  Urinalysis.   4th
  Edition.  Illustrated.                                 In Press.

  *** Special Catalogue of Books on Chemistry free upon application.


                     CHILDREN.

BROTHERS. Infantile  Mortality During Childbirth and  Its
  Prevention.                                            $1.50
GOODHART  AND  STARR.  Diseases  of Children.  Edited,
  with Notes and Additions, by Louis Starr, m.d.     Out 0/ Print.
HALE.  On  the Management of Children in Health and Dis-
  ease.                                                     .50
HATFIELD.  Compend of Diseases  of Children.   With a
  Colored Plate.  2d Edition.  Just Ready.    .80;  Interleaved, $1.25
MEIGS.  Infant Feeding and Milk Analysis.   The Examination
  of Human and Cow's Milk, Cream,  Condensed Milk, etc.,  and
  Directions as to the Diet of Young Infants.                    .50
MONEY.  Treatment  of Diseases in Children.  Including the
  Outlines of Diagnosis and the Chief Pathological Differences Between
  Children and Adults.  2d Edition.                          $2.50
MUSKETT.   Prescribing and Treatment in  the Diseases of
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POWER.  Surgical Diseases of Children and their Treat-
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STARR.  The Digestive  Organs in Childhood.  The Diseases of
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  the Investigation of Disease and the Management of Children.  2d
  Edition, Enlarged.  Illustrated by two Colored Plates and numerous
  Wood Engravings.                                       $2.00
STARR.  Hygiene of the Nursery.  Including the General Regi-
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  ment of the  Ordinary Emergencies of Early Life, Massage, etc.  4th
  Edition.  25 Illustrations.                                  $1.00
TAYLOR  AND WELLS.   Diseases of  Children.  Illustrated.
  A New Text-Book.                              Nearly Ready.


              CLINICAL CHARTS.

GRIFFITH.   Graphic Clinical Chart.  Printed in three  colors.
  Sample copies free.  Put up in loose packages of  fifty, .50.  Price to
  Hospitals, 500 copies, $400;  1000 copies,  $7.50.  With  name of
  Hospital printed on, .50 extra.
TEMPERATURE CHARTS.  For  Recording Temperature,
  Respiration, Pulse, Day of Disease,  Date, Age, Sex,  Occu-
  pation, Name, etc.  Put up in pads of fifty.           Each, .50 
MEDICAL  BOOKS.
7
                   DEFORMITIES.
REEVES.  Bodily Deformities and Their  Treatment.   A
  Hand-Book of Practical Orthopedics.  228 Illustrations.       $i-75
HEATH   Injuries and Diseases of the Jaws.  187 Illustrations.
  4th Edition.                                        Cloth, $4.50


                     DENTISTRY.
  Special Catalogue of Dental Books sent free upon application.

BARRETT.  Dental Surgery for General Practitioners  and
  Students  of Medicine and  Dentistry.  Extraction of  Teeth,
  etc.  2d Edition.  Illustrated.                              $1.00
BLODGETT.  Dental  Pathology.  By Albert  N.  Blodgett,
  m d., late Professor of  Pathology and Therapeutics, Boston  Dental
  College.  33 Illustrations.                                  $1.25
FLAGG. Plastics and  Plastic Filling, as Pertaining to the  Filling
  of Cavities in Teeth of all Grades of Structure.  4th Edition.   $4.00
FILLEBROWN.   A   Text-Book  of  Operative   Dentistry.
  Written by invitation of the  National Association of Dental  Facul-
  ties. Illustrated.                                          $2.25
GORGAS.  Dental  Medicine. A Manual of Materia Medica and
  Therapeutics.  5th Edition, Revised.                       $4.00
HARRIS.   Principles  and Practice  of Dentistry.   Including
  Anatomy,  Physiology,   Pathology, Therapeutics,  Dental Surgery,
  and Mechanism.  13th  Edition.  Revised by F. J. S. Gorgas, m.d.,
  d.d.s.  1250  Illustrations.            Cloth, $6.00; Leather, $7.00
HARRIS. Dictionary of Dentistry. Including Definitions of Such
  Words and Phrases of the Collateral Sciences as Pertain to the Art and
  Practice of Dentistry.   5th Edition.  Revised and Enlarged by  Fer-
  dinand F. S. Gorgas,  m d., d.d.s.    Cloth,  $4.50; Leather, $5.50
HEATH.   Injuries and Diseases of the Jaws.  4th Edition   187
  Illustrations.                                              $4-5°
HEATH.   Lectures on Certain  Diseases  of  the Jaws.  64
  Illustrations.                                         Boards, .50
RICHARDSON.  Mechanical Dentistry.   6th  Edition.  Thor-
  oughly Revised by  Dr.  Geo. W.  Warren.   600  Illustrations.
                                      Cloth, $4.00; Leather, $5.00
SE'WELL.  Dental  Surgery.   Including  Special Anatomy  and
  Surgery.   3d Edition, with 200 Illustrations.                  $2 00
TAFT.  Operative Dentistry.  A Practical Treatise.  4th Edition.
  100 Illustrations.                     Cloth, $3.00; Leather, $4.00
TAFT.  Index of Dental Periodical Literature.           $2.00
TALBOT.   Irregularities of the Teeth and Their Treatment.
  2d Edition.  234 Illustrations.                             $3 00
TOMES.  Dental  Anatomy.  Human and Comparative.  235 Illus-
  trations.  4th Edition.                                    $3-5o
TOMES.  Dental  Surgery.  3d Edition.  292 Illustrations.   $4.00
WARREN.  Compend of Dental Pathology and Dental Medi-
  cine.  With a Chapter  on Emergencies.  Illustrated.
                                           .80; Interleaved, $1.25
WARREN. Dental Prosthesis and Metallurgy. 129 Ills. $1.25
WHITE.  The Mouth  and Teeth.  Illustrated.               .40
  *** Special Catalogue of Dental Books free upon application. 
8                  SUBJECT CATALOGUE.
                  DICTIONARIES.

