CLINICAL PEDIATRICS 
BY 
SIGMUND A. AGATSTON, M.D. 
LECTURER IN PEDIATRICS, NEWYORK POLYCLINIC 
MEDICAL SCHOOL INTRODUCTION 
To write this brief introduction has been more of a 
pleasure than a task. lam convinced that a treatise of 
this nature, summarizing, as it does, the essentials of 
the various diseases and conditions met with in the 
practice of pediatrics, giving particular attention to the 
newer methods of diagnosis and therapy, and present- 
ing the subjects in a succinct, comprehensive manner, 
is of real practical benefit. The general practitioner 
and the post-graduate student, especially, will find it 
a compendium of considerable value. 
Henry Heiman, M.D. PREFACE 
The object of this work is to give the student and 
general practitioner a brief review of the most com- 
mon conditions and diseases found in infancy and 
childhood, as an aid in diagnosis. 
It is both tedious and confusing to go through an 
exhaustive and voluminous book on the subject, and 
a description of diseases from a clinical and practical 
standpoint only may be found useful. 
To become a good diagnostician, one must be famil- 
iar with the cardinal symptoms of conditions found 
in every-day practice. With this idea in view, I have 
endeavored to make this work as brief and concise as 
possible. 
My information is derived from recognized text- 
books, current literature, personal experience and 
judgment. 
I might add, that in omitting the mention of the rarer 
conditions and less important classifications, I have 
done so with a view of facilitating the formation of 
memory pictures of the more common groups of 
diseases. CLINICAL PEDIATRICS 
BIRTH INJURIES 
Caput succedaneum: CEdema, subcutaneous and 
subaponeurotic hemorrhage, due to pressure on the 
head during labor. 
Similar condition may be found over the gluteal 
region following breech presentation. 
Cephalaematoma: Hemorrhage is subperiosteal. It 
is usually accompanied by caput succedaneum. Attains 
its largest size at the end of a week. Found over one 
of the parietal bones. Never extends beyond the su- 
tures, as the pericranium is attached there. In the 
course of healing, bone tissue at surrounding border 
makes the central part appear like a depressed frac- 
ture. 
Differentiated from a meningocele by the fact that 
the latter swells when the child cries, and is located 
over the sutures. 
Treatment: Protection from injury. Incision only 
when extremely large or suppurating. 
Haematoma of the sterno-cleido-mastoid muscle: 
This condition appears within a few days after child- 
birth. It appears as a hard mass, the size of a hazel- 
nut, in the central portion of the muscle. It is due to 
a laceration of some of the muscle fibres. When the 2 
CLINICAL PEDIATRICS 
muscle is relaxed, it is movable. The head may be 
turned to the healthy side, and sometimes to the 
affected side. It is usually painless and disappears 
spontaneously. 
Treatment: Gentle massage, and passive motion. OBSTETRICAL PARALYSES 
The Erb-Duchenne Type occurs most frequently. It 
is due to injury of the brachial plexus; particularly 
the sth and 6th cervical nerves. The arm is turned in, 
and the forearm is turned out. Supination is impos- 
sible. Sometimes the sensory nerves on the inner sur- 
face are affected. Soon after birth it is noticed that 
the child cannot raise its arm at the shoulder, or flex 
its forearm at the elbow. The muscles affected are: 
Deltoid, biceps, infraspinatus, supinator longus, and 
supinator brevis. 
The Klumpke Type: In this form the 7th and Bth 
nerves are involved in conjunction with the upper cer- 
vical nerves. This results in paralysis of all the mus- 
cles of the upper extremity with extensive sensory 
involvement. Especially characteristic is the oculo- 
pupillary reflex. This consists of a narrowing of the 
palpebral aperture, with contracted pupil, caused by 
an affection of the sympathetic nerve. The pupils react 
to light. 
Diagnosis: Fracture of the clavicle and scapula and 
separation of the epiphysis of the humerus may be 
definitely ascertained by the X-ray. We must also 
exclude congenital peripheral paralyses, and pseudo- 
paralysis syphilitica (Parrot’s disease). In cerebral 
paralysis, we find a different distribution of the par- 
alysis, as well as increased muscular tone in the mus- 
cles affected, also increased reflexes. 
3 4 
CLINICAL PEDIATRICS 
Prognosis: Mild cases usually get well. Severe 
cases may be followed by paralysis and contractures. 
Treatment: Massage, Faradic and Galvanic current. 
Mastitis: Almost every new-born baby shows some 
swelling of the mammary gland, which appears on the 
second or third day and gradually increases in size 
until about the tenth day. Upon pressure of the gland, 
usually a drop of milk exudes. Sometimes we get an 
inflammation of the gland, which may result in sup- 
puration. 
Treatment: Wet dressing, or incision and drainage, 
if found necessary. 
Icterus neonatorum: This is a form of jaundice, 
which appears on the first to the fourth day after birth. 
It is of varying intensity. It takes six days to three 
weeks for the jaundice to disappear. The liver and 
spleen are normal. If the intensity of the jaundice 
increases during the second or third week, then it is 
due to sepsis, or congenital obliteration of the bile duct. 
In the latter condition, the urine shows the presence 
and the stools the absence of bile. 
Icterus is more intense in premature babies. 
No treatment is required. 
Hernia of the umbilical cord (congenital umbilical 
hernia) : In the sixth to the tenth week of foetal life, 
the cord contains loops of the intestines, which are 
subsequently drawn in. Sometimes the opening per- 
sists, and the proximal portion of the cord contains 
loops of the intestines and other organs. The sac is 
formed by the peritoneum and the amniotic membrane. 
The hernia appears as a swelling, egg- or pear-shaped, CLINICAL PEDIATRICS 
5 
and varying- in size from that of a chestnut to that of 
a child’s head. 
This hernia should be operated without delay. 
Persistent omphalomesenteric duct (Meckel’s Di- 
verticulum) : This duct should be obliterated in the 
second month of foetal life. It leads from the yolk to 
the intestines. Sometimes it fails to become oblit- 
erated, and causes the formation of a fistula between 
the intestines and the umbilicus. Prolapse of the 
mucous membrane gives it the appearance of a soft 
velvety tumor surmounted by the opening of the fis- 
tula. This fistula may be probed and discharges a 
cloudy fluid, coming from the intestinal tract. It may 
be differentiated from the urachus fistula, by the direc- 
tion of the canal. 
Treatment: Palliative—Touching the fistulous tract 
with silver nitrate stick, or actual cautery. Radical— 
Excision of Meckel’s diverticulum. 
Urachus fistula: The stalk of the allantois, which 
extends from the umbilicus to the bladder, should be- 
come obliterated during the second month of foetal life. 
Sometimes, however, it remains patent, resulting in 
the presence of a fistulous tract. 
The external appearance is very much the same as 
the omphalomesenteric fistula. Probing will show 
the communication with the bladder. The fistula dis- 
charges urine. 
Treatment: Cautery, or operation. DISEASES OF THE UMBILICUS 
Gangrene: This occurs when the cord refuses to 
mummify. There is great danger of infection. Treat 
by actual cautery. 
Infection of the Umbilicus: In the course of separa- 
tion of the cord, the umbilicus may be a portal of 
entry for infection. The infection may be local or 
general. 
Catarrhal omphalitis: This is manifested by a muco- 
purulent discharge. Treatment; Application of silver 
nitrate solution 1—5%,I—5%, or continuous wet dressing. 
Acute umbilical cellulitis: Redness, swelling and 
suppuration. Treatment: Wet dressing with liq. 
aluminii acetatis (dil. 10 times). When abscess for- 
mation is present, incision and drainage. 
Arteritis or Phlebitis : The former is more common 
than the latter. There may be no external evidence of 
infection. Arteritis may be present without any symp- 
toms except a slight rise in temperature and may be 
followed by complete recovery. Sometimes a fistulous 
opening may be found at the umbilicus, from which 
pus may be expressed. Care must be exercised in prob- 
ing not to bring on a hemorrhage. The deeper portion 
of the artery may be affected, in which case probing 
will be negative. Severe cases may be followed by 
peritonitis and symptoms of septic and pyemic infec- 
tion, including pleurisy, pneumonia, abscesses of or- 
6 DISEASES OF THE UMBILICUS 
gans and meningitis, with increasing icterus and 
hemorrhage from the umbilicus and organs. Phlebitis 
is recognized by symptoms of sepsis. It is less fre- 
quent and more unfavorable than arteritis. It occurs 
in feeble children. No pus can be expressed from the 
umbilicus. It may be complicated by erysipelas and 
umbilical gangrene. Phlebitis is usually fatal. Treat- 
ment is of very little avail. 
Granuloma of the umbilicus : This is simply “proud 
flesh,” caused by infection, in the course of healing. 
It has a raspberry appearance and may be sessile, or 
pedunculated. 
Treatment: The easiest method is to tie off the 
growth with sterile silk or iodine catgut. It may be 
excised with a pair of scissors, touching the base with 
a silver nitrate stick. 
Hemorrhage from the Umbilicus: This may be ar- 
terial, venous, or parenchymatous. Slight bleeding 
during the first few days is of no consequence. Con- 
tinuous bleeding during the second or third week, even 
parenchymatous, may result in death from exsanguina- 
tion. 
Hemorrhage may be a symptom of sepsis, syphilis, 
or rarely haemophilia. 
Umbilical hernia: Protrusion of the abdominal con- 
tents through the abdominal ring, causing a swelling of 
varying size, which can be reduced. Recovery is us- 
ually spontaneous. If it does not disappear during 
the first three years of life, operation is necessary. 
Treatment: Pressure; ligature; suture. 
Treatment: After reduction, draw the skin over the 
hernial opening in two lateral longitudinal folds. These 
may be held in place by two overlapping strips of Z. O. CLINICAL PEDIATRICS 
plaster, 4 inches long and 1 inch wide. These may be 
changed in one or two weeks. Bathing does not re- 
move the plaster, but it can be easily removed with 
benzene. DISEASES OF THE NEWBORN 
Tetanus neonatorum: Infection enters through the 
umbilicus. Symptoms appear during the second or 
third week. There is a slight rise in temperature, 
tonic spasm of the jaw muscles (trismus). Later 
these are followed by tonic spasms of muscles all over 
the body. Spasms are produced by the slightest irri- 
tation. The tonic contraction finally becomes constant, 
especially the trismus, causing risus sardonicus. Swal- 
lowing becomes impossible. Death comes after a few 
hours to a few days, and is caused by a spasm of the 
diaphragm, or exhaustion. Only 20% recover. Re- 
covery is slow and takes a few weeks. 
Diagnosis: It may be differentiated from cerebral 
hemorrhage, meningitis and encephalitis by lumbar 
puncture and absence of trismus. We must also think 
of hydrocephalus and congenital diplegia. 
Treatment: Solution of Ac. Carbolic strength, 
dose oi q. 2 h., hypodermatically, by mouth or rectum. 
Atropine Sulph 1/5000 gr. daily. We may also try 
Magnesium Sulph 8-io gr., subcutaneously, frequently 
repeated. 
Antitetanic serum is of value only when used before 
the development of the disease. 
Reed as much as possible by mouth, or through a 
catheter, passed by the nasal route. 
Erysipelas: This infection usually begins at the 
umbilicus, and spreads downward, rarely upward. The 
9 CLINICAL PEDIATRICS 
main characteristics are: Redness with a definite bor- 
der, induration, formation of blebs, sometimes gan- 
grene and rarely a phlegmonous process. Temperature 
may be normal or high. The disease is usually fatal. 
Prognosis is better in older children. 
Treatment: Paint Tr lodine along the border line 
of the redness, then use a wet dressing of Liq Aluminii 
Acetatis 50% strength. 
The following is a good ointment 
Ichthyol oss 
Pot. lodide grxv 
Pulv. Belladonna Fol grxv 
Lanoline §i 
Vaccines (autogenous, or polyvalent) have so far 
proved of little value. 
Internal medication of carbolic acid 14% Sol. oss-i 
q. 2 or 3 h. is safer than is generally believed. 
Ophthalmia neonatorum; Conjunctival mucous 
membrane becomes infected in the course of parturi- 
tion. The inflammation may be simple, or gonor- 
rhoeal. 
The latter is more intense. There is more discharge, 
which is thick and greenish yellow. In the gonor- 
rhoeal form there is also a marked oedema of the lids. 
It may spread to the cornea and cause perforation. The 
simple blenorrhoea is mild and usually gets well in a 
few days if treated properly. The gonorrhoeal form 
usually lasts two to four weeks. In rare cases arthritis 
will develop as a complication. Still more rarely, 
stomatitis may develop. 
A pneumococcus infection may be quite severe, but 
the cornea remains intact. DISEASES OF THE NEWBORN 
Treatment: Prophylaxis—Crede’s method, i. e., 2% 
Silver instilled soon after delivery. When the disease 
18 developed, keep the baby in a dark room and use 
applications to the eyes. Douche the eyes 
Wlth a 4% Boric acid sol., or 1/5000 Bichloride, as often 
as is necessary to keep the eye free from discharge. 
Once daily we may instil a drop of a 2% solution of 
silver nitrate, or 25% solution of argyrol. 