 GOULD.  The Illustrated Dictionary of Medicine, Biology,
   and Allied Sciences.   Being an  Exhaustive Lexicon of Medicine
   and those Sciences  Collateral to it:  Biology (Zoology and Botany),
   Chemistry,  Dentistry, Parmacology, Microscopy, etc., with many
   useful  Tables  and numerous fine Illustrations.   1633  pages.
    Sheep or Half Dark Green Leather, $10.00;  Thumb Index, $11.00
                                 Half Russia, Thumb Index, $12.00
 GOULD.  The Medical Student's  Dictionary. Including all the
   Words and  Phrases Generally Used in Medicine, with their Proper
   Pronunciation  and Definition, Based on Recent Medical Literature.
   With Tables of the Bacilli, Micrococci, Leucomains, Ptomains, etc.,
   of the  Arteries, Muscles, Nerves, Ganglia, and  Plexuses, etc.
       Half Dark Leather, $2.75 ;  Half Morocco, Thumb Index, $3.50
 GOULD.  The Pocket Pronouncing Medical Lexicon.  (12,000
   Medical Words Pronounced and Ucfineil.) Containing all the Words,
   their  Definition  and  Pronunciation,  that the Medical, Dental, or
   Pharmaceutical Student  Generally Comes  in Contact With; also
   Elaborate Tables of the Arteries, Muscles, Nerves, Bacilli, etc., etc.,
   a Dose List in both  English and Metric System, etc., Arranged in  a
   Most Convenient Form for Reference and Memorizing.
           Full Limp  Leather, Gilt Edges, $i.oj; Thumb Index, $1.25
  *** Sample  Pages and Illustrations and  Descriptive  Circulars  of
 Gould's Dictionaries sent free upon application.
 HARRIS.  Dictionary of Dentistry. Including Definitions of Such
   Words and Phrases of the Collateral Sciences as Pertain to the Art
  and Practice of Dentistry.  5th Edition.   Revised and Enlarged by
   Fekdinand J.  S. Gori.as, m.d., d.d.s. Cloth, $4.50;  Leather, $5 50
 LONGLEY. Pocket Medical Dictionary. Giving the Definitionand
   Pronunciation  of Words and Terms  in General Use in Medicine and
  Collateral Sciences, with an Appendix, containing Poisons and their
  Antidotes, Abbreviations used in Prescriptions, and a Metric Scale
  of Uoses.                    Cloth, .75; Tucks and  Pocket, $1.00
 CLEVELAND. Pocket Medical Dictionary.  33d Edition. Very
  small pocket size.               cloth. .50 ;  Tucks with Pocket, .75
 MAXWELL.   Terminologia  Medica  Polyglotta.   By Dr.
  Theodore Maxwell, Assisted by Others.                   $3.00
  The object ol this work is to assist the  medical men of any nationality
 in reading medical literatme wiitten in a  language  not  their own.
 Each term is usually given in seven languages, viz. : English, French,
 German, Italian, Spanish. Russian, and  Latin.
 TREVES AND LANG.  German-English Medical Dictionary.
                                               Half Russia, $3.25

           EAR  (see also Throat and Nose).

 HOVELL.  Diseases of the Ear and Naso-Pharynx.  Includ-
  ing Anatomy and Physiology of the Organ, together with the Treat-
  ment of the Affections of the Nose and  Pharynx which Conduce to
  Aural Disease.   122  Illustrations.                           $5.00
BURNETT.  Hearing and How to  Keep  It.   Illustrated.     .40
DALBY.   Diseases and  Injuries of the  Ear. 4th Edition.  28
  Wood Engravings and 7 Colored  Plates.                      $2.50
HALL.   Compend of Diseases of  Ear and Nose.  Illustrated.
                                           .80 ; Interleaved, $1.25
PRITCHARD.   Diseases of the Ear.   3d Edition.  Many Illus-
  trations and Formulae.                                  In Press. 
MEDICAL  BOOKS.
9
                   ELECTRICITY.

BIGELOW.  Plain  Talks  on  Medical  Electricity and  Bat-
  teries.   With a Therapeutic Index  and a Glossary.   43 Illustra-
  tions.  2d Edition.                                        $1.00
JONES.  Medical  Electricity. 2d Edition.  112 Illustrations.  $2.50
MASON. Electricity ; Its Medical and Surgical Uses. Numer-
  ous Illustrations.                                            .75


                            EYE.

A Special Circular  of Books on the Eye  sent free upon application.
ARLT.   Diseases of the Eye.   Clinical Studies on Diseases of the
  Eye,  Including the  Conjunctiva, Cornea and  Sclerotic, Iris  and
  Ciliary  Body.  Authorized  Translation by Lyman Ware,  m.d.
  Illustrated.                                               $125
FICK.  Diseases  of  the Eye  and Ophthalmoscopy.  Trans-
  lated by A. B. Hale, m. d.   157  Illustrations, many of which are in
  colors.                                               In Press.
FOX AND  GOULD.  Compend on Diseases of the  Eye and
  Refraction, Including Treatment and  Surgery.   2d Edition.  71
  Illustrations and 39 Formula?.               .80; Interleaved,  $1.25
GOWERS.   Medical Ophthalmoscopy.   A Manual and Atlas
  with Colored Autotype  and Lithographic Plates and  Wood-cuts,
  Comprising Original Illustrations of the Changes of the Eye in Dis-
  eases of the Brain, Kidney, etc.  3d Edition.                 $4.00
HARLAN.  Eyesight, and How to Care for It.  Illus.       .40
HARTRIDGE.   Refraction.  96  Illustrations  and Test Types.
  7th Edition.                                              $1.00
HARTRIDGE.   On  the Ophthalmoscope.   2d Edition.   With
  Colored Plate and  many Wood-cuts.                         $1.25
HANSELL AND BELL.   Clinical Ophthalmology.  Colored
  Plate of Normal F'undus and 120 Illustrations.                $1.50
MACNAMARA.  On the Eye.   5th Edition.  Numerous Colored
  Plates, Diagrams of Eye, Wood-cuts, and Test Types.        $3-5°
MEYER.  Ophthalmology.   A  Manual  of Diseases of the  Eye.
  Translated  from the 3d French Edition by A. Freedland Fergus,
  mb. 270 Illustrations, 2 Colored Plates.  Cloth, $3.50;  Sheep,  $4.50
MORTON.  Refraction of the Eye.  Its Diagnosis and the  Cor-
  rection of its  Errors.    With Chapter on Keratoscopy and  Test
  Types.  5th Edition.                                      $1.00
PHILLIPS.   Spectacles and Eyeglasses.   Their Prescription
• and Adjustment.   2d Edition.  49 Illustrations. Just Ready.  $1.00
SWANZY.  Diseases of the Eye and Their  Treatment.   5th
  Edition, Revised.   166  Illustrations, 1  Plain Plate, and a Zephyr
  Test Card.                             Cloth,$2.50; Sheep,  $3.00
WALKER.   Students' Aid in Ophthalmology.  Colored Plate
  and 40 other Illustrations and Glossary.   Just Ready.         $150
                        FEVERS.
COLLIE.   On Fevers.  Their History, Etiology, Diagnosis, Prog-
  nosis, and Treatment.  Colored Plates.                     $2.00 
10                SUBJECT CATALOGUE.
       GOUT  AND  RHEUMATISM.
DUCKWORTH. A Treatise on Gout.  With Chromo-lithographs
  and Engravings.                                   Cloth, $6.00
GARROD.  On Rheumatism.  A Treatise  on  Rheumatism and
  Rheumatic Arthritis.                               Cloth, $5.00
HAIG.  Causation of Disease by Uric Acid.  A Contribution to
  the Pathology of High Arterial Tension, Headache, Epilepsy, Gout,
  Rheumatism, Diabetes, Bright's Disease, etc.  New Ed.  In Press.


                  HEADACHES.
DAY.  On Headaches.  The  Nature, Causes,  and Treatment of
  Headaches.  4th Edition.  Illustrated.                      $1.00
HEALTH   AND   DOMESTIC  MEDI-
      CINE  (see also Hygiene  and Nursing).

BUCKLEY. The Skin in Health and Disease.  Illus.       .40
BURNETT.  Hearing and How to Keep It.  Illustrated.     .40
COHEN.  The Throat and Voice.  Illustrated.               .40
DULLES.  Emergencies.  4th Edition.   Illustrated.        $1.00
HARLAN.  Eyesight and How to Care for It.  Illustrated.   .40
HARTSHORNE.   Our Homes.  Illustrated.                 .40
OSGOOD.  The Winter and its Dangers.                   .40
PACKARD. Sea  Air and Bathing.                        .40
PARKES.  The Elements of Health.  Just Ready.       $1.25
RICHARDSON.  Long Life and How to Reach It.         .40
WESTLAND.  The  Wife and Mother.                  $1.50
WHITE.  The Mouth and Teeth.  Illustrated.               .40
WILSON.  The Summer and its Diseases.                 .40
WOOD.  Brain Work and Overwork.                      .40
STARR.  Hygiene of the Nursery.  4th Edition.          $1.00
CANFIELD.  Hygiene of the Sick-Room.                $1.25


                        HEART.
SANSOM.  Diseases of the Heart. The Diagnosis and Pathology
  of Diseases of the Heart and Thoracic Aorta. With Plates and other
  Illustrations.                                            $6.00

                   HISTOLOGY.
STIRLING. Outlines of Practical Histology.  368 Illustrations.
  2d Edition, Revised and Enlarged.  With new Illustrations.    $2.00
STOHR.  Histology and Microscopical Anatomy.  Translated
  by A. Shaper, m.d., Howard Medical School.  260 Illus.  In Press. 
MEDICAL  BOOKS.                    11
HYGIENE  AND WATER  ANALYSIS.

Special Catalogue of Books on Hygiene sent free upon application.

CANFIELD.  Hygiene of the Sick-Room.  A Book for Nurses
  and Others  Being a Brief Consideration of Asepsis, Ant'sepsis, Dis-
  infection, Bacteriology, Immunity,  Heating  and Ventilation, and
  Kindred Subjects.                                        $1.25
COPLIN AND  BEVAN.   Practical   Hygiene.   A  Complete
  American Text-Book.  138 Illustrations.                     $3-25
FOX. Water,  Air, and Food.  Sanitary Examinations of Water,
  Air, and Food.   100 Engravings.  2d Edition, Revised.        $3-5°
KENWOOD.  Public Health Laboratory Work.  116 Illustra-
  tions and 3 Plates.                                        $2.00
LEFFMANN.    Examination  of Water  for  Sanitary and
  Technical Purposes. 3d Edition. Illustrated. Just Ready. $1.25
LEFFMANN.   Analysis of Milk and Milk Products.   Illus-
  trated.                                                  $1-25
LINCOLN.  School and Industrial Hygiene.               .40
MACDONALD.   Microscopical Examinations of 'Water and
  Air.  25 Lithographic Plates, Reference  Tables, etc.  2d Ed.   $2 50
McNEILL. The Prevention of Epidemics and the Construc-
  tion and Management of Isolation Hospitals. Numerous Plans
  and Illustrations.                                         $3-5°
PARKES.   Practical Hygiene.  8th Edition.   Edited by J. Lane
  Notter. 10 Lithographic Plates and over too other Illustrations. $4.50
PARKES.  Hygiene and  Public Health.  By Louis C. Parkes,
  m.d.  4th  Edition.   Enlarged.  Illustrated.                  $2S°
PARKES.   Popular Hygiene.  The Elements of Health.  A Book
  for Lay Readers.  Illustrated  Just Ready.                 $J-25
STARR. The Hygiene of the  Nursery.  Including the General
  Regimen and Feeding of Infants and Children, and  the Domestic
  Management of the Ordinary Emergencies of Early Life, Massage,
  etc.  4th Edition.  25 Illustrations.                         $1.00
STEVENSON AND MURPHY.  A Treatise on Hygiene.  By
  Various Authors.  In Three Octave Volumes.  Illustrated.
                       Vol. I, $6.00; Vol. II, $600;  Vol. Ill, $5.00
  *** Each Volume sold separately. Special Circular upon application.

WILSON.  Hand-Book  of Hygiene  and Sanitary  Science.
  Wiih  Illustrations.   7th Edition.                            $3 °°
WEYL. Sanitary Relations of the Coal-Tar Colors.  Author-
  ized Translation by Henry LEFFMANN, M.D., PH.D.          $1.25

  *** Special Catalogue of Books on Hygiene free upon application.
                JOURNALS,  ETC.

OPHTHALMIC REVIEW. A Monthly Record of Ophthalmic
  Science.  Publ. in London.  Sample number .25 ;  per annum $3.00
NEW SYDENHAM SOCIETY PUBLICATION. Three  to six
  volumes each year.  Circular upon application.     Per annum $8.00 
12
SUBJECT  CATALOGUE.
             KIDNEY  DISEASES.

RALFE.  Diseases  of  the Kidney  and Urinary  Derange-
  ments.  Illustrated.                                     t2 °°
THORNTON.  The Surgery of the Kidney. 19 Illus.  Clo., $1.50
TYSON.  Bright's Disease and Diabetes.  With Especial Ref-
  erence to Pathology and Therapeutics. Including a Section on Reti-
  nitis in Bright's Disease.  Illustrated.                      $2.5°


           LUNGS  AND  PLEUR-rE.
HARRIS AND BEALE.  Treatment of Pulmonary Consump-
  tion.                                                  $2-5°
POWELL.  Diseases  of the Lungs  and Pleurae, including
  Consumption.  Colored Plates and other Illus.  4th Ed.    $4.00


                      MASSAGE.

KLEEN AND HARTWELL. Hand-Book of Massage.  Autho-
  rized translation by Mussey Hartwell, m.d., ph.d.  With an In-
  troduction by  Dr.  S. Weir Mitchell.   Illustrated by a series, of
  Photographs Made Especially  by  Dr.  Kleen for the  American
  Edition.                                               *2-25
MURRELL.  Massotherapeutics. Massage as a Mode of Treat-
  ment.  5th Edition.                                     $1.25
OSTROM.   Massage  and  the Original   Swedish  Move-
  ments.   Their Application to Various Diseases of the Body.   A
  Manual  for Students, Nurses, and Physicians.  Third Edition, En-
  larged.  94 Wood Engravings, many of which are original.    $1.00


MATERIA  MEDICA  AND    THERA-

                      PEUTICS.