Instead of argyrol we may use cresatin (meta- 
cresol), 25% in albolene once daily, until the discharge 
stops. Excellent results have been obtained (Bar- 
nert). 
Sepsis in infancy: Infection may enter through the 
nmbilicus, eyes, any abrasion of the skin, mouth, geni- 
tals, and gastrointestinal tract. There may be no char- 
acteristic symptoms, the first sign of sepsis being col- 
lapse. Then we may have cases that show symptoms 
°I gastroenteritis only. Other cases may produce 
various clinical pictures, depending on the intensity of 
the infection, or the organs affected. 
Thus we may have: high temperature, pallor, jaun- 
dice, hasmatemesis, hemorrhage from the bowels, kid- 
neys, genitals and umbilicus, pneumonia, peritonitis, 
Meningitis, suppuration of the parotid glands, suppu- 
ration of the joints, rarely osteomyelitis. We may also 
find multiple skin abscesses, scleroedema, and some- 
times sclerema, especially in premature babies. 
Buhl's disease: Probably a form of sepsis. It is 
usually found in babies who have had asphyxia. The 
temperature remains normal. The umbilicus appears 
normal except for a little subcutaneous hemorrhage 
around it. There may be vomiting of blood, blood in 12 
CLINICAL PEDIATRICS 
the stools, oedema of the dependent parts of the body; 
asthenia and death is the usual outcome. 
Pathological finding: a fatty degeneration of the organs. 
Epidemic hasmoglobinuria (Winckel’s disease) : This 
is another form of septic infection. The symptoms ap- 
pear on the 4th to the Bth day after birth. The char- 
acteristic signs are: Icterus, cyanosis, h£emoglobinu- 
ria. Death usually follows after two days. 
Treatment: Stimulation with Tr Digitalis (TUss-i) ; 
Caffeine sodium benzoate (grss), camphor (grss), 
given every 3 or 4 hours. 
Open abscesses, wherever present. We may also 
give physiological saline solution of hypodermoclysis 
(4 oz. every 4 hours) or transfusion. 
Colloidal silver (Gr iss) may also be given intra- 
venously, or by rectum. 
Melaena neonatorum: This term denotes hemor- 
rhage from the intestinal tract in the newborn. The 
probable cause is weakening of the capillaries, through 
asphyxia, or the formation of ulcers on the mucous 
membrane of the stomach, or duodenum. Hemophilia 
may be excluded, as it does not occur during the first 
few months of life; it is also more frequent in the male 
and is hereditary. The other causes to be considered 
are; sepsis and syphilis. On the other hand, blood, 
sucked up from the mother’s breast, may be swallowed 
and later vomited. Blood may also come from the 
baby’s mouth or nose. 
Tendency to bleed may last a few days or weeks. 
Bleeding usually begins during the first few days 
and rarely after the twelfth day. Cases vary in in- 
tensity. The bad cases are fatal in one to three days. DISEASES OF THE NEWBORN 
Treatment: This, as a rule, is of little avail. We 
may try hypodermoclysis with a 10% solution of Rus- 
sian gelatin. Injection of horse serum and trans- 
fusion may be resorted to in desperate cases; or injec- 
tion of coagulose (P. & D.) subcutaneously. Sub- 
cutaneous injection of fresh blood or human serum 
may be tried (4 c.c. at a time). 
Prematurity: Causes.—Severe traumatism, too 
much exercise, insufficient exercise, poor nutrition of 
the mother, twin pregnancy. The most common dis- 
eases to cause prematurity are: syphilis, tuberculosis, 
nephritis, endocarditis, scarlet fever, typhoid pneu- 
monia, chorea, intoxication, such as alcoholism, lead, 
phosphorus, mercury, or arsenic poisoning. 
hhe average weights and length are as follow: 
Weight 
Length 
6 months 2,y2 lbs 14 in. 
61/> months 3 lbs in. 
7 months lbs in. 
7/4 months 5 lbs 17 in. 
8 months 6 lbs 18in. 
Healthy premature children usually get on very well, 
and in later months almost equal full-term babies in 
Slze and development. Debilitated children do very 
poorly and remain below par for years. Prognosis is 
better in children that weigh 5 or 6 lbs. than those who 
weigh less. The functions of all the organs are slug- 
gish. Thus, we have constipation, uric acid infarction, 
which may cause suppression of urine and colic. 
Treatment: Heat and careful feeding. Heat may 
be supplied by the incubator, or hot water bottles. 
Only very small babies should be wrapped up in cotton 14 
CLINICAL PEDIATRICS 
batting. Watch the baby, as there is danger of raising 
the temperature too high. 
Feeding: Breast milk, whenever possible. This 
is imperative. Feed every two hours. The quantity 
given should be 1/5 of the body weight to 1/6 at full 
term per day. When we have to resort to artificial 
feeding, we may use cow’s milk, pasteurized or pep- 
tonized. As to quantity used, we must be guided by 
the child’s weight. The caloric requirement for 24 
hours is 50 calories for each pound of weight. Thus a 
child weighing 5 lbs. should get 250 calories. Total 
quantity of fluid per day would have to be about 18 oz. 
(1/5 of the body weight). To get 6-7% sugar, we 
would have to use 1 oz. of milk sugar. 
1 oz. sugar . .. 120 calories 
6 oz. milk 126 calories 
Total 246 calories 
Add 12 oz. water to make up 18 oz 
Divide into 9 bottles. 
We cannot depend on calories to give us the exact 
quantity, as some babies stand more food than others. 
It is safer, therefore, to start them on smaller quantity 
and gradually increase. 
Congenital asphyxia—Causes: Compression, or 
twisting of the cord, premature detachment of the 
placenta, abnormal cerebral pressure of the foetus, pre- 
mature efforts at respiration, maldevelopment of the 
heart and lungs, prematurity; on the mother’s side: 
prolonged labor, hemorrhage, convulsions, ergot, death 
of the mother. 
Symptoms: Cyanosis, varying from a livid color to DISEASES OF THE NEWBORN 
15 
a deep blue. Skin is not irritable, and slapping does 
not bring on respiration. Heart action is weak and 
meconium flows out. The cord is flaccid and almost 
empty. The condition must be differentiated from 
cerebral hemorrhage, which is characterized by the 
following: history of forceps delivery, coma, possibly 
paralysis, bulging of the fontanelles. Severe hemor- 
rhage, as from rupture of the cord, may simulate as- 
phyxia. 
Treatment: Turn the child upside down and spank. 
Hot bath at no° F., followed by cold plunge at 68° F. 
Artificial respiration (swinging of Schultze, or arti- 
ficial respiration of Dew). Expiratory movement must 
he made first. Inflation of the lungs, mouth to mouth 
(may distend the stomach). We may use catheter in 
the larynx, or Draeger pulmotor. Baby must be 
watched for 24 hours. 
Atelectasis: This is a state of incomplete inflation 
°f the lungs in the newborn. It usually affects the 
Posterior portion of the lungs. The inflated portion is 
usually emphysematous. There may be cyanosis at 
hirth from which the baby may never recover, or else 
the baby may die after a few hours, or days, in a feeble 
condition, or in convulsions. It may live for a few 
months, during which time it is prone to attacks of 
cyanosis, from which it may recover or die. The child 
is feeble, the cry is weak. Physical signs are not sig- 
nificant, except when one side only is affected, when, 
°n comparing with the normal side, we find dullness 
and diminished, rough or bronchial breathing. 
Treatment: Spanking, immersing in hot and cold 
water. Take baby up, do not let it lie in the crib all 
the time. CLINICAL PEDIATRICS 
Scleroedema: Premature children, with poor cir- 
culation, are predisposed to the condition, also infants 
with hereditary syphilis, or congenital heart disease, 
or sometimes nephritis. The affection occurs only in 
the newborn. The skin is pale, or bluish in color. The 
swelling begins on the back of the feet, or the face, 
mons Veneris, scrotum and penis, and then the oedema 
becomes general. The chest is not affected. The oede- 
ma is doughy and pits on pressure. Serous cavities are 
not affected. The urine may show a heavy sediment, 
but does not contain any albumen. The temperature 
is subnormal (may go down to 86°). The child grad- 
ually becomes weaker and sometimes gets convulsions. 
Death usually takes place after three days. Recovery 
is possible. Sometimes this disease is associated with 
sclerema. 
Treatment: Warm baths, stimulation and careful 
feeding. 
Sclerema: This may occur at any time during the 
first few months of life. Onset is similar to scler- 
oedema. The head and upper extremities are last 
involved. The genitals and soles of feet are free, as 
also are the palms of the hands. 
At first the skin is doughy, but it soon becomes hard 
and board-like. The child gradually becomes stiff, 
as if frozen, is unable to take any nourishment, loses 
strength rapidly, may get convulsions. Death usually 
takes place in a state of coma after three or four days. 
Recovery is possible, but is very gradual. 
Treatment: Avoid chilling of premature and atelec- 
tatic babies. Subcutaneous injection of a .3% solu- 
tion of sodium chloride, twice daily; also enemata of 
normal saline solution. DISEASES OF THE NEWBORN 
17 
Pemphigus, traumatic: May be brought on by 
hot baths. 
Specific: Usually present at birth and does not ap- 
pear later than two weeks after birth. Bullse are pres- 
ent on the soles of the feet and palms of the hands. 
Other signs of syphilis are generally present. 
Infectious form (Demme found diplococcus) ; The 
entire body may be covered with large vesicles (%. 
lnch in diameter). The trunk is affected first. The 
vesicles may fuse and form large bullse. Soles and 
palms are not affected. The affection appears on the 
third or fourth day after birth. The bullse dry and 
form crusts, which upon shedding leave a red or vio- 
let surface. 
Prognosis is usually good, unless the entire surface 
18 covered. 
Inanition fever: Starvation may cause a rise in 
temperature. The fever is usually not higher than 
1o 1 -1020 F., but may sometimes go up as high as 104°. 
Give water every two hours and attend to the feeding. NUTRITION 
Proteids: Build up tissue. 
Fats: Save tissue and build up nerve and bone 
tissue. 
Carbohydrates: Save tissue and make fat. 
Salts: Phosphates of calcium and magnesium help 
in formation of bone. 
Water: 90% of animal food. Acts as a diluent, 
helps digestion and excretion. In proportion, babies 
use six times as much water as adults. 
Woman’s milk: During the first two or three days 
after childbirth the breasts secrete a thick yellow fluid 
called colostrum. Sp. Gr. of this fluid is 1040, fat 
globules are uneven. Microscopical examination dis- 
closes the presence of large granular cells called colos- 
trum cells. The colostrum coagulates to solid upon 
boiling. Its principal ingredients are: 
Proteids 5.70% 
Sugar 3.70 
Fats 2.00 
Salts .28 
Water 88.00 
Mother’s milk is bluish in color and sweet. The 
fat globules are very fine; sometimes epithelial cells 
are present. Reaction is neutral or alkaline. 
18 NUTRITION 
19 
Quantity at one nursing 
Ist week oz. 2nd month 2-5 oz. 
2nd week 1-3 oz. 3rd month 3'5JA oz- 
3rd week oz. 4th month 3-6 oz. 
4th week 13/2-434 oz. sth month 4-634 oz. 
6th month 5-7 oz. 
The increase in quantity taken is not always uni- 
form. We often find that the baby will take less 
during the fourth month than during the third, and 
Will not increase again until the sixth. 
Composition of woman’s milk: 
Fats 4% 
Sugar 7% 
Proteids 13/2% 
Salts 20% 
Water 87% 
There is little change in quality of the milk after the 
Ist month. 
Examination of breast milk: Full breasts are firm 
and hard. Poor breasts are soft and flabby. From a 
normal breast a child ought to get enough in 20 min. 
or less. The first part of the milk contains more pro- 
teids, and the last part more fats. To tell exactly the 
amount taken at each feeding, weigh the baby before 
and after the feeding. For examination, get all the 
milk that you can from one or both breasts. 
The quantity of proteids is recognized by the Sp. Gr. 
The quantity of fats—allow milk to stand 24 hours; 
5 parts of cream = 3 parts of fat. 
High fats give a low Sp. Gr.; high proteids give a 
high Sp. Gr. 20 
CLINICAL PEDIATRICS 
Condition affecting the mother’s milk: 
Age—Quality poor when too young or past 35 yrs. 
Illness—Poor milk. 
Menstruation—No constant effect. 
Diet—Nitrogenous diet gives best milk. 
Alcoholic malted drinks increase proteids and fats 
and quantity. 
Simple nutritious diet is best. 
Malt preparations may improve the quality of the 
milk. 
Pregnancy affects the quality of the milk. The milk 
becomes poor. 
Nervous impressions and shocks may change the 
character of the proteids and cause a toxic effect, with 
vomiting, undigested stools, fever and even convul- 
sions. 
Cow’s milk; It should be fresh. Delivery should 
be made 12 hours after it is drawn. Milk should come 
from healthy cows, which have been subjected to the 
tuberculin test. The milk is better when it comes 
from a herd than from a single cow. Cleanliness 
should be practiced in milking. It should be bottled 
and kept at a temperature of 450 until used. 