ALLEN,  HARLAN,  HARTE,  VAN   HARLINGEN.   A
  Hand-Book of Local Therapeutics, Beinga Practical Description
  of all those Agents Used in the Local Treatment of Diseases of the
  Eye, Ear, Nose and Throat, Mouth, Skin, Vagina, Rectum, etc.,
  such as Ointments, Plasters, Powders, Lotions, Inhalations, Supposi-
  tories, Bougies, Tampons, and the Proper Methods of Preparing and
  Applying Them.                                       $3-°°
BIDDLE.  Materia  Medica and Therapeutics.   Including Dose
  List, Dietary for the  Sick, Table  of Parasites, and Memoranda of
  New  Remedies.  13th  Edition, Thoroughly  Revised  in  accord-
  ance with the  new U. S. P. 64 Illustrations and a Clinical Index.
                                       Cloth,  $4.00;  Sheep, $5.00
BRACKEN.   Outlines of Materia Medica and Pharmacology.   By
 • H.  M. Bracken, Professor of Materia  Medica and Therapeutics
  and of Clinical Medicine, University of Minnesota.           $2.75
DAVIS.  Materia Medica and  Prescription  Writing.    $1.50
FIELD.  Evacuant  Medication.  Cathartics and Emetics.  $1.75
GORGAS.  Dental Medicine.   A Manual of Materia Medica and
  Therapeutics.  5th Edition, Revised.                       $4.00
MAYS.  Therapeutic Forces ; or, The Action  of Medicine in
  the  Light of Doctrine  of Conservation of Force.      $1.25
MAYS.  Theine in the Treatment of Neuralgia.  % bound, .50 
MEDICAL  BOOKS.                    13
NAPHEYS.  Modern Therapeutics,  gth Revised Edition, En-
  larged and Improved. In two handsome volumes.  Edited by Allen
  J. Smith, m.d., and J Aubrey Davis, m.d.
  Vol. I. General Medicine and Diseases of Children.           $4.00
  Vol. II.  General Surgery, Obstetrics, and Diseases of Women.  $4.00
POTTER.  Hand-Book of Materia Medica, Pharmacy, and
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  tics, Pharmacology, etc., including over 600 Prescriptions and For-
  mulae.  5th Edition, Revised and Enlarged.  With Thumb Index in
  each copy.                            Cloth, $4.00; Sheep, $5.00
POTTER.  Compend of Materia Medica, Therapeutics, and
  Prescription Writing, with  Special Reference to the Physiologi-
  cal Action of Drugs.  6th Revised and Improved Edition, based upon
  the U. S. P. 1890.                          .80; Interleaved, $1.25
SAYRE.   Organic Materia Medica and Pharmacognosy.  An
  Introduction to the Study of the Vegetable Kingdom and the  Vege-
  table and Animal Drugs. Comprising the Botanical and Physical
  Characteristics,  Source, Constituents, and  Pharmacopeial Prepara-
  tions.  With chapters on Synthetic Organic Remedies, Insects In-
  jurious to Drugs, and Pharmacal Botany.  A Glossary and 543 Illus-
  trations, many of which are original.                        $4.00
WARING.  Practical Therapeutics. 4th Edition, Revised and
  Rearranged.                         Cloth, $2.00; Leather, $3.00
WHITE  AND WILCOX.  Materia Medica, Pharmacy, Phar-
  macology, and Therapeutics. 3d American Edition, Revised by
  Reynold W. Wilcox, m.a.,  m.d., ll.d.   Clo., $2.75; Lea., $3.25
MEDICAL   JURISPRUDENCE   AND

                   TOXICOLOGY.
REESE. Medical Jurisprudence and Toxicology.  A Text-Book
  for Medical  and Legal  Practitioners and Students.  4th Edition.
  Revised by Henry Leffmann, m.d.   Clo., $3.00; Leather, $3.50
  " To the student of medical jurisprudence and toxicology it is in-
valuable, as it is concise, clear, and thorough in every respect."—The
American Journal of the Medical Sciences.
MANN.  Forensic Medicine and Toxicology.   Illus.     $6.50
MURRELL.   What to  Do  in  Cases  of Poisoning.   7th
  Edition, Enlarged.                                        $1.00
TANNER.  Memoranda of Poisons.  Their Antidotes and Tests.
  7th Edition.                                                -75


                   MICROSCOPY.
BEALE.  The  Use of the Microscope in Practical Medicine.
  For Students and Practitioners.with Full Directions for Examining the
  Various Secretions,etc., by the Microscope. 4th Ed. 500 Illus. $6.50
BEALE.  How to Work with  the Microscope.   A Complete
  Manual of Microscopical  Manipulation, containing a Full Description
  of many New Processes of Investigation, with Directions for Examin-
  ing Objects Under the  Highest Powers, and for Taking Photographs
  of  Microscopic  Objects.   5th  Edition.  400  Illustrations, many of
  them colored.                                            $6.50
CARPENTER.   The  Microscope and  Its  Revelations.   7th
  Edition.  800 Illustrations and many Lithographs.            $5-5° 
14                 SUBJECT  CATALOGUE.
LEE.   The Microtomist's  Vade  Mecum.  A Hand-Book of
  Methods of Microscopical Anatomy.  881 Articles.   4th Edition,
  Enlarged.                                            In Press.
MACDONALD.  Microscopical Examinations of Water and Air.
  25 Lithographic Plates, Reference Tables, etc.  2d  Edition.    $2.50
REEVES.  Medical Microscopy, including Chapters on Bacteri-
  ology, Neoplasms,  Urinary  Examination, etc.   Numerous  Illus-
  trations, some of which are printed in colors.                 $2.50
WETHERED. Medical Microscopy.  A Guide  to the Use of the
  Microscope in Practical Medicine.   100 Illustrations.          $2.00
               MISCELLANEOUS.

BLACK.   Micro-Organisms.   The  Formation of  Poisons.  A
  Biological Study of the Germ Theory of Disease.               .75
BURNETT.  Foods and Dietaries.  A Manual of Clinical Diet-
  etics.  2d Edition.                                        $l-5°
DAVIS.  Biology.   Illustrated.                            $3.00
GOWERS.  The Dynamics of Life.                        .75
HAIG.  Causation of Disease by Uric Acid.  A Contribution to
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  Rheumatism, Diabetes, Bright's Disease, etc.  Nezv  Ed. In Press.
HARE.   Mediastinal Disease.  Illustrated by six Plates.    $2.00
HENRY.  A Practical Treatise on Anemia.     Half Cloth, .50
LEFFMANN.  The Coal-Tar Colors.  With Special Reference to
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  lation of Theodore Weyl's Monograph.                   $125
TREVES.  Physical Education :  Its Effects, Value, Methods,
  Etc.                                                     .75
LIZARS.  The Use and Abuse of Tobacco.                .40
PARRISH.  Alcoholic Inebriety from a Medical Standpoint,
  with Cases.                                            $1.00
            NERVOUS  DISEASES.

GOWERS.  Manual of Diseases of the  Nervous System.  A
  Complete Text-Book.  2d Edition, Revised, Enlarged, and in many
  parts Rewritten.  With many new Illustrations.  Two volumes.
  Vol. I.   Diseases of the Nerves and Spinal Cord.             $3.00
  Vol. II. Diseases of the Brain and Cranial Nerves;  General and
    Functional Disease.                                     $4.00
GOWERS.  Syphilis and the Nervous System.           $1.00
GOWERS.  Diagnosis of Diseases  of the  Brain.  2d Edition.
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GOWERS.  Clinical Lectures.  A New Volume of Essays on the
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  Just Ready.                                              $2.00
FLOWER.  Diagram of  the Nerves of the Human Body.
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MEDICAL  BOOKS.                   15
HORSLEY.  The  Brain and Spinal Cord.  The Structure and
  Functions of.  Numerous Illustrations.                      $2.50
OBERSTEINER.  The Anatomy of the Central Nervous Or-
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  ease.  198 Illustrations.                                   $S-SO
ORMEROD.  Diseases of the Nervous System.  66 Wood En-
  gravings.                                                $1.00
OSLER.  Cerebral Palsies of Children.  A Clinical Study.  $2.00
OSLER. Chorea and Choreiform Affections.             $2.00
PAGE.  Injuries of the Spine and Spinal Cord. In their Surgical
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PAGE.  Railroad Injuries. With Special Reference to Those of the
  Back and Nervous System.                                $2.25
THORBURN.  Surgery of the Spinal Cord.  Illustrated.   $4.00
WATSON.  Concussions. An Experimental Study of Lesions Aris-
  ing from Severe Concussions.                   Paper cover, $1.00
WOOD.  Brain Work and Overwork.                      .40
                       NURSING.

  Special Catalogue of Books for Nurses sent free upon application.

CANFIELD.  Hygiene of the Sick-Room.  A Book for Nurses and
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  tion, Bacteriology, Immunity, Heating and Ventilation, and Kindred
  Subjects for the Use of Nurses and Other Intelligent Women.  $1.25
CULLINGWORTH.  A Manual of Nursing, Medical and Sur-
  gical. 3d Edition   18 Illustrations.                         .75
CULLINGWORTH.  A Manual for Monthly Nurses. 3d Ed. .40
DOMVILLE.  Manual for  Nurses and Others Engaged in At-
  tending the Sick.  7th Edition. With Recipes for Sick-room Cook-
  ery, etc.                                                   .75
FULLERTON,  Obstetric Nursing.  40 Ills.  4th Ed.     $1.00
FULLERTON. Nursing in Abdominal Surgery and Diseases
  of Women.  Comprising the Regular Course of Instruction at the
  Training-School of the Women's Hospital, Philadelphia.  2d Edition.
  70 Illustrations.                                          $1-5°
HUMPHREY.   A  Manual for  Nurses.   Including  General
  Anatomy and Physiology, Management of the Sick-Room, etc. 13th
  Edition.  Illustrated.                                     $1.00
SHAWE.  Notes for Visiting Nurses, and all those Interested
  in the Working and Organization of District, Visiting, or
  Parochial  Nurse  Societies.  With an Appendix Explaining the
  Organization and Working of Various Visiting and District Nurse So-
  cieties, by Helen C. Jenks,  of Philadelphia.                $1.00
STARR.   The Hygiene of the Nursery.  Including the General
  Regimen and Feeding of Infants and Children, and the Domestic Man-
  agement of the Ordinary Emergencies of Early Life, Massage, etc. 4th
  Edition.  25  Illustrations.                                 $1.00
TEMPERATURE CHARTS.  For Recording Temperature, Res-
  piration,  Pulse,  Day of Disease, Date, Age,  Sex, Occupation,
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VOSWINKEL.  Surgical Nursing,  in Illustrations.      $1.00
  *** Special Catalogue of Books on Nursing free upon application. 
16                 SUBJECT  CATALOGUE.
                    OBSTETRICS.

BAR.  Antiseptic Midwifery.  The Principles of Antiseptic Meth-
  ods Applied  to  Obstetric  Practice.  Authorized Translation by
  Henry D. Fry, m.d . with an Appendix by the Author.       $1.00
CAZEAUX  AND TARNIER.   Midwifery.  With Appendix by
  Mundb.  The Theory and Practice of Obstetrics, including the Dis-
  eases  of Pregnancy and  Parturition,  Obstetrical Operations, etc.
  8th Edition.   Illustrated by  Chromo-Lithographs, Lithographs, and
  other full-page Plates, seven of which are beautifully colored, and
  numerous Wood Engravings.      Cloth, $4.50 ; F'ull Leather, $5.50
DAVIS.  A Manual of Obstetrics.   Being a Complete Manual for
  Physicians and Students.  2d Edition.  16 Colored and other Plates
  and 134 other  Illustrations.                                 $2.00
LANDIS.  Compend of Obstetrics. 5th Edition, Revised by Wm.
  H. Wells, Assistant  Demonstrator of Clinical Obstetrics, Jefferson
  Medical College.   With many Illustrations, .80 ; Interleaved, $1.25.
SCHULTZE.   Obstetrical  Diagrams.   Being a series  of 20 Col-
  ored Lithograph Charts, Imperial Map Size, of Pregnancy and Mid-
  wifery, with accompanying  explanatory (German) text illustrated
  by Wood Cuts.  2d Revised  Edition.
      Price in Sheets, $26.00  ; Mounted on Rollers, Muslin Backs, $36.00
STRAHAN.   Extra-Uterine Pregnancy.  The Diagnosis  and
  Treatment of Extra-Uterine Pregnancy.                       .75
WINCKEL.   Text-Book of Obstetrics,  Including the Pathol-
  ogy and Therapeutics  of the  Puerperal State.  Authorized
  Translation by J. Clifton Edgar, a.m. , m.d.  With nearly 200 Illus-
  trations.                             Cloth, $5.00; Leather, $6.00
FULLERTON. Obstetric  Nursing.  4th Ed.  Illustrated. $1.00
SHIBATA.  Obstetrical Pocket-Phantom with Movable Child
  and Pelvis.  Letter Press and Illustrations.                $1.00
                    PATHOLOGY.
BLACKBURN.  Autopsies.  A Manual of Autopsies Designed for
  the Use of Hospitals for the Insane and other Public Institutions.
  Ten full-page Plates and other Illustrations.                  $'-25
BLODGETT.  Dental  Pathology.  By  Albert  N. Blodgett,
  m d., late Professor of Pathology and Therapeutics, Boston Dental
  College.  33 Illustrations.                                  $1.25
GILLIAM.   Pathology. A Hand-Book for Students.  47 Illus.  .75
HALL.  Compend of General Pathology and Morbid Anatomy.
  91  very fine Illustrations.                   .80;  Interleaved, $1.25
VIRCHOW.   Post-Mortem Examinations.  A Description and
  Explanation of the Method of Performing Them in the Dead House
  of  the  Berlin Charity  Hospital, with Special Reterence to Medico-
  Legal Practice.  3d Edition, with Additions.                   .75