Composition: 
Fats, 3.50 
Sugar, 4.30 
Proteids, 4.00 
Salts, .70 
Water, 87.00 
Sp. Gr. 10.28-10.33 
Milk that has been skimmed may have a slightly 
higher Sp. Gr. 
Reaction is neutral, or slightly acid. NUTRITION 
21 
If the milk is too alkaline, something has been put in. 
Fats may be determined by Babcock’s centrifugal 
machine. (After sulphuric acid acts on the proteids, 
fats are brought to the surface). 
Cream is not reliable. Four parts of cream = I part 
of fat. 
Cream: Upper 9 oz. of qt. bottle contain 12% of 
cream. Upper 16 oz. of qt. bottle contain 7% of 
cream. 
Milk sterilization; This may be accomplished by 
boiling. Even after boiling, the milk is not free from 
germs, as some spores are very resistant. Boiled 
milk may remain standing at ordinary room tempera- 
ture for a few days without souring. It is, however, 
unsafe to use, as injurious bacteria are apt to grow, 
owing to the fact that lactic acid bacilli are destroyed. 
The presence of lactic acid bacilli prevents the growth 
of injurious bacteria. 
Pasteurization: Bottles are heated at a temperature 
of 167° in a water bath for j/2 hour. We may obtain 
the same result by heating the milk in a parboiler until 
the milk begins to steam. Most of the pathogenic 
bacteria are thus destroyed. Cool off and keep in the 
ice-box. 
Peptonized milk; To one pint of milk add 4 oz. of 
water and 15 gr. of bicarbonate of soda; 5 gr. of pan- 
creatic ext., or 10 gr. of Fairchild’s peptogenic milk 
powder are then added. Place in a water bath at a 
temperature of ios°-iis° F. We get partial peptoniza- 
tion after 10 minutes. Bring then to a boil to arrest 
further fermentation. Taste is unchanged. Complete 
peptonization is obtained after two hours. This last 
product is bitter. This milk is given to babies with 22 
CLINICAL PEDIATRICS 
poor digestive power. Do not continue for longer 
than a month; then gradually shorten the peptoniz- 
ing process. 
Condensed milk: Rich in sugar and poor in fat. 
We may use this when weaning, or when cow’s milk 
does not agree with the baby. Use it in dilution of 
i-io. Condensed milk should not be given as a per- 
manent food. 
Skimmed milk: This is obtained by decanting off 
the cream which collects at the top of the milk. It 
is used in cases of diarrhoea caused by seeming intol- 
erance of the fat ingredient of cow’s milk. 
Buttermilk: Poor in fat and sugar. Contains lactic 
acid bacilli and is especially adapted in cases of 
diarrhoea. We may sweeten it by the addition of 
saccharin, I gr. to a quart. 
Whey: Rich in salts and lactic acid, poor in pro- 
teids. May sometimes be tried in cases of poor diges- 
tion. 
Beefjuice: Broil steak rare and express the juice 
with meat squeezer. Given as additional food after 
the Bth month and sometimes earlier. Quantity given 
at a feeding is to 2p2 oz. 
Broth; No nutritional value; only stimulating, but 
is useful as a vehicle for bread, cereal and potatoes. 
Barleywater: Prepared from Robinson’s patent 
barley. Use one teaspoon to a tablespoon to a pint of 
water. Mix the barley in a cup of cold water, then add 
to boiling water; cook slowly for 10-15 min. It is 
used as a diluent and modifier of milk. The starch is, 
as a rule, digested after the third month. INFANT FEEDING 
i. Breast. 
2. Partially breast, 
Breast feeding: Nursing every 3to 4 hours. Each 
nursing takes 5 to 20 minutes. If the child cries to 
remain longer than 20 min., it means that the milk 
is insufficient. 
3. Artificial. 
Care of breast: Wash nipples before and after feed- 
ing, keep breast covered with clean gauze between 
feedings. 
Nursing during the first days: 
First day, every 8 hours. 
Second day, every 6 hours. 
Third day, every 4 hours. 
After that, every 3 to 4 hours. 
It is best not to allow the baby to go longer than 
4 hours during the day, but never arouse a baby for 
feeding at night. Usually the baby will get along 
with one feeding at night and some babies will sleep 
right through the night. 
Nursing habits: Good ones are easily acquired. The 
tendency of the mother is to interpret every cry as 
that of hunger. Frequently a baby may, through 
overfeeding, suffer from indigestion, vomiting, colic, 
diarrhoea, and yet it continues at the breast every 
hour or two, thus adding insult to injury. It is a poor 
policy to nurse at intervals of less than three hours, as 
23 24 
CLINICAL PEDIATRICS 
nursing frequently at an empty breast will not help 
matters. 
Inadequate nursing: Sometimes mother’s milk is 
either insufficient in quantity or poor in quality. De- 
termine quantity by weighing the baby before and 
after feeding. If the quantity is insufficient, the baby 
will cry immediately after feeding, or half an hour to 
an hour before feeding time it will have a tendency 
to suck its fingers and tug at the bedclothes. The 
other features are; no vomiting, small, constipated 
stools of normal color. 
Treatment: Give water after each feeding; treat 
the mother. May have to give a supplemental feed- 
ing or get a wet-nurse. If the mother’s milk is ab- 
solutely inadequate, and it is impossible to procure 
a wet-nurse, then we have to resort to artificial feed- 
ing. 
Excessively rich milk, or too frequent, or too pro- 
longed feedings; The child at first has frequent and 
undigested stools. Later, vomiting also develops. 
Treatment: Lengthen intervals between feedings 
and shorten duration of each feeding. 
Management of woman’s milk, when child does not 
thrive: Mother must not worry. She must have good 
food and plenty of out-door exercise. Stimulate the 
appetite, also give tonic foods, such as malt food, 
malted drinks, etc. 
Quantity deficient—Will increase with the improve- 
ment of the mother’s condition. Sometimes it is due 
to a poor condition of the nipples, when it is neces- 
sary to bring them out by gentle massage. 
Quantity abundant, but quality poor: Try to im- 
prove the mother’s health. Sometimes the quality INFANT FEEDING 
25 
never improves and it is necessary then to get a wet- 
nurse or start artificial feeding. 
Wet -nurse: She must be healthy, 20-30 years of 
a"e. Primiparse are preferable. Examine carefully 
for tuberculosis (physical examination and Von Pir- 
fiUet test) ; also for syphilis (Wassermann test). Ex- 
amine the nurse’s baby, if possible. Breasts must be 
good and nipples normal. Examine before and after 
feeding and note the difference. For a baby 3 weeks 
old, the nurse must not be more than 6 weeks after 
labor; for a baby 6 weeks old, the nurse must not be 
more than 2-5 months after labor. The nurse’s habits 
must be good and she must be temperate. 
Weaning: The baby must be weaned at the age of 
10 months to one year. 
Causes for early weaning: Pregnancy, menstrua- 
Pon during the period of lactation (if the quality of 
fhe milk becomes poor), severe illness of the mother, 
ff the illness is of short duration, we may keep the 
breast from drying up by pumping. 
If the milk continues in poor quality, in spite of 
continued efforts to improve the mother’s health, and 
fbe baby loses, instead of gaining, it is best to wean. 
Weaning should be gradual, if possible. The breast 
feedings may be dropped one by one, substituting arti- 
ficial feedings. 
Mixed feeding: Breast and bottle. We have to 
resort to this method when the baby does not gain on 
fhe breast alone. 
We may start in by substituting a bottle for one 
°f the breast feedings, and watching the weight. If 
fbe gain is not sufficient, we may substitute bottles 
for two feedings, etc. . ARTIFICIAL FEEDING 
Breast milk is the natural food for the baby, and we 
should obtain it whenever possible. Only when our 
attempts to obtain good breast milk have failed should 
we resort to artificial feeding. 
The best substitute for breast milk is cow’s milk. 
Fortunately, most babies take kindly to it. 
The percentage of the ingredients of cow’s milk 
differs from that of mother’s milk. Thus: 
Fats Sugar Proteins 
Mother’s milk .... 3.5% 7% 1.5% 
Cow’s milk 4.0% 4% 4.0% 
Attempts have been made to modify cow’s milk in 
such a manner as to simulate mother’s milk. The 
principal difference is in the percentage of proteids, 
which in mother’s milk is about one-third of that found 
in cow’s milk. 
If we reduce the proteids by simple dilution we also 
reduce the fats and sugars. To get, therefore, the 
proper percentage of fat, it is necessary to use milk 
rich in cream. To get the proper percentage of sugar, 
it is necessary to add sugar. 
Thus to get a mixture containing three times as 
much fat as proteid, we must use 12% top milk for 
dilution. (Gravity cream, upper 9 oz. of the bottle.) 
To get a mixture containing twice as much fat as 
proteid, we use for dilution 7% milk (upper 16 oz. of 
the bottle). 
To illustrate: For example, we wish to get a mix- 
26 ARTIFICIAL FEEDING 
27 
ture containing 5% fat, 6% sugar, and one per cent, of 
proteid: 
The ratio between the proteid and fat is 113. There- 
fore we use the twelve per cent, gravity cream. To 
a baby 2 months old, we would give 7 bottles, 4 oz. 
each; total for 24 hours, 28 oz. 
Multiply the total number of ounces required by 
per cent, of fat desired, and divide by the per cent, of 
milk used for dilution. Then add enough water to 
up 28 oz. 
Thus: 7 Mixture: 
A X j QZ 7 oz. milk 
12 21 oz. wate 
24 Total 28 oz. divide into 7 Bottles 
21 oz. water 
To determine the amount of sugar to be used, we 
calculate the quantity necessary to make a 5% solu- 
tion. This would mean oz. to each 10 oz. of 
the mixture. One-half oz. is approximately one level 
tablespoon. This additional sugar, together with 1% 
aEeady present, after the milk has been properly di- 
luted, would give us 6% sugar. 
To get a 4-6-2 mixture, we would have to use the 
milk, in which the ratio between fat and proteid 
Is 2:1. Thus, to get a total of 28 oz.: 
4 
2$ X 4 f. 
= io oz. 
1 
16 oz. 7% milk. 
12 oz. water. 
Total 28 oz 
Percentage feeding, logical as it may seem, has not 
solved the problem of infant feeding, and we use it now 
°nly occasionally. 28 
CLINICAL PEDIATRICS 
Whole milk feeding; The cream must be evenly 
distributed by vigorous shaking of the bottle. To 
determine the quantity to be used, it is necessary to 
have some guide. It has been ascertained that the 
body requires a certain number of calories (heat 
units), according to its weight, so that it may be prop- 
erly sustained and developed. 
A calorie: Amount of fuel, yielding heat, sufficient 
to evaporate i c.c. of water, or to raise the temperature 
of i litre of water i° C. 
During the first three months—The baby requires 50 
cal. for each pound of weight, for 24 hours. 
During the second three months—4s cal. 
During the third three months—40 cal. 
During the fourth three months—3s cal. 
1 oz. milk = 21 calories 
1 oz. sugars 120 calories 
Example; 
Baby during the first month, weighing 7 lbs. 
350 cal. is the amount necessary for 24 hours. 
7 X 5° = 350 cal. 
We use 1 oz. sugar, which equals 120 cal. 
To get the proper amount of milk to be used, we 
subtract 120 from 350, and divide by 21. Thus: 
350— 120 = 230 -f- 21 = ny2 
I oz. sugar 
oz. milk 
35° cal. 
This gives the maximum amount that can be ordered 
for this baby for 24 hours. Some babies require less 
than others. It is not safe, therefore, to begin with the 
maximum caloric requirement. Some babies require ARTIFICIAL FEEDING 
29 
even more than the amount indicated by caloric figures. 
It is safest to begin with less and gradually increase 
according to the baby’s progress. 
Calories give us only an approximate guide. We 
must really be guided by the baby’s gain in weight, 
and the behavior of its stomach and bowels. 
Dilution: We usually begin with two parts of water 
to one part of milk. The milk is then gradually in- 
creased until at six weeks we use equal parts of milk 
and water. After that the milk is gradually increased 
until at three months two parts of milk and one part 
°f water are used. Even less water may be used. 
Number of feedings: 
Ist 3 months—7 bottles at intervals of hours 
2nd “ “ 6 “ “ “ “ 4 
3rd “ “ 5 “ “ “ “ 4 
4th “ “ 4 “ “ “ “ 4 
It is never necessary to use more than 1 quart of 
milk a day, as during the last three months other food 
Is added. 
Watch the baby’s weight and stools and increase 
accordingly. 
Indications for increase: 
If the baby drains its bottle and cries. 
If it cries hours after feeding, and the stools 
are normal, or small and constipated. 
If the baby seems to be doing well, but does not 
gain in weight. 
Increase 1 oz. for 24 hours at a time, and sugar 
accordingly, until the baby is satisfied and shows 
Uornial weekly gain. CLINICAL PEDIATRICS 
30 
Sugar: We generally use one level tablespoon to 
each 10 oz. of the mixture, which makes it about 1-13/2 
oz. for 24 hours. 
Sometimes, owing to constipation, it is necessary 
to change to another form of sugar. 
We use milk sugar by preference. 