                     PHARMACY.
Special Catalogue of Books on Pharmacy sent free  upon application.
COBLENTZ.  Manual of Pharmacy.   A  New and  Complete
  Text-Book by the Professor in  the New York College of Pharmacy.
  2d  Edition, Revised and  Enlarged.  437 Illustrations.         $3-So 
MEDICAL  BOOKS.                   17
BEASLEY.   Book of 3100 Prescriptions.  Collected from the
  Practice of the  Most Eminent  Physicians and  Surgeons—English,
  French, and  American   A Compendious  History  of the Materia
  Medica, Lists of the Doses of all the Officinal and Established Pre-
  parations, an  Index of Diseases and their Remedies.   7th Ed. $2.00
BEASLEY.   Druggists'  General Receipt Book.  Comprising
  a Copious Veterinary Formulary, Recipes in Patent and Proprietary
  Medicines,  Druggists' Nostrums, etc.;  Perfumery  and Cosmetics,
  Beverages,  Dietetic Articles and Condiments,  Trade Chemicals,
  Scientific Processes, and an Appendix of Useful  Tables.  10th Edi-
  tion, Revised.                                           $2.00
BEASLEY.  Pocket Formulary.   A Synopsis of  the British  and
  Foreign  Pharmacopoeias.   Comprising  Standard  and Approved
  Formulae for the Preparations and Compounds Employed in Medical
  Practice,  nth  Edition.                                   $2 00
PROCTOR.  Practical Pharmacy.  Lectures on  Practical Phar-
  macy.   With Wood Engravings and 32  Lithographic Fac-simile
  Prescriptions.   3d Edition, Revised, and with Elaborate  Tables of
  Chemical Solubilities, etc.                                 $3.00
ROBINSON.   Latin  Grammar of Pharmacy and Medicine.
  2d Edition.  With elaborate Vocabularies.                   $1 75
SAYRE.  Organic Materia Medica and  Pharmacognosy.  An
  Introduction  to  the  Mudy of the Vegetable  Kingdom and  the Vege-
  table and Animal  Drugs.  Comprising the  Botanical and Physical
  Characteristics,  Source, Constituents, and   Pharmacopeial  Prepar-
  ations.   With Chapters on  Synthetic Organic  Remedies, Insects
  Injurious to  Drugs, and  Pharmacal  Botany.  A Glossary and 543
  Illustrations, many of which are original.                    $4.00
SCOVILLE.  The Art of Compounding.  A Text-Book  for the
  Student and a Reference Book for the Pharmacist.           $2.50
STEWART.  Compend of Pharmacy.   Based  upon " Reming-
  ton's  lext-Book of Pharmacy". 5th Edition, Revised in Accord-
  ance with  the  U. S.  Pharmacopoeia, 1890.  Complete Tables of
  Metric and  English Weights and Measures.   .80; Interleaved. $1.25
UNITED  STATES PHARMACOPOSIA.  1890.  7ih Decennial
  Revision.  Cloth, $2 50  (postpaid, $2.77); Sheep,$3.00 (postpaid,
  $3.27); Interle ived, $4 00 (postpaid,  $4 50  ;  Printed on one side of
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  Select Tables  from  the U. S.  P. (18901.   Being Nine of the Most
    lniportai tand Useful Tables, Printed  on  Separate Sheets.  Care-
    fully put up in patent envelope.                              .25
WHITE AND WILCOX.  Materia Medica,  Pharmacy, Phar-
  macology, and Therapeutics.  2d American Edition.  Revised
  by Reynold  \V. Wilcox  m.d.,lld.  Cloth,$2 75; Leather, $3.25
POTTER.   Hand-Book  of Materia Medica, Pharmacy, and
  Therapeutics.   600 Prescriptions and Formulas.  5th Edition.
                                       Cloth, $4.00; Sheep, $5.00

  *** Special Catalogue of Books on Pharmacyfree upon application.
           PHYSICAL DIAGNOSIS.
TYSON.  Hand-Book of Physical Diagnosis.  For Students and
  Physicians.  By the Professor of Clinical Medicine in the University
  of Pennsylvania. Illus. 2d Ed., Improved and Enlarged.     $125
MEMMINGER. Diagnosis by the Urine.  23 Illus.       $1.00 
18                 SUBJECT CATALOGUE.
                   PHYSIOLOGY.

BRUBAKER.  Compend of Physiology.  7th Edition, Revised
  and Illustrated.                           .80;  Interleaved, $1.25
KIRKE. Physiology.  (13th Authorized Edition.  Dark Red Cloth.)
  A Hand-Book of Physiology.   13th London Edition, Revised and
  Enlarged.   516 Illustrations, some of which are  printed in colors.
                                      Cloth, $3.25 ;  Leather, $4.00
LANDOIS. A  Text-Book  of Human  Physiology, Including
  Histology  and  Microscopical Anatomy, with Special  Reference  to
  the Requirements of Practical Medicine.  5th American, translated
  from the 9th German Edition, with Additions  by Wm.  Stirling,
  m.d ,d.sc  845 Illus., many of which are printed  in colors. In Press.
STARLING.  Elements of Human Physiology.  loollls.  $1.00
STIRLING.    Outlines of  Practical  Physiology.   Including
  Chemical and  Experimental  Physiology, with Special Reference to
  Practical Medicine.  3d Edition.  289  Illustrations.           $2.00
TYSON. Cell  Doctrine.   Its  History  and  Present  State,  ad
  Edition.                                                  £i-5°
YEO.   Manual  of Physiology.   A Text-Book for Students  of
  Medicine.   By Gerald F. Yeo, m.d., f.r.cs.  6th Edition.  254
  Illustrations and a Glossary.           Cloth, $2.50 ;  Leather, $3.00


                      PRACTICE.

BEALE.  On Slight Ailments; their Nature and Treatment.
  2d Edition, Enlarged and Illustrated.                        $1.25
CHARTERIS.   Practice  of  Medicine.  6th  Edition.  Thera-
  peutical Index and Illustrations.                             $2.00
FOWLER.   Dictionary of  Practical  Medicine.   By various
  writers. An Encyclopaedia of Medicine. Clo., $3.00; Half Mor. $4.00
HUGHES.  Compend of the Practice of Medicine. 5th Edition,
  Revised and Enlarged.
  Part I.  Continued, Eruptive, and Periodical Fevers, Diseases of the
    Stomach, Intestines,  Peritoneum, Biliary Passages, Liver, Kid-
    neys, etc., and General Diseases, etc.
  Part  II.  Diseases of the Respiratory System, Circulatory System,
    and Nervous System;  Diseases of the Blood, etc.
                         Price of each part, .80; Interleaved, $1.25
  Physician's  Edition.   In  one volume,  including the  above two
    parts, a  Section on Skin Diseases,  and  an Index.  5th Revised,
    Enlarged Edition.   568 pp.        Full Morocco, Gilt Edge, $2.25
ROBERTS.  The Theory and Practice of   Medicine.   The
  Sections on  Treatment  are  especially exhaustive.  9th Edition,
  with Illustrations.                     Cloth, $4.50 ; Leather, $5.50
TAYLOR.  Practice of Medicine.      Cloth, $2.00; Sheep, $2.50



          PRESCRIPTION BOOKS.

BEASLEY.  Book  of 3100  Prescriptions.   Collected from the
  Practice of the Most Eminent Physicians and  Surgeons—English,
  French, and American.  A Compendious  History of the Materia
  Medica, Lists of the  Doses  of all Officinal  and Established Prepara-
  tions, and an Index of Diseases and their Remedies.   7th Ed.  $2.00 
MEDICAL  BOOKS.
19
BEASLEY.   Druggists'  General Receipt Book.  Comprising
  a Copious Veterinary  F'ormulary, Recipes in Patent and Proprie-
  tary  Medicines,  Druggists'  Nostrums, etc. ;  Perfumery and Cos-
  metics, Beverages, Dietetic Articles and Condiments, Trade Chem-
  icals,  Scientific  Processes,  and an Appendix  of Useful Tables.
  ioth Edition, Revised.                                     $2.00
BEASLEY.  Pocket Formulary.   A Synopsis of the British and
  F'oreign Pharmacopoeias.  Comprising  Standard  and  Approved
  Formulae for the Preparations and Compounds Employed in Medical
  Practice,  nth Edition.                              Cloth, $2.00
PEREIRA.  Prescription  Book.  Containing  Lists of Terms,
  Phrases, Contractions, and Abbreviations Used in Prescriptions, Ex-
  planatory  Notes, Grammatical Construction  of  Prescriptions, etc.
  16th Edition.                             Cloth, .75 ; Tucks, $1.00
WYTHE.  Dose and Symptom Book.  The  Physician's Pocket
  Dose and Symptom Book.  Containing the Doses  and Uses of all
  the Principal Articles of  the Materia Medica and Officinal Prepara-
  tions.   17th Ed.  Cloth, .75;  Leather, with Tucks and Pocket, $1.00

                          SKIN.

BULKLEY.  The Skin in Health and Disease.   Illustrated.  .40
CROCKER.  Diseases of the Skin.  Their  Description, Pathol-
  ogy, Diagnosis, and Treatment, with Special Reference to the Skin
  Eruptions of Children.  92 Illus.  2d Edition.  Enlarged.      $4.50
VAN HARLINGEN.  On Skin Diseases.  A Practical Manual
  of Diagnosis and Treatment, with special reference to Differential
  Diagnosis.  3d Edition, Revised and  Enlarged.   With Formulae
  and 60 Illustrations, some of which  are printed in colors.    $2.75


   SURGERY  AND  SURGICAL  DIS-

                         EASES.

CAIRD AND CATHCART.   Surgical Hand-Book.  5th Edition,
  Revised.  188 Illustrations.               Full Red Morocco, $2.50
DEAVER.  Appendicitis, Its Symptoms,  Diagnosis, Pathol-
  ogy, Treatment, and Complications.  Elaborately Illustrated.
                                                       In Press.
DEAVER. Surgical Anatomy.  With 200 Illustrations, Drawn by a
  Special Artist from Directions made for the Purpose.  In Preparation.
DULLES. What  to Do First in Accidents and  Poisoning.
  4th Edition.  New Illustrations.                            $1.00
HACKER.  Antiseptic  Treatment of Wounds, Introduction to
  the, According to the  Method in Use at Professor  Billroth's Clinic,
  Vienna.  With a Photo-engraving of Billroth in his  Clinic.       .50
HEATH.   Minor Surgery and  Bandaging,  ioth Ed   Revised
  and Enlarged.  158 Illustrations, 62 Formulae,  Diet List, etc   $1.25
HEATH.   Injuries and Diseases of the  Jaws. 4th  Edition.
  187 Illustrations.                                           $4 5°
HEATH.   Lectures on Certain  Diseases of the Jaws. 64 Illus-
  trations.                                            Boards, .50
HORWITZ.  Compend of Surgery and Bandaging, including
  Minor Surgery, Amputations, Fractures, Dislocations, Surgical  Dis-
  eases, and the Latest Antiseptic Rules, etc., with Differential Diagno-
  sis and Treatment.  5th Edition, very much  Enlarged and Rear-
  ranged.  167  Illustrations, 98 Formulae.  Clo., .80; Interleaved, $1.25 
20                SUBJECT CATALOGUE.
JACOBSON.  Operations  of Surgery.  Over 200 Illustrations.
                                      Cloth, $3.00 ; Leather, 5+.00
JACOBSON.  Diseases of the  Male Organs of Generation.
  88 Illustrations.                                          $6.00
MACREADY.  A Treatise on  Ruptures.  24 Full-page Litho-
  graphed Plates and Numerous  Wood Engravings.      Cloth, $6.00
MOULLIN.  Text-Book of Surgery.  With Special Reference to
  Treatment.  3d American Edition.  Revised and edited by John B.
  Hamilton,  m.d., ll.d., Professor of the  Principles of Surgery  and
  Clinical Surgery, Rush Medical College, Chicago.  623 Illustrations,
  over 200 of which are original, and many of  which are printed in
  colors. Just Ready.        Handsome Cloth, $6 00; Leather, $7.00
  " The aim to make this valuable treatise practical by giving special
attention to  questions of treatment has been admirably carried  out.
Many a reader will consult the work with a feeling of satisfaction that
his wants have been understood, and that they have been intelligently
met."—The American Journal of Medical Science.
PORTER.  Surgeon's  Pocket-Book.  3d Ed.  Lea. Cover, $2.00.
SMITH.  Abdominal Surgery.  Being a Systematic Description of
  all the Principal  Operations. 80 Illus.  5th Edition.     In Press.
SWAIN.  Surgical Emergencies.  New Edition.       In Press.
VOSWINKEL.  Surgical  Nursing,  in Illustrations.      $1.00
WALSHAM.  Manual  of Practical  Surgery.   5th Ed.,  Re-
  vised and Enlarged.  With 380 Engravings.  Clo., $2.75;  Lea., $3.25
WATSON.  On Amputations of  the Extremities and Their
  Complications.   250 Illustrations.                         $550

   THROAT  AND  NOSE  (see also  Ear).

COHEN.  The Throat and Voice.  Illustrated.              .40-
HALL.   Diseases of  the Nose  and Throat.   Two  Colored
  Plates and 59 Illustrations.                                 $2.50
HALL.  Compend of Diseases  of the Ear  and Nose.  Illus-
  trated.                                  .80; Interleaved, $1.25
HUTCHINSON.   The Nose and Throat.   Including  the Nose,
  Naso-Phar>nx, Pharvnx, and  Larynx.  Illustrated  by Lithograph
  Plates and 40 other Illustrations   2d Edition.            In Press.
MACKENZIE.  The  Pharmacopoeia of the  London Hospital
  for Diseases of the Throat.   5th  Edition,  Revised  by Dr. F.
  G  H^KVEY.                                             gt oo
McBRIDE.  Diseases of the Throat, Nose,  and Ear.  A Clinical
  Manual  With colored Illus  from  original drawings. 2d Ed.   $6.00
MURRELL.  Chronic Bronchitis and its Treatment.  (Author-
  ized fc-dition.)  A Clinical Study.                           $1.50
POTTER.  Speech and its Defects.  Considered Physiologically,
  Pathologically, and Remedi.dly.                            $1.00
WOAKES.  Post-Nasal  Catarrh  and  Diseases  of  the  Nose
  Causing Deafness.  26 Illustrations.                      $1.00


  URINE  AND  URINARY  ORGANS.