The other forms of sugar are as follows: 
Malto-dextrose 
Cane sugar 
Malt extract 
When constipation persists, we may use one tea- 
spoonful of milk of magnesia to one or two of the 
bottles. Often we find that the stool is in the rectum 
but that owing to weak muscular tone the baby is in- 
capable of expulsion. In these cases the treatment 
does not depend on change in the formula. 
Children suffering with constipation, with loss of 
weight, should be tried on the Maltsoup mixture: 
A—One pint of milk, mixed together with one 
heaping tablespoon of wheat flour 
B—One pint of water; oz. Maltsoup (Loe- 
Mix A and B together, and cook slowly over a small 
flame for half an hour; then bring to a boil to stop 
further fermentation. Strain this mixture through 
cheesecloth. Feed in quantity corresponding to the 
age and weight of the baby. 
flund’s) 
The following table is based on caloric require- 
ment, according to the babies’ weight and age. The 
quantities given are a little below the exact figures. 
If after one week the baby acts well but does not show 
a normal gain, we simply increase the 24-hour quan- ARTIFICIAL FEEDING 
tity, one ounce at a time, and continue to increase 
each week until we get the desired result. In later 
months the increase in the quantity used is propor- 
tionately less than in the earlier months. This is due 
to the fact that additional food is allowed, making 
up the necessary calories. 
During the first three months we use plain boiled 
■water for dilution; subsequently, barley water may 
be used. 
Weight Whole Milk Sugar Water Divided into No. Bottles 
6 lb. 9 oz. 2 level 15 oz. “ “ 7 “ 
tablespoons 
7 “ ii “ 2 “ 15 “ “ “ 7 
8 “ i 3 “ 2 “ 14 “ “ “ 7 “ 
9 “ I 5 •* 2 “ 10 «< “ “ 6 
10 “ I 7 “ 2IA “ io “ “ “ 6 
11 “ I 9 « - .< 10 « “ « 6 
12 » 22 « 3 « „ « » « 6 
13 <* .. 3 “ 8 “ “ “ 5 
14 “ 25 “ 3 “ 8 “ “ “ 5 
is « 26 .. 3 “ 7 “ “ “ 5 
16 “ 28 “ 3 “ 7 “ “ “ 5 “ 
17 » 29 “ 3 “ 7 “ “ “ 5 
18 “ 3! “ 2 “ 7 “ “ “ 5 “ 
19 “ 32 “ ! “ 6 “ “ “ 5 
20 “ 32 “ o “ o “ “ “ 4 
Supplementary diet from 9to 18 months: The fol- 
lowing may be allowed in rotation: Orange juice 
(5-§i gr., an hour before the 6 o’clock bottle), farina 
(boiled in water for an hour), oatmeal (macerated in 
Water over night and boiled for two hours in the morn- 
lng), crust of bread or zwieback (dry or soaked in 
uulk), egg, beef-juice (with baked potato or bread), 
baked potato, carrots and peas, spinach, prunes, 
S(waped raw apple, asparagus, apple sauce, stewed 
pears or peaches, custard, scraped beef. We may also 
give soups with farina, potato, barley, etc. During 
tbe second year the diet may be divided into three 
Aguiar meals, 8 ounces of milk being given at the 
end of each meal. 32 
CLINICAL PEDIATRICS 
Diet from 18 months to three years: In addition to 
the articles of diet mentioned above, we may give: 
chicken, steak, roast beef, chops (cut up very fine) ; 
also ripe apples, pears and peaches. Do not give meat 
at evening meal. Raw fruit should be given after 
breakfast; vegetables at noon; stewed fruit at supper. 
Diseases of Nutrition 
Acute inanition: This may occur in cases of acute 
indigestion, but there are cases of inanition in which 
symptoms of indigestion are not prominent. 
Causes: Insufficient quantity of milk. 
Milk of poor quality. 
Inability to assimilate food (frequent in prema- 
ture babies). 
The child for some reason refuses food. 
Sudden change of food. 
Pyloric stenosis, pylorospasm. 
Symptoms: There may be loss of weight. Symp- 
toms may come on suddenly, with death in two or 
three days. The child loses weight rapidly, 3 or 4 
ounces daily. The skin is pale and dry, or it may 
be covered with a clammy perspiration. Sometimes 
petechial spots appear. Bad cases are cyanotic. The 
child whines and is fretful or semistuporous. The 
pulse is weak and rapid, the extremities are cold, res- 
pirations are rapid. The fontanelles are depressed. 
Pupils are sometimes contracted. The child may take 
food; when fed, retain it for a few hours, and then 
vomit the whole quantity. Stools are diarrhoeal, rarely 
constipated. If the child has not taken any food for 
two days, the stools look like meconium. DISEASES OF NUTRITION 
33 
Babies under one month succumb very rapidly. 
Temperature may be high, or subnormal. 
Prognosis is uncertain, depending on the rapidity 
of the loss of weight. 
Treatment: First, make sure that the baby is not 
suffering from disturbance of balance, caused by over- 
feeding. If such is not the case, get a wet nurse, if 
Possible. 
We may try breast milk or cow’s milk, in small 
quantities, given every two hours. It is best to pep- 
tonize the milk from 10 minutes to 2 hours. If the 
child vomits that, give water and no food until the baby 
stops vomiting. 
May try gavage (feeding through a stomach tube). 
May add 2 gr. of sodium citrate to each ounce of 
milk. 
If the baby cannot retain milk, may try: Animal 
broths, whey, dilute buttermilk, malted milk, condensed 
milk. All these must be given in small quantities and 
Very much diluted. 
Keep the baby warm with hot water bottles or cot- 
ton batting. 
Use inunctions of cocoa butter or oil. 
Malnutrition: Caused by poor heredity. There is 
Usually a history of tuberculosis, syphilis, gout, al- 
coholism, etc., in the parents. May be weak from 
birth, or premature. Other possible causes are; im- 
proper feeding, insufficient fresh air, severe acute 
diseases. 
Malnutrition may persist for many years. 
Infants—Babies are much under weight, gain very 
slowly (4-6 oz. a month, instead of 1-2 lbs.). They 
me anaemic, cannot sit up before the end of the first 34 
CLINICAL PEDIATRICS 
year, or stand before the age of ij/2 or 2 years. They 
have a tendency to be fretful and sleepless. There is 
feeble power of digestion and gastrointestinal disturb- 
ance from the slightest cause. The skin is dry. They 
are prone to sweating about the head. Dentition may 
or may not be delayed. They may gradually develop 
and become normal, or go on to marasmus. These 
babies are susceptible to diseases of childhood and 
tuberculosis. 
Older children: Pale and thin, sometimes over- 
grown and nervous. They do not sleep well and are 
subject to night terrors. They also have poor diges- 
tion, constipation, anaemia. With proper care they 
may improve, if heredity is not bad. 
Treatment: Attention to feeding. Feeding must be 
given at regular intervals, in proper quantities, approxi- 
mately in accordance with the caloric requirement. 
The baby should be out in the open air as much as 
possible. 
In older children, must pay strict attention to the 
rule of three meals a day, with no food between meals. 
This means no candy, cake, fruit, bread and butter, 
etc. The meals must be simple and nourishing. An- 
other important rule is to train the mother not to 
coax the child to eat, but be guided by the child’s 
appetite and do nothing to spoil it. The parents must 
not try to give tempting food in order to please the 
palate and thus to make up for a neglected meal. The 
child must eat only because it is hungry. Coaxing will 
make the child associate food with something disagree- 
able and a dislike for food follows. The child must 
also have plenty of out-door exercise. A daily bath DISEASES OF NUTRITION 
35 
with a cold sponge is important. As an aid, we may 
also give tonics: 
Maltine and iron 
Liq. ferri peptomangan. 
Arsenic. 
Marasmus (infantile atrophy, simple wasting) : This 
does not include wasting from tuberculosis, syphilis, 
°r ileocolitis. It is a disease of nutrition. 
Causes: Prematurity, weak heredity, improper feed- 
ing, or poor assimilation of food. 
Symptoms: Appearance is characteristic. The fea- 
tures are thin and prominent, large eyes, hollow tem- 
ples, body emaciated, skin wrinkled, senile appearance, 
and large abdomen. Anaemia is marked. Sometimes 
followed by oedema, beginning by gain in weight. 
There is vomiting and regurgitation of food, stools 
inay be normal, or may contain undigested food and 
niucus. Digestion is easily upset. The baby refuses 
food and must often be kept up by gavage. Tem- 
perature is subnormal. Sometimes sudden death ad- 
venes from some unknown cause, possibly due to 
aspiration of regurgitated food, which the baby is too 
Weak to vomit. During the summer, death may result 
from slight digestive disturbance. We may also have 
thrush, erythema of the buttocks, opisthotonos. 
Treatment: Careful feeding, fresh air, warm baths. 
Make the baby cry once a day and keep it warm. 
Scurvy: This disease is characterized by a spongy 
condition of the gums, ecchymosis about the joints, 
especially the ankles and knees, extreme hypersesthesia 
°f the lower extremities, sometimes pseudoparalysis 36 
CLINICAL PEDIATRICS 
and hemorrhage from the mucous membranes. Fre- 
quently, but not always, associated with rickets. 
Etiology: Found in the rich as well as the poor. It 
is due to some nutritional disturbance. Cow’s milk, 
particularly, if sterilized or pasteurized, especially 
when no other food is given, may be a cause. Duration 
depends on treatment. It may be weeks or months. 
Symptoms: Hyperaesthesia about the knees and 
legs, increased by pressure or motion. Pseudopa- 
ralysis is due to pain or separation of the epiphyses by 
hemorrhage (similar to osteochondritis of syphilis). 
Hemorrhagic gingivitis is rarely seen early. When 
present, the breath is foetid. Swelling and ecchymosis 
about the large joints (knees, ankles and shoulder), is 
caused by hemorrhage, which may be subperiosteal, 
or into the epiphyses. We may have hemorrhage, 
which is subcutaneous, or between the muscles in 
severe cases. We may find ecchymosis in any part of 
the body. In mild cases there may be no ecchymosis. 
In older children, symptoms in the legs are not so 
common, or not so marked. 
We may have hemorrhage from the mouth, nose, 
stomach, bowels, and sometimes kidney, bladder and 
urethra. In rare cases we may get hemorrhage into 
the orbit, causing exophthalmos; hemorrhage into the 
spleen, or lungs. 
Cachexia, anaemia and rickets are frequently present. 
Diagnosis: It is often mistaken for rheumatism, 
ostitis, paralysis, or purpura. Diagnosis is made by 
the improvement under treatment. X-ray examina- 
tion shows a characteristic white line between the 
epiphysis and diaphysis, which is in evidence before DISEASES OF NUTRITION 
37 
the periosteal hemorrhage and persists for a few 
months after treatment has been instituted. 
Treatment: Fresh milk, beef juice, orange juice, 
other fruit juices and potatoes. Most cases improve 
rapidly. 
Rachitis: This disease is characterized by a change 
in bones, organs, muscles and ligaments. 
Etiology: Improper food, usually poor in fat and 
proteid, seems to be the most prominent cause. Breast 
fed babies seldom get rickets, unless nursed too long, 
without other food. It is very common among the 
Italians and negroes. Other ■ factors are : improper 
environment, city life, poorly ventilated tenements, in- 
sufficient fresh air. These causes, however, have very 
little effect on a properly fed baby. 
It is more common in the temperate zone. 
Heredity may be a predisposing cause (syphilis or 
tuberculosis in the parents). 
Rickets does not prevent tuberculosis. 
The disease occurs between the ages of 6 months 
and 2 years. 
It is a disease of nutrition, there being a lack of as- 
similation of calcium salts. 
Rickets may occur congenitally, or late, i. e., in 
utero, or after 2 years. 
Lesions: Delayed ossification of bones, epiphyses 
soft and large. 
Long bones are porous, flat bones have swelling at 
points of ossification. 
Lungs may be partially collapsed (Harrison’s 
groove). 
Spleen congested and large. 38 
CLINICAL PEDIATRICS 
Liver congested and sometimes large. 
Lymph sometimes hyperplastic. 
Cerebral change is rare, and large head is due to 
swelling of bones. 
Sometimes hydrocephalus, but it is questionable 
whether there is any association. 
There is usually a low grade catarrh of the stomach 
and intestines, with loss of tone. 
The muscles are weak and undeveloped. 
Symptoms: Early symptoms—Sweating at the back 
of the head, with hair worn off, restlessness, constipa- 
tion, beading of the ribs, cranio-tabes (bones of the 
skull thin as parchment, yield to pressure). 
Deformities: Head is characterized by frontal and 
parietal bosses. The head is square and large, the 
fontanelles closing late; the veins are prominent. The 
head is large in proportion to the body, usually re- 
maining large. The occiput is flattened from lying 
down. 
Cachexia appears only after a few months. 
Chest—Rachitic rosary is brought about by beading 
of the ribs at the epiphyses. The ensiform is de- 
pressed, the sternum is prominent. There is a groove 
corresponding to the attachment of the diaphragm 
to the ribs (Harrison’s groove). This deformity is 
more marked in cases of hypertrophic tonsils and 
adenoids. The clavicles are curved forward at inner 
third, and shortened; greenstick fractures are frequent. 
Spine: Kyphosis (round back), or scoliosis (lateral 
curvature). These disappear on raising the body by 
the feet. 
Humerus—curved, epiphyses large. DISEASES OF NUTRITION 
39 
Radius and ulna—epiphyses large at the wrist. 
Greenstick fractures are frequent. 
There are similar changes in other long bones, but 
they are not as easily palpated. Other deformities are: 
Knock-knee, bow legs, curvatures of the tibia and 
fibula forward, backward, outward, or inward. Walk- 
ing is a factor, though not a necessary one, in produc- 
ing curvature. 
Pelvis flattened, growth of the child arrested. 
Ligaments loose, cause genu recurvatum (over- 
extension), loose joints, curvatures of the spine. 
Muscles are flabby and weak, sometimes pseudo- 
paralysis. 
We must differentiate from infantile palsy and 
cerebral flaccid paralysis. 
Babies suffering from rickets cannot sit up or stand, 
and begin to walk very late. 
Pot-belly is caused by weakness of the abdominal 
muscles, with relaxation of the stomach and intestines, 
as well as tympanites caused by fermentation. Con- 
stipation is caused by the same factors. Hard stools 
result in catarrhal condition of the rectum. Sometimes 
constipation alternates with diarrhoea. Tenderness of 
the limbs is rare. If present, it is most likely a case 
of scurvy. 
Dentition is late. The first teeth may appear early, 
but after that the rest of the teeth appear very late. 
The teeth are good. 
Ansemia present, 30% haemoglobin, leucocytosis. 
The baby is usually fat and flabby, but sometimes 
thin. 
Adenoids, large tonsils, and large lymph glands are 
frequent. 40 
CLINICAL PEDIATRICS 
The children are susceptible to bronchitis, broncho- 
pneumonia and gastroenteritis, which often persists. 
The spleen and liver are displaced downward, some- 
times moderately enlarged during the acute stage, 
between the 6th and 12th month. 
Nervous symptoms: Restlessness, spasmophilia 
(tetany, laryngismus stridulus, general convulsions). 
Course and termination: The duration of the dis- 
ease is usually 3to 6 months. Recovery is spontaneous 
at 18 months, owing to the variation of diet. 
Late rickets: Cases have been reported as late as 
6 to 12 years. 
Congenital rickets may occur. 
Diagnosis: Hydrocephalus—Large head, no parie- 
tal bosses, very large fontanelles. 
Cretin—Body short and fat, facial expression stupid, 
very large tongue, spade-like hand, broad nose, etc. 
Cerebral, or spinal paralysis—History, reflexes in- 
creased, intelligence impaired. 
Syphilis—Boggy infiltration of shafts, not ends, ne- 
crosis sometimes present, other signs of syphilis, Was- 
sermann reaction, X-ray. 
Scurvy—Hyperaesthesia, blue gums, anti-scorbutic 
diet, X-ray examination (white line). 
Pott’s disease—Angular curvature and permanent. 
Achondroplasia—The long bones are normal but 
short, body is normal. 
Prognosis depends on the treatment, occurrence of 
intercurrent diseases and progress of the disease before 
treatment. 
Treatment: This is most important from the third 
to the fifteenth month, as by that time all the harm 
has been done if left untreated. Proper feeding is most DISEASES OF NUTRITION 
important. This should consist of breast milk, if pos- 
sible, or cow’s milk. After the 6th or 7th month, we 
must give supplementary feeding, consisting of cereals, 
potato, beef juice, orange juice. The baby should have 
plenty of fresh air. 
Medication; 
Oil Phosphorus (i%) Tilxv i.oo 
Emulsio Morrhuse §ii 60.00 
Sig. 3i t i d p c 
Elix Phosphorus, Dose 
Syr Ferri lodid., Dose iriv-xx 
Deformities should be treated by massage, manipula- 
tion and exercise. Sometimes we have to resort to 
orthopedic braces and operations in order to correct 
deformities. 
It is important to attend to hypertrophied tonsils 
and adenoids. 
It is best to have the child lie on its bed without 
any pillow. DISEASES OF NUTRITION 
Disturbance of nutrition in breast-fed infants: 
A. Overfeeding. 
B. Insufficient feeding. 
C. Unsuitability of special breast milk. 
D. Insufficiency of digestive organs 
heredity, malformations, etc.). 
E. Bacterial contamination. 
Disturbance of nutrition in artificially fed infants 
A. Overfeeding. 
B. Insufficient feeding. 
C. Failure of utilization of the food (either as a 
whole or in its individual constituents). 
D. Bacterial contamination. 
Clinical diagnosis: 
Body weight. 
Examination of the milk (breast, or cow’s). 
Examination with the stomach tube, especially to 
determine the motility of the stomach. The stomach 
should be empty after hours in the breast-fed, and 
after hours in the artificially fed. 
Examination of the stools. 
Disturbance of nutrition in the breast-fed—Over- 
feeding: Normally, hydrochloric acid saturates 
food and acts as a stimulant to secretion of bile and 
pancreatic juice. Too great a quantity of food, or too 
frequent feedings, will prevent this normal action. At 
first, nature tries to correct this error by regurgitation 
42 DISEASES OF NUTRITION 
43 
of milk immediately after feeding, frequent stools and 
loss of appetite. If overfeeding is still continued, the 
baby will begin to vomit a half to one hour after 
feeding. The vomitus has a sour odor and contains 
curds both small and large. The baby is irritable and 
does not sleep, but cries after feeding. Diarrhoea de- 
velops, a great deal of gas is passed, and the stools 
contain green and white curds, and smell sour. The 
child has colic. The stools are yellow at first and then 
turn green around the border. The stools are acid, 
irritating the skin, causing intertrigo. The baby fre- 
quently develops eczema. Usually there is no fever, 
but occasionally there is an initial rise in temperature. 
Treatment: Stop feeding. 
Give castor oil, calomel, or magnesia and rhubarb. 
Give water, or tea with saccharin every three or four 
hours. 
Continue this for two or three days if necessary, 
until the diarrhoea and vomiting stop. Then start 
in with very small quantities of breast milk (begin- 
ning with one or two minutes), preceding the water. 
Gradually increase the feeding, in accordance with 
the baby’s behavior. 
If the vomiting does not stop, try sodium citrate, 2 
gr. to each 2 oz. of fluid given. 
We may also try peptonizing the milk after it has 
been procured by means of a breast pump, or we may 
give 5-10 grains of peptogenic milk powder after each 
feeding. 
As a last resort, wash the stomach and bowels. 
For colic, we may use a hot water bag to the abdo- 
men, or chloral hydrate 1/3 gr. every hour or two. 44 
CLINICAL PEDIATRICS 
A rectal injection of oi-ii of cold water will often cause 
expulsion of gas. 
For intertrigo; 
Liq. Carbonis Detergensis 
Zinci Oxidi 
Glycerin 3v 
Lac. Magnesias ad q\v 
Apply this lotion twice daily. 
Insufficient feeding: The baby should gain 4 to 6 
ounces a week. If the gain is less than that, we should 
investigate. Weigh the baby before and after the 
feeding, to ascertain how much below the average 
amount it is getting during 24 hours. A baby getting 
insufficient food is thin, abdomen is flat, it may 
cry after each feeding, struggles at the breast without 
swallowing and may in extreme cases lose power to 
swallow. Sometimes the baby will not cry between 
feedings on account of lowered vitality. It may even 
sleep a great deal and has to be awakened for feed- 
ing. Stools are infrequent and dark brown, or mucoid 
and greenish-black. 
Treatment: Attention to the mother’s health. If 
the case is extreme, get a wet nurse, or give supple- 
mentary artificial feeding. Find out how much is lack- 
ing during 24 hours, supply accordingly. Additional 
feeding may be given after each nursing, every three 
hours, or we may substitute an artificial feeding for 
one, two, or three breast feedings. If that does not 
help, try to get a wet nurse, or change wet nurses if 
the child is less than six months old. If the baby is 
older than six months, we may wean. 
When giving supplementary artificial feeding, we DISEASES OF NUTRITION 
45 
determine the quantity to be given in each bottle by 
calculating the quantity that the baby would require 
for 24 hours and dividing by six. 
Unsuitability of special breast milk: This may cause 
vomiting, diarrhoea, loss of weight. The milk may be 
too rich in fat, or there may be some other cause which 
is difficult to determine. It is a known fact that in 
these cases a change of food often results in imme- 
diate improvement. 
Do not condemn the breast milk until you are cer- 
tain that overfeeding has not started the trouble. 
Insufficiency of digestive organs: This is caused by 
premature birth, hereditary taint, intrauterine infec- 
tion, malformation of digestive organs, mechanical ob- 
stacles to sucking, such as high arched palate, with 
narrowing of the nasal cavity, harelip, tongue-tie, etc. 
Bacterial contamination: Rare in breast-fed babies. 
Breast milk is not always sterile. The duct and nipples 
may become infected (most frequently staphylococcus, 
or colon bac., less frequently streptococcus). 
Will cause acute gastro-enteritis with sudden onset. 
Treatment: Pump breast well, paint outside with 
Tr. lodine. 
If contamination still exists, change feeding. 
At first give baby a cathartic, water, tea, etc. 
Disturbance of artificially fed infants—Overfeeding: 
This means too great a quantity of food, or milk that 
is too rich in quality, or food that is given too fre- 
quently. 
The tendency of the mother is to interpret every cry 
as that of hunger. At first, we have vomiting imme- 
diately after feeding; later, vomiting will take place 
some time after the feeding. Vomitus contains large 46 
CLINICAL PEDIATRICS 
curds, water, and sometimes serum and bile. It smells 
sour. 
Stools are normal at first, later becoming diarrhceal. 
They contain white and green curd, also mucus. There 
are usually four to six stools a day. 
The stools may be irritating, causing intertrigo. 
The abdomen is distended. 
We may have high temperature. Urine contains in- 
dican (putrefaction). 
These symptoms are of varying intensity. 
The condition may result in cholera infantum, with 
excessive vomiting and diarrhoea, causing rapid wast- 
ing, sunken features, and depressed fontanelles. 
Treatment: Water, tea, calomel, or castor oil. If 
nothing is retained, we must employ lavage and enema. 
If the baby is very young, try to get a wet nurse, if 
possible. 
When that is impossible, add cow’s milk in very 
small quantity to the water, increasing very gradually. 
If stimulation is necessary, use caffeine sodium 
benzoate, dose %-yi2 gr. subcutaneously. If the chol- 
era infantum type is present, we may use hypoder- 
moclysis (subcutaneous injection of .4% saline solu- 
tion with .3% sod. bicarb.). The amount given is 
about four ounces, two or three times a day. 
Failure in utilization of the food (as a whole, or in 
its individual constituents)—Anaphylaxis (food al- 
lergy) : To some babies, cow’s milk acts as a poison. 
Just as some patients cannot tolerate even a fraction 
of a grain of quinine (drug idiosyncrasy), so these 
babies cannot stand even a teaspoonful of cow’s milk 
without symptoms of toxaemia. 
These symptoms may be quite severe. DISEASES OF NUTRITION 
47 
Thus: fever, pallor, toxic erythema, vomiting, even 
convulsions. 
Attempts have been made to immunize by, injection 
of cow’s serum in gradually increasing doses. The 
results are promising. 
It is imperative to put these babies on breast milk. 
Too much fat in the milk mixture: This may at 
first cause dry, brittle, light-colored stools (soapy 
stools) ; later, vomiting, diarrhoea, oily stools, with 
yellow curds. Urine has a strong ammoniacal odor. 
If continued, atrophy may develop. 
Bacterial contamination at this period is not un- 
common. 
Starch; Used in abundance, too early, will cause 
moist, dark stool, containing undigested starch, which 
may be recognized microscopically, or by means of the 
iodine test. 
If continued, it is apt to cause vomiting, diarrhoea 
and atrophy. 
Sugars: Too much sugar will cause acid and green 
stools. 
It is the chief factor in the etiology of gastroenteritis, 
or summer diarrhoea. Finkelstein pointed out that con- 
tinued use of excess of sugar and salts in the food will 
cause the following in succession : 
i. Disturbance of balance—Regurgitation of food, 
frequent stools. 
2. Dyspepsia—Vomiting, diarrhoea. 
3. Decomposition—Atrophy, marasmus. 
4. Intoxication—Bacterial contamination, cholera 
infantum. CLINICAL PEDIATRICS 
48 
This has given rise to casein, or Eiweissmilch, which 
is rich in proteids, poor in salts, and contains very little 
sugar. 
Treatment: When the case has not gone further 
than disturbance of balance, reduce the sugar content 
of the milk mixture, after having administered an ini- 
tial cathartic. 
If the case has gone further and developed dys- 
pepsia : 
Give castor oil (p2-i teaspoonful), or calomel (i/io 
gr., i every hour, 10 tablets). 
Take away all food. 
Give water or tea with saccharin (i gr. to a quart 
of water). 
Continue this for two or three days. If diarrhoea 
stops, begin with small quantities of milk in the water 
every four hours. 
If the diarrhoea does not stop, try the albumen milk 
in gradually increasing quantities. 
Preparation of albumen milk: 
To a quart of milk, in a water bath at ioB° F. 
(420 C), add two tablets of rennet, or a table- 
spoon of Fairchild’s pepsin. 
Allow this to stand three-quarters of an hour. 
Strain through cheesecloth for one hour. 
Rub casein through a fine sieve, with a potato 
Wash the remnants with one pint of water, poured 
through the sieve. 
masher. 
Add one pint of buttermilk. 
This will give us a quart of casein milk. Add gr. i of 
saccharin to sweeten. DISEASES OF NUTRITION 
49 
Use in quantities corresponding to the age and 
weight of the baby. 
Make dilutions similar to those of regular milk mix- 
tures. 
Bacterial contamination: Streptococcus—Causes 
severe form of gastroenteritis, with fever, vomiting 
and diarrhoea, prostration and sepsis. Prognosis is 
bad. 
Bacillus pyocyaneus—Symptoms are not severe. 
Bowel discharges are green or blue. 
Dysentery bacillus (Shiga or Flexner)—Symptoms 
are those of acute or subacute colitis. 
Amoeba coli—Subacute colitis. Amoebae in the 
stools. 
Colon bacillus—May become virulent and cause en- 
terocolitis. 
Bacillus aerogenes capsulatus (gas bacillus)—The 
stools are diarrhoeal, and are accompanied by the ex- 
pulsion of a good deal of gas. 
Cholera infantum: This is a condition resulting 
from a very acute infection. It seldom occurs in a 
previously healthy child, but usually follows a milder 
gastrointestinal disturbance. 
Symptoms: We may have fever and prostration a 
few hours before the appearance of other symptoms. 
Vomiting then starts in, followed by purging, or both 
may begin simultaneously. At first, there is vomiting 
of food, then, serum and bile. If vomiting ceases, food 
starts it again. 
There may be 12-15 stools in half a day. Sometimes 
there is relaxation of the anus and small stools ooze 
out every few minutes. 
The stools are yellow, green, or brown; later serous. CLINICAL PEDIATRICS 
50 
At first, the stools are acid, then neutral, and finally 
alkaline. 
There is great loss of weight. The tongue is coated 
at the start; later red and glazed. The fontanelles are 
depressed, the cranial bones sometimes overlapping. 
The abdomen is soft and sunken. Thirst is a promi- 
nent symptom, the baby, sometimes, not passing urine 
in 24 hours. 
The nervous symptoms are crying, moaning, border- 
ing on delirium, followed by stupor, coma, and con- 
vulsions. 
Breathing is rapid, later stertorous; pulse is rapid, 
weak, and intermittent. 
Temperature is io2°-ios° F. 
These symptoms rarely continue longer than 24 
hours, the case either improving or becoming worse. 
If the case is fatal, we get hyperpyrexia, coma, and 
convulsions. 
In other cases, the temperature is subnormal, and 
there is irritability, apathy, pinched appearance, pulse 
intermittent or imperceptible, breathing irregular or 
Cheyne-Stokes, skin clammy, pupils covered with a 
film, fontanelle depressed, abdomen retracted, no de- 
sire for food, but thirst, rigidity of the muscles of the 
back of the neck. 
These symptoms may gradually disappear, and re- 
covery follow. Death is a more likely outcome. 
When recovery takes place, vomiting gradually 
ceases, stools diminish in number and become more 
solid. 
Sometimes diarrhoea continues for a few days and 
ileocolitis follows. 
Recovery is slow. Sometimes there is recurrence DISEASES OF NUTRITION 
of the symptoms after two or three days, which is fatal. 
Sometimes it is followed by sclerema, which is fatal. 
Prognosis: 66% fatal. 
Treatment: Stop all diet. 
Give water by hypodermoclysis, 8 oz. in 12 hours. 
We may use subcutaneously morphine 1/100 gr. and 
atropine 1/800 gr. when no coma is present. Stimu- 
late with whiskey, q. 3 h. by hypo, (diluted). 
We may also give camphor in oil gr. i q. 3h. These 
doses are for a one-year-old baby. 
Wash out the stomach and bowels. 
Keep warm with hot-water bottles, if the extremi- 
ties are cold. 
When the vomiting stops, give water, and gradually 
add milk, one drachm at a time. 
Instead of milk, we may use albumen milk, butter- 
milk, or peptonized milk. Breast milk, if obtainable, 
is best of all. DISEASES OF THE MOUTH 
Malformations: Harelip—Due to failure of union of 
the foetal arches (Globular arches). 
the palate. 
Cleft palate—The failure of union is extended into 
Stomatitis—Catarrhal: This form may be caused 
by irritants, heat, etc., and precedes all other forms of 
stomatitis. 
The mucous membrane is red and sensitive, asso 
ciated with salivation. 
Maculofibrinous (aphthous) : This form is caused 
by some infection. 
number of yellowish spots of varying- size. These are 
surrounded by a reddish area. The spots are called 
aphthae. They are in reality little vesicles, which soon 
Scattered all over the mucous membrane, we see a 
become ulcers. 
A number of small ones may coalesce and form large 
ones. We get salivation and burning pain in the 
mouth. Fever is generally present, also diarrhoea. 
Treatment: Warn the mother against the use of a 
pacifier and dirty utensils. 
Local application of 5-10% silver nitrate. 
Internal medication: For one-year-old baby— 
Kali Chlor 0.5-grviiss 
Tr. ferri Chi 1.0-Hlxv 
Glycerin i5.0-§ss 
Aquam ad 60.0-§ii 
Dose, 3i q. 2 h. 
52 DISEASES OF THE MOUTH 
53 
Ulcerative: The gums are first affected. These 
separate from the teeth, discharge pus and ulcerate. 
The contiguous portions of the tongue and buccal mu- 
cous membrane also become ulcerated (rarely the pal- 
ate). Duration is 6to 10 days. The child is irritable 
and has some rise in temperature. 
The odor of the breath is offensive. 
Treatment: Local application of 10% silver nitrate, 
and internal administration of potassium chlorate. 
Gangrenous (cancrum oris, noma) : This form al- 
ways follows some severe illness (measles, typhoid, 
etc.). 
At the onset it looks like an ulcerative stomatitis. 
Usually affects only one side. It begins as a swelling 
on the cheek, which has a pale, waxy appearance and 
is painless. In the mouth we notice a dirty yellow ul- 
cer. The breath is foetid. Gangrene spreads rapidly, 
and in a few days eats away a good part of the mouth 
and cheek. 
At first the child is playful, but soon severe symp- 
toms develop: fever, delirium, diarrhoea, coma, death. 
Sometimes it is associated with abscess of the lung 
or pneumonia. 
Prognosis—ls% recoveries. In cases which recover, 
a marked deformity of the mouth results. 
Treatment: Fulguration (high-frequency current), 
excision, Paquelin cautery, salvarsan, or neosalvarsan 
in glycerin, locally applied. 
Thrush; Most commonly found in babies that are 
unhealthy, ill-fed, and suffer from gastroenteritis, also 
in infants with mouth deformities. The infection is 
brought on by uncleanliness of nipples, pacifiers, etc. 
It is caused by a fungus, saccharomyces albicans. 54 
CLINICAL PEDIATRICS 
It appears as a white flaky growth on the buccal mu- 
cous membrane and the tongue. Small spots coalesce 
and form large areas. 
Any attempt to rub it off causes bleeding. 
It may extend to the nose and oesophagus and rarely 
to the stomach, as well as to the intestines. 
In rare cases it may get into the circulation and 
cause sepsis, with formation of metastatic abscesses. 
Streptococcus and staphylococcus may be found as- 
sociated with it. 
Symptoms: The mouth is sore, sucking is difficult. 
There is a slight rise in temperature, and diarrhoea, 
which may be the underlying cause. 
Treatment: Cleanliness, 2% boric acid solution, 
which may be used on a gauze teat. 
Bednar’s aphthae (ulcera pterygoidea) ; We find a 
bilateral ulcer on the hard palate. It may also be cen- 
tral. 
It may become confluent, and assume the shape of a 
butterfly. 
It is caused by too energetic washing of the mouth. 
Treatment: 5% silver nitrate applications daily. 
If nursing is painful, apply 1% cocaine, or insuf- 
flation of prthoform before each feeding. 
Gonorrhoeal stomatitis: This affection is rare. 
Without any preliminary redness, a yellow exudate 
appears along the angles of the palate, the raphe and 
gingivo-labial fold. 
The surface is rough and gradually assumes a yel- 
low discoloration. 
The process is confined to the mucous membrane 
and heals spontaneously in a few days. 
Perleche (Epstein’s faule Ecken) : This is an affec- DISEASES OF THE MOUTH 
55 
tion characterized by a development of a concentric 
fissure in the corners of the mouth. The skin area 
surrounding- the corners is slightly reddened and 
darker than normal. A little discharge oozes from the 
fissure. It is most frequent in ill-nourished children. 
It is probably of infectious origin. 
Treatment: Tr. iodine, balsam Peru, camphor ice. 
Exanthemata: Upon examination of the mouth we 
must not mistake eruptions, such as those of measles 
and chicken-pox, for stomatitis. 
Anomalies of the tongue—Geographical tongue 
(glossitis exfoliativa areata, annulus migrans) : This 
is a congenital tendency to persistent desquamation of 
the epithelial covering of the tongue. At first we see 
a grayish spot at the tip of the tongue, which spreads 
and extends towards the dorsum. Then the central 
part becomes red and is surrounded by a grayish bor- 
der. This process repeats itself. 
There is no cure. 
We may apply a strong solution of chromic acid, fol- 
lowed by a solution of aluminium acetate. 
Ulcer from irritation of a carious tooth: A painful 
condition. File the rough edge of the tooth, and have 
cavity filled. 
Macroglossia: Found in myxoedema, Mongolian 
idiocy, acromegaly. 
Subglossitis: Phlegmon under the tongue; opens 
spontaneously. 
Ulcer of the frenum: Found in whooping cough. 
Fibroma of the frenum: Probably caused by irrita- 
tion by the lower incisors. Treat surgically. 
Teething: Teething is a normal process and usu- 
ally does not give any symptoms. 56 
CLINICAL PEDIATRICS 
Sometimes the gums appear swollen and red. 
Teething does not cause fever, diarrhoea, etc. If 
present, look for other causes. 
Teeth appear usually in the following order: 
Between the sd-Qth month—2 central lower incisors. 
Between the 9th-i2th month—4 upper incisors. 
Between the I2th-iBth month—2 lateral lower in- 
cisors and Ist molars. 
Between the iBth-24th month—the canines. 
Between the 24th~30th month—the 2d molars. 
At age of 6 years—lst molars (6-year molars) form 
behind the 2d molars of the milk teeth. 
Between the yth-Sth years—incisors. 
Between the gth-ioth years—bicuspids. 
Between the I2th-I4th years—canine. 
Between the I2th-isth years—2nd molars, 
Between the I7th-25th years—3rd molars (wisdom 
teeth). 
Hutchinson’s teeth : Short stumpy teeth with semi-’ 
lunar excavation of the borders, found in children suf- 
fering from congenital lues. Only permanent teeth 
are affected. 
Scrofulous teeth: There is a greenish or brown 
discoloration of the teeth (first incisors) near the 
gums. This is followed by caries near the gums. 
Diseases of the salivary glands—Ranula: A cystic 
tumor situated beneath the tongue, due to occlusion of 
the salivary duct. It appears as a grayish tumor on 
both sides of the frenum. Treatment is surgical. 
Acute inflammation of sublingual or submaxillary 
glands: Pus oozes out from the ducts. Prognosis is 
good. DISEASES OF THE MOUTH 
57 
Primary idiopathic parotitis: Same as mumps. 
Secondary parotitis: This form may follow stoma- 
titis, or otitis media. It may also be secondary to 
typhoid, or one of the exanthemata. 
Treatment: Try an embrocation of iodovasogen. If 
pus forms, incision and drainage. TONSILS, PHARYNX, (ESOPHAGUS 
Tonsillitis: (Angina) Catarrhal,—follicular,—lacu- 
The tonsils are swollen and red. In the follicular 
form the follicles are filled with a yellowish detritus, 
which gives the tonsil the spotted appearance. In 
the lacunar form large masses of detritus collect in 
the crypts. 
The onset is acute, with a sudden rise of the tem- 
perature (102-103°), general malaise, headache, pains 
all over the body, pain upon swallowing. During 
the first three or four days, the pain in the throat 
increases in intensity especially at night, when pa- 
tients complain most bitterly. After that, there is a 
subsidence of the inflammation, with recovery at the 
end of a few days. 
The cervical glands are frequently enlarged. 
The temperature remains high during the first three 
or four days, unless modified by the use of antipyret- 
ics. 
Tonsillitis may be a forerunner of a general in- 
fection. 
It is frequently associated with rheumatic fever, 
endocarditis, and chorea. 
Treatment: Give a cathartic. 
2 years old). 
Also: 
Aspirin and phenacetin (aa 1 gr. q. 4 h. for a child 
58 TONSILS, PHARYNX, CESOPHAGUS 
59 
Kali chlor. I—gr.1—gr. 15, 
Tr ferri chlor. 2—H 30. 
Glycerin 15—§ ss oz. 
Aquam cinnamon ad 60—§ii. Dose: 1 teaspoonful 
q. 2 h. 
In place of the aspirin and phenacetin and the iron 
mixture, we may use a solution of carbolic acid—2%. 
Dose: A teaspoonful q. 2 h. for a child years old. 
Its action is local and systemic. These doses are 
larger than the pharmacopeia allows, but experience 
has proven them to be safe. 
Retronasal angina (Adenoiditis, inflammation of 
the pharyngeal tonsil) : The symptoms and course are 
similar to those of ordinary tonsillitis. 
Parenchymatous tonsillitis: (Tonsillar and peritonsil- 
lar abscess, Quinsy). There is an infiltration of the ton- 
sil and surrounding tissues causing a swelling that 
may extend to the uvula and beyond. Sometimes, 
the inflammation subsides without suppuration, but 
usually it goes on to pus formation. If left alone, it 
ruptures spontaneously. Sometimes the inflammation, 
instead of remaining circumscribed, spreads and be- 
comes phlegmonous. 
Symptoms are: Extreme pain, especially on swal- 
lowing or talking, excessive flow of saliva, a gradual 
rise in temperature, a general malaise. Evacuation 
of pus is followed by immediate relief of all symp- 
toms. Cervical glands are enlarged. 
Treatment: Compress around the lower jaw, ap- 
plied from ear to ear. Pain may be relieved either by 
swallowing ice, or gargling with hot water. Internal 
medication the same as in follicular tonsillitis. Sur- CLINICAL PEDIATRICS 
gical treatment—incision as soon as you find fluctu- 
ation. 
Pseudomembranous angina (Angina ulcerosa, Vin- 
cent’s angina) : Onset is the same as that of ordinary 
tonsillitis. The temperature is not high. The ap- 
pearance of the tonsil is characterized by the forma- 
tion of an ulcer, which is covered by a viscid dis- 
charge. In mild cases there is only a slight erosion 
of the mucous membrane, with a membranous cover- 
ing. In severe cases the ulceration is marked. The 
membrane may disappear after a week, or it may re- 
main longer. 
Prognosis is good in the majority of cases. In rare 
cases ulceration is very extensive, with a fatal out- 
come. 
Diagnosis: We must exclude diphtheria and 
syphilis. 
A microscopic examination of a smear of the mem- 
brane will show a large thick bacillus (Bac. of Vin- 
cent) and a long spirillum (Spin of Miller). When 
still in doubt, take a culture and do a Wassermann 
test. 
Treatment: Local application of a solution of 
methylene blue (i%) and 10% silver nitrate. 
Gangrenous angina: Gangrenous inflammation of 
the pharynx. The odor is frightful and the cases are 
fatal. 
Septic phlegmon and erysipelas of the pharynx may 
occur in the newborn and is fatal. 
Hyperplasia of the tonsil: Hypertrophy is caused 
by repeated inflammations in susceptible subjects. 
When very large, it interferes with respiration and 
proper development of the child. TONSILS, PHARYNX, (ESOPHAGUS 
61 
Treatment: Excision. 
Hyperplasia of the pharyngeal tonsil (Adenoid vege- 
tations) : This affection is prevalent between the ages 
of six to eleven years. It is very rare after puberty. 
It is marked by the following characteristics; 
Stupid facial expression, sometimes exophthalmos, 
mouth open, nose discharging mucopus and nasal 
breathing impossible; the palate is high arched. The 
chest is deformed (chicken breast). Frequently there 
is deafness and otitis media. Physical condition is 
poor and mental development is retarded. Cervical 
glands are enlarged. 
Sometimes it is the cause of persistent temperature, 
especially after some infectious disease. 
Children with adenoids are more susceptible to in- 
fections and colds. 
Treatment: Adenoidectomy. In cases in which 
adenoids are only slightly developed we may employ 
palliative treatment by douching the nose with salt 
and water. Use a half teaspoon of salt to a glass of 
warm water. In douching the nose, be careful to turn 
the child’s head to the side opposite the nostril 
douched, so as not to drive the discharge into the 
Eustachian tube opening. 
Tumors of the nasopharynx are rare. The follow- 
ing may occur: 
Dermoid cyst, fibroma, lipoma, fibrosarcoma, lym- 
phosarcoma of the tonsil, or rhinoscleroma. 
Retropharyngeal abscess (Lymphadenitis) : Symp- 
toms : Fever, pallor, head to one side, laryngeal stri- 
dor, weak cry (in infants), brassy cough, difficulty in 
swallowing, mouth kept open. Examination discloses 
a swelling in the posterior pharynx, usually a little to CLINICAL PEDIATRICS 
62 
one side, behind the tonsil. At first this swelling is 
hard and movable, but later it becomes immovable and 
fluctuating. It may be felt or seen. Pus may burrow 
its way to the region of the parotid, or to the neck, or 
down to the mediastinum. Cervical glands are en- 
larged. The abscess may open spontaneously and in- 
spiration pneumonia may result. It may cause pyae- 
mia, or septicaemia. 
Diagnosis: We must differentiate from tuberculo- 
sis of the cervical vertebrae, wry neck, diphtheria of 
the larynx, catarrhal croup. Prognosis is good if treat- 
ment is given early. 
Treatment: Early incision, with head low, turning 
head to one side quickly after the incision has been 
made to prevent inspiration of the pus. It is best to 
use a blunt instrument and make the opening ragged- 
edged to get better drainage. 
Diseases of the oesophagus: Congenital atresia, or 
stenosis: Regurgitation of food, early death. 
Acute oesophagitis: This may be caused by some 
corrosive poison. If recovery takes place, it is fre- 
quently followed by the development of a stricture, 
which must be treated by gradual dilatation with 
bougies. LOCAL DISEASES OF THE STOMACH AND 
INTESTINES 
Ulcer of the stomach: This is of rare occurrence 
in children, and very difficult to recognize, as not all 
cases show vomiting of blood. 
The characteristic signs are: hsematemesis, tarry 
stools, gastralgia, localized peritonitis. 
Ulcer of the duodenum gives similar symptoms, and 
is still harder to recognize. This condition is prob- 
ably more frequent than generally believed. 
Treatment: When bleeding, inject a 2% solution 
of Russian gelatine hypodermatically, oz. every 
few hours until the bleeding stops. Injection of horse 
serum 5-10 c.c. may increase the coagulability of the 
blood. Before giving the horse serum, try a few 
drops first, in order to exclude anaphylaxis. We may 
try transfusion, or intramuscular injection of human 
blood or serum 4to 6 oz. Nourishment should be lim- 
ited to rectal feeding, or by means of a duodenal tube. 
Medication; bismuth subnitrate, 5-10 gr. q. 3 h., or 
carbolic acid 2%, 3 i q. 2 h. 
Fissure of the anus: Caused by constipation. It is 
a longitudinal linear ulcer above the anal opening. 
The child suffers severe pain after bowel move- 
ment, also tenesmus. The stool is streaked with blood, 
and sometimes there is a loss of a few drops of blood. 
Treatment: First apply a 10% sol. of cocaine, 
with an applicator, follow this with a 10% sol. of silver 
63 64 
CLINICAL PEDIATRICS 
nitrate. Give a few of these treatments, one every 
day. Also give a laxative. 
In the majority of the cases no other treatment is 
necessary. If the fissure persists in spite of treatment, 
we must then resort to the surgical procedure of for- 
cible dilatation of the anus under gas or ether an- 
aesthesia or excision and suture. 
Prolapse of the rectum: This is a protrusion of 
the rectal mucous membrane outside the anal opening. 
Causes: Diarrhoea, constipation, rectal polyps, 
whooping cough. First treat the causes. The child 
must be made to defecate in a recumbent posture. 
Draw the gluteal parts closely over the anus, hold 
together with Z. O. adhesive plaster. We may at- 
tach strings to adhesive strips on either side and some 
distance from anus. After the strips are properly ap- 
plied, draw the two sides over the anus by tying the 
strings. These may be opened during bowel move- 
ment. CONSTIPATION OF INFANTS 
Causes: Malformation, partial atresia of the anus 
or rectum, congenital dilatation of the lower bowel 
(Hirschsprung’s disease), fissure in ano, insufficient 
amount of food, unsuitable form of sugar, used in ar- 
tificial feeding, too much fat (brittle soapy stools), 
atony of the large intestines, caused by malnutrition, 
rickets, etc. 
Some infants may get on very well in every way, 
but they do not seem to be able to expel the stool, 
without some local irritation, or stimulation. There 
is a moderate amount of atony of the rectum present, 
and a large quantity of faeces collects there, and be- 
comes dry and hard. Suppositories and soapsuds ene- 
mata are resorted to, which only tend to confirm the 
habit of constipation. 
Treatment: Try to find out the cause. When ar- 
tificially fed, modify the form of sugar used, chang- 
ing from milk sugar to maltodextrose. If that does 
not produce the desired effect, substitute one to four 
drachms of malt extract, for an equivalent amount of 
sugar, used in a 24-hour mixture. 
In marantic babies, with constipation, try the malt- 
soup and flour mixture. 
For babies that seem to be doing well we may add 
a teaspoonful of milk of magnesia to one or two of 
the bottles. 
If the stools are dry, brittle and clay-colored, reduce 
65 66 
CLINICAL PEDIATRICS 
the amount of cream used. This may be done by de- 
canting some of the gravity cream off the top of the 
bottle before shaking. 
In older infants we may aid by adding orange juice, 
prune juice and mashed prunes, or scraped raw apple 
to the diet. 
If constipation still persists after all these meas- 
ures, it is then necessary to resort to some form of 
local stimulation. This consists of the use of supposi- 
tories, gluten, or glycerin, or the injection of water, 
plain, or with soapsuds (*ss-ii) into the rectum, every 
morning after a feeding. This usually has the desired 
effect, but also confirms the habit of constipation. 
Very good results have been obtained from the use of 
Russian mineral oil. It may be administered inter- 
nally in older infants, but ordinarily it seems unneces- 
sary to lubricate the entire canal, as the obstruction 
is only at the lower end. 
Very satisfactory action has been obtained by in- 
jection of §i of the oil into the rectum early in the 
morning or at night. Sometimes it is necessary to 
aid at first by the use of a gluten suppository. Stools 
that had previously been hard and caused much pain 
upon expulsion become soft and easy to expel. It 
frequently happens that the baby begins to have nor- 
mal movements without the use of the oil. Even when 
it is necessary to use a gluten suppository as an aid 
the stools are soft and are expelled without pain. 
Congenital Dilatation of the Colon (Hirschsprung’s 
Disease) : It may appear at birth, or a few months 
later. The appearance is characterized by a balloon- 
shaped abdominal distention. The dilatation may first 
appear in the sigmoid region. The stools are small CONSTIPATION OF INFANTS 
67 
at the start, later spontaneous evacuation is impos- 
sible. The colon is long and dilated, also constricted 
in spots; some sections of the muscular wall are hy- 
pertrophied, others are atrophied; ulcers as well as 
submucous abscesses may form. 
The child is restless and has no appetite. The su- 
perficial veins of the abdomen are dilated; the dia- 
phragm may be pushed up and cause dyspnoea and 
cyanosis. 
These symptoms may be temporarily relieved by 
enemata and abdominal massage, etc. 
Death from weakness and exhaustion, or pneumo- 
nia, is the usual outcome. 
Treatment: Kneading massage of the colon; irri- 
gation, with digital removal of the faecal accumulation. 
We may try faradic current, with one pole in the rec- 
tum, the other on the abdomen. 
Operation: Removal of a section of the colon. Re- 
sults have not been brilliant. 
Intestinal atresia and stenosis: Causes: Malde- 
velopment, intrauterine syphilis, tuberculosis, intus- 
susception, volvulus, pressure by tumors, persistent 
omphalomesenteric duct, amniotic bands, by which 
occlusion occurs in the form of transverse septum. 
The acquired form may be caused by strangulation 
(hernia into peritoneal fossae), intussusception, volvu- 
lus, pressure by tumors, Meckel’s diverticulum. The 
acquired form differs from the congenital by the sud- 
den onset, colic, vomiting, diarrhoea with bloody stools, 
etc. 
In the congenital form we have distention, per- 
sistent vomiting, no bowel movement. The vomitus 
contains bile (except in pyloric stenosis). Distention 68 
CLINICAL PEDIATRICS 
may cause pressure on the ureters and stop the flow 
of urine. Prognosis is bad. 
Treatment is surgical. 
Intussusception (Invagination) : There is an in- 
vagination of one of the intestines into another. This 
is usually descending, but may rarely be ascending. 
The ileo-csecal section is most frequently affected. 
The ileum descends into the caecum, rolling itself in- 
side out, becoming thus telescoped. It is caused by 
the presence in the intestines of some foreign indi- 
gestible substance, which causes colic. 
At first there is severe abdominal pain, which is 
soon localized, if the child is old enough to explain. 
It is most common in children 5-6 years of age. Later 
we have vomiting and frequent small bloody mucous 
stools. Vomiting persists and finally becomes faecal. 
Physical examination discloses a sausage-shaped tu- 
mor on the right side of the abdomen. This is some- 
times difficult to feel, owing to the rigidity of the 
abdominal muscles, caused by colic, but may be felt 
between attacks. Sometimes the intestine keeps on 
descending until it reaches the rectum, and may be 
felt there by digital examination, not unlike a soft cer- 
vix. Must be differentiated from a rectal polyp. 
Sometimes the intestine descends still lower and ap- 
pears outside like a prolapse of the rectum. Here 
we recognize the difference by the symptoms and 
physical finding. Mild cases may return to normal. 
Symptoms may recur. Rarely nature will cause the 
invaginated portion to become sloughed off, and thus 
bring about spontaneous recovery. An acute attack 
usually lasts one week. It may last two weeks, or CONSTIPATION OF INFANTS 
69 
become chronic. In chronic cases the obstruction is 
not complete. 
Treatment: We must bear in mind the fact that 
operative procedure is successful only during the first 
24-36 hours. We must, therefore, confine our pallia- 
tive measures to that period. First, give an enema 
with saline solution, using 1 pint to a quart of water, 
introducing it from a height of 2 feet, with pelvis 
elevated. Then try to reduce by taxis. If unsuccess- 
ful, we may then try to balloon out the colon with 
air or fluid. Do not try this method too long, as you 
may rupture the colon. It is most advisable not to 
try distention, unless you are in all readiness to start 
the operative procedure. In chronic cases, make sev- 
eral attempts at taxis. The majority of the cases have 
to be operated. 
Atresia of the rectum or anus: This may some- 
times be complicated by communication with the blad- 
der, urethra, or vagina. 
Sometimes there is fistulous opening in the region of 
the scrotum, which communicates with the rectum. 
Treatment is surgical. GASTROINTESTINAL DISEASES OF OLDER 
CHILDREN 
Gastric indigestion: Duration is one to three days, 
sometimes longer, if improperly treated. The child 
feels and looks sick. There is headache, pallor, diz- 
ziness, nausea, vomiting, and possibly convulsions. 
The temperature may go up to 105° F. Vomiting may, 
sometimes, relieve all symptoms, especially if soon 
after the offending meal. The abdomen is distended 
and there is usually constipation. Similar symptoms 
may be caused by influenza, or the case may look like 
typhoid, one of the exanthemata, or pneumonia. 
Treatment: Calomel, lavage, if necessary, starva- 
tion. If vomiting persists give cerium oxalate and 
sodium bicarbonate aa gr. iiss q. 2 h., in a little water. 
Mustard plaster over the epigastrium. When vomit- 
ing stops give weak tea, and later small quantities 
of milk well diluted. We may add 2 grains of sodium 
citrate to each ounce of fluid given. We may also 
give barley water with a little orange juice. When 
loss of fluid through vomiting is great, give saline 
enema. 
Recurrent vomiting with acetonuria: There is a 
state of acidosis of the blood, caused by autointoxi- 
cation. It is most frequent between the ages of 2to 
8 years. The onset is preceded by some prodromal 
symptoms. Temperature may be normal, or may run 
70 GASTROINTESTINAL DISEASES 
71 
up to 104°. Acetone is present in the urine before the 
attack. Vomiting comes without nausea or loss of 
appetite. Every bit of food is vomited, then serum and 
even blood. When bile comes, it usually means the 
end of the attack, which generally lasts a few hours. 
Vomiting may recur in a few hours. It has been 
known to recur after a few days, but, usually, the 
intervals are a few weeks or months. 
The tendency to these attacks may last throughout 
childhood. Prognosis is good. 
Treatment: Abstinence from food: hypodermocly- 
sis (2-6 oz. twice daily). Saline enemata with 3i-ii of 
sodium bicarbonate twice daily. As soon as vomiting 
ceases, give sodium bicarb. Gr, xv q. 3 h. by mouth. 
Also give weak tea, barley water. 
Catarrh of the intestines: This may follow gastric 
indigestion and may occur without it. It is caused 
by indiscretion in diet. 
Symptoms: Colicky pains, diarrhoea (3 to 10 stools 
a day), expulsion of gas. The stools are yellow, with 
yellow or white particles. Severe cases may resemble 
cholera infantum, or may be ptomaine poisoning. If 
left untreated, there is great loss of weight. 
Treatment: First give a purgative, such as castor 
oil, citrate of magnesia, or Epsom salts. No food 
should be given. The child should be kept on water 
and weak tea, until the diarrhoea and colic stop. If 
diarrhoea persists, give codeine or opium. Return to 
the regular diet very gradually. 
Chronic disturbance of digestion in older children 
has its origin in infancy. Irregular feeding and im- 
proper food are most important immediate causes. 
The children are constantly in a state of malnutri- 72 
CLINICAL PEDIATRICS 
tion. The appetite is poor. Some children are so 
intent on their amusements that they do not take 
sufficient time to eat, and swallow their food im- 
properly masticated. Other children will refuse to 
eat at meal time, but will eat candy and fruit between 
the regular meal hours. This interferes with digestion 
of the previous meal and spoils any chance of a good 
appetite for the next meal. 
The symptoms are pain in the epigastric region, 
or attacks of colic, poor appetite, frequent headaches, 
constipation, anaemia, malnutrition. 
Treatment: Careful diet, only three meals a day, 
nothing between meals. The child must eat slowly. 
Do not urge the child to eat more than it takes will- 
ingly. Mothers have a tendency even to go so far as to 
bribe the child in order to force it to eat, though the 
stomach may be in no state to receive the food. Let 
the child have plenty of fresh air and outdoor exer- 
cise. Medication is of very little importance. We 
may give Dil. Hydrochloric acid with Elix. Lactopep- 
tin as a vehicle, or Tr. Nuc. Vomic. with Mist. Rhei 
et Sodse. 
Catarrh of the large intestines: The condition may 
be localized in the colon, may ascend, or may be last 
stage of gastroenteritis. 
Causes: Constipation, swallowing large pieces of 
meat, continuing sterilized milk too long. 
Symptoms: Frequent bloody mucus, foul-smelling 
stools, tenesmus. The child may seem well other- 
wise. Prognosis is good. 
Treatment: Castor oil, powdered rhubarb, or Comp. 
Licorice powder. 
Diet; Tea, soup, zwieback, cereals, vegetables GASTROINTESTINAL DISEASES 
73 
(spinach, yellow beets), very little milk* Rectal irri- 
gation with i% alum, tannic acid, i-iooo silver 
nitrate. We may give tannigen 2-4 gr., bismuth sub- 
nitrate 5-10 gr. q. 3 h. 
Acute colitis: In later childhood it may appear like 
regular dysentery, with symptoms of intoxication, and 
sometimes albuminuria. It may be improved without 
any difficulty, if treated early. It may come from per- 
sistent constipation (small, hard stools, covered with 
mucus and blood). 
Chronic membranous or mucous colitis: This is 
caused by constipation and eating too large quanti- 
ties of meat. It is found mostly in anaemic children. 
Palpating the abdomen, we may feel the cord-like 
colon, which is sore to the touch. 
Treatment: Exclude meat from the diet, give only 
cereals, vegetables and milk. Colon irrigations may 
help. 
Constipation in older children: Causes: Malforma- 
tion, or anatomical anomaly of position of the rec- 
tum. Fissure in ano, etc., improper diet (insufficient 
bread, vegetables, cereals and potatoes, too much eggs, 
meat, milk and sweets), failure to respond to the call 
of nature, irregular attention to the bowels, insuf- 
ficient exercise. There may be no symptoms, or the 
symptoms may be quite severe. Sometimes they may 
resemble those of meningitis. Thus we may have con- 
vulsions, tache cerebrale, stupor, fever, irregular pulse 
and loss of pupillary reflex. All these symptoms are 
relieved by a cathartic. Other patients develop 
anaemia. 
Treatment: First find out the cause, attend to the 
diet, induce regular habit of attention to the bowels, 74 
CLINICAL PEDIATRICS 
at the same time every day. Urge plenty of outdoor 
exercise. Daily massage of the bowels yields good 
results. Rectal irrigation is not advisable, unless coli- 
tis is present. 
Medication: Russian mineral oil, one tablespoon, 
night and morning. Cascara, phenolphthalein, aloes, 
belladonna and strychnine, syrup of figs. 
Proctitis: Inflammation of the rectum, occasionally 
found in children. It may be catarrhal, membranous, 
or ulcerative. 
Causes: Constipation, colitis, worms, traumatism, 
diphtheritic infection, gonorrhoea, syphilis, tubercu- 
losis. 
Symptoms: Tenesmus,- especially after a bowel 
movement. There is a discharge of muco-pus and 
blood. 
Treatment: Laxatives, rectal irrigations, or local 
applications through a proctoscope. Constitutional 
treatment, if indicated. 
Ischiorectal abscess: Causes: Constipation, anal 
fissure, worms, pruritus, hemorrhoids, polypi. The 
condition is not as common in children as it is in 
adults. The abscess is very painful and it may open 
externally and result in a blind fistula; or it may open 
into the rectum and be followed by a complete fistula. 
It may heal spontaneously, without the formation of 
any fistula. 
Treatment: Wet dressing and incision. Early and 
free incision will prevent fistula. 
Hemorrhoids: This affection is rather uncommon 
in children. Bleeding from the rectum is more fre- 
quently caused by the presence of polypi. 
Intestinal tuberculosis: This is usually secondary GASTROINTESTINAL DISEASES 
75 
to tuberculosis of the lungs. It may possibly be pri- 
mary, from swallowing infected milk or other food. 
Miliary tuberculosis—tubercles are present in the 
serous coat. 
Chronic tuberculosis—crater-like ulcers, particu- 
larly near the ileocsecal valve. The ulcers may become 
confluent and may cause the formation of scar tissue. 
The mesenteric glands are involved. The appendix is 
often affected, also the peritoneum, causing the intes- 
tines and the omentum to become matted together and 
form large masses. 
Symptoms are not definite. There may be atrophy. 
In some cases there is diarrhoea. Sometimes the stools 
are bloody. Examine the stool for tubercle bacilli 
(dilute the stool, centrifuge, decant, add alcohol and 
centrifuge again). If the peritoneum is involved, 
physical examination will disclose fluid, or the pres- 
ence of a mass. If the appendix is involved, we get 
symptoms of appendicitis. The appendix may per- 
forate and give symptoms of intestinal perforation. 
The patient may run an afternoon temperature, with 
gradual wasting. 
Treatment: Prophylaxis, climate, tuberculin. 
Congenital pyloric stenosis: There are two forms; 
Hypertrophic, probably caused by continued spasm 
of the pylorus. 
Pyloric stenosis will give symptoms a few days to 
a few weeks after birth. 
Pyloric spasm, probably caused by dyspepsia. 
Hypertrophic: There is persistent vomiting of acid 
stomach contents. Practically no stools are present, 
with the exception of a small quantity of foul-smelling CLINICAL PEDIATRICS 
substance, resembling meconium in appearance. The 
stomach may be distended and peristalsis may be 
visible. This is followed by copious vomiting. Under 
partial anaesthesia, a tumor may be felt on palpation 
in the region of the pylorus. There is progressive loss 
of weight. The child is apparently very hungry, and 
yet there is a fear of ingestion of food after the first 
mouthful. Ten hours after a meal there is still food 
in the stomach. 
Pyloric spasm: The symptoms are less marked 
than in the above condition. Vomiting may stop for 
a few days. There is some stool present, which may 
be constipated, or diarrhoeal. There is usually no tu- 
mor on palpation. It is rarely fatal. 
Prognosis: The hypertrophic cases are generally 
fatal. Some of these, in which the hypertrophy is not 
too great, may in rare instances recover. Improve- 
ment, if it comes, usually takes four to twenty weeks. 
Diagnosis: Stenosis of the oesophagus—Food re- 
gurgitates unchanged. 
Stenosis of the duodenum—vomiting of bile. 
Atresia of the pylorus—rapid emaciation and death. 
Unsuitable breast milk, or artificial food—Change 
to proper food is followed by immediate improve- 
ment. 
Treatment: After ascertaining that the condition is 
not caused by overfeeding, change food. If the baby 
is breast-fed, get a wet nurse; if artificially fed, modify 
the quantity and quality of the food. If improvement 
does not follow, try to obtain a wet nurse whenever 
possible. May wash the stomach twice daily, and 
try to feed by gavage. If there is no improvement GASTROINTESTINAL DISEASES 
77 
and a small tumor may be felt under slight ansesthe- 
sia, operate. 
The operation consists of a longitudinal incision 
through the hypertrophic ring cutting through the per- 
itoneum and muscularis (Ramstead). 
Appendicitis: Appendicitis is an inflammation re- 
sulting from an infection of the appendix, predisposed 
by previous irritation, caused by chronic constipation, 
or worms. This condition may also exist in associa- 
tion with some of the infectious diseases, such as 
tonsillitis, rheumatism, typhoid, or tuberculosis. 
This inflammation may be catarrhal, purulent (em- 
pyema of the appendix), perforative, or gangrenous. 
It may result in localized abscess, or general peri- 
tonitis. 
The local symptoms vary in accordance with the 
severity