ACTON.  The Functions and Disorders of the Reproductive
  Organs in Childhood, Youth, Adult Age, and Advanced Life,
  Considered  in  their Physiological,  Social, and Moral   Relations.
  8th Edition.                                              «! _, 
MEDICAL  BOOKS.                    21
ALLEN.  Albuminous and Diabetic Urine.  Illus.       $2.25
BEALE.  One Hundred Urinary  Deposits.  On eight sheets,
  for the Hospital, Laboratory, or Surgery.             Paper, $2.00
HOLLAND.  The  Urine, the Gastric Contents, the Common
  Poisons, and the  Milk.  Memoranda, Chemical and Microscopi-
  cal, for Laboratory Use. Illustrated and Interleaved.  5th Ed.  $1.00
LEGG.  On the Urine. 7th Edition, Enlarged.  Illus.       $1.00
MEMMINGER.  Diagnosis by the Urine.  23 Illus.       $1.00
MOULLIN.  Enlargement of the Prostate.  Its Treatment and
  Radical Cure.  Illustrated.                                 $1.50
THOMPSON.  Diseases of the Urinary Organs.  8th Ed.  $3.00
THOMPSON.  Calculous Diseases.  The Preventive Treatment
  of, and the Use of Solvent Remedies.  3d Edition.             .75
TYSON.  Guide to Examination of the Urine.  For the Use of
  Physicians and Students.  With Colored Plate and Numerous  Illus-
  trations engraved on wood.  9th Edition, Revised.            $'.25
VAN  NUYS. Chemical  Analysis  of Healthy and  Diseased
  Urine, Qualitative and Quantitative.  39 Illustrations.    $1.00

           VENEREAL  DISEASES.

COOPER.  Syphilis.   2d  Edition,  Enlarged and Illustrated with
  20 full-page Plates.                                        $5.00
GOWERS.   Syphilis and the Nervous  System.           $1.00
HILL AND COOPER. Venereal Diseases.  Being a Concise De-
  scription of Those Affections and Their Treatment.   4th Ed.   .75
JACOBSON.  Diseases of the Male Organs of Generation.  88
  Illustrations.                                             $6.00
                  VETERINARY.

ARMATAGE.  The Veterinarian's Pocket Remembrancer.
  Being Concise Directions for the Treatment of Urgent or Rare Cases,
  Embracing Semeiology, Diagnosis, Prognosis, Surgery, Treatment,
  etc.  2d Edition.                                  Boards, $1.00
BALLOU.  Veterinary Anatomy and Physiology.  29 Graphic
  Illustrations.                             .80;  Interleaved, $1.25
TUSON.  Veterinary Pharmacopoeia.  Including the  Outlines of
  Materia Medica and Therapeutics.  5th Edition.              $2.23

          WOMEN,  DISEASES  OF.

BYFORD (H. T.).  Manual  of Gynecology.  With 234 Illustra-
  tions, many of which are from original drawings. Just Ready.  $2.50
BYFORD  (W. H.).  Diseases  of  Women.  4th  Edition. 306
  Illustrations.                        Clotn, $2.00;  Leather, $2.50
DUHRSSEN.  A Manual  of  Gynecological  Practice.   105
  Illustrations.  Just Ready.                                 J1^0
LEWERS.   Diseases of Women.  146  Illus. 3d Edition.   $2.00
WELLS. Compend of Gynecology. Illus. .80; Interleaved, $1.25
WINCKEL.  Diseases of Women. Translated by special auihority
  of Author, under the buperv.sion of,  and  with an Introduction by,
  Theophilus Parvin, m.d.  152 Engravings on Wood.   3d Edition,
  Revised.                                      In Preparation.
FULLERTON.   Nursing in Abdominal Surgery and Diseases
  of Women. 2d Edition.  70 Illustrations.                  $'-5° 
22
SUBJECT  CATALOGUE.
COMPENDS.
From The Southern Clinic.
  " We know of no series of books  issued by any house that so fully
meets our approval as these ? Quiz-Compends?.  They are well ar-
ranged, full, and concise, and are really the best line of text-books that
could be found for either student or practitioner."
BLAKISTON'S  ? QUIZ-COMPENDS?

   The Best Series of Manuals for the Use of Students.

Price of each, Cloth, .80.     Interleaved, for taking Notes, $1.25.

    4®" These Compends are based on the most popular text-books
and the lectures of prominent professors, and are kept constantly re-
vised, so that they may thoroughly represent the present state of the
subjects upon which they treat.
    ,63$" The authors have had large experience as Quiz-Masters and
attaches of colleges, and are well acquainted with the wants of students.
    4£S* They are arranged in the most approved form, thorough and
concise, containing over 6oo fine illustrations, inserted wherever they
could be used to advantage.
    &S~ Can be used by students of any college.
    >8S" They contain information nowhere else  collected in such  a
condensed, practical shape. Illustrated Circular free.

No. i. POTTER.   HUMAN ANATOMY.   Fifth  Revised and
    Enlarged  Edition.  Including Visceral Anatomy.  Can  be  used
    with either Morris's or Gray's Anatomy.  117 Illustrations and 16
    Lithographic Plates of Nerves and Arteries, with  Explanatory
    Tables, etc.  By Samuel O. L. Potter, m.d.,  Professor of the
    Practice of Medicine, Cooper Medical College, San Francisco ; late
    A. A. Surgeon, U. S. Army.
No. 2. HUGHES. PRACTICE OF MEDICINE. Part I.  Fifth
    Edition, Enlarged and Improved.  By Daniel E. Hughes.m.d.,
    Physician-in-Chief, Philadelphia Hospital, late Demonstrator of
    Clinical Medicine, Jefferson Medical College, Phila.
No. 3. HUGHES.   PRACTICE  OF  MEDICINE.   Part II.
    Fifth Edition, Revised and Improved.   Same author as No.  2.
No. 4. BRUBAKER.  PHYSIOLOGY.  Seventh Edition, with
    new Illustrations and a table of Physiological Constants.  Enlarged
    and Revised.  By A. P. Brubaker, m.d., Professor of Physiology
    and General  Pathology in the  Pennsylvania  College of Dental
    Surgery ; Demonstrator of Physiology, Jefferson Medical College,
    Philadelphia.
No. 5. LANDIS.  OBSTETRICS. Fifth Edition. By Henry G.
    Landis, m.d.  Revised and Edited by Wm. H. Wells,  m.d.,
    Assistant  Demonstrator of Obstetrics, Jefferson Medical College,
    Philadelphia.  Enlarged.  47 Illustrations.
No. 6. POTTER.  MATERIA  MEDICA,  THERAPEUTICS,
    AND  PRESCRIPTION WRITING.  Sixth Revised Edition
    (U. S.  P. 1890).  By  Samuel O. L. Potter, m.d., Professor of
    Practice, Cooper Medical College, San Francisco ; late A. A. Sur-
    geon, U. S. Army. 
MEDICAL  BOOKS.                   23
          PQUIZ-COMPENDS ?—Continued.

No. 7. WELLS.  GYNECOLOGY.   A  New  Book.  By Wm.
    H. Wells, m.d., Assistant Demonstrator of Obstetrics, Jefferson
    College, Philadelphia.  Illustrated.
No. 8. FOX AND GOULD.  DISEASES OF THE EYE AND
    REFRACTION.   Second Edition.  Including Treatment and
    Surgery.  By L. Webster Fox, m.d, and George M.  Gould,
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No. 13. WARREN.  DENTAL  PATHOLOGY  AND  DEN-
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A^M* S      y •   Third Edition,
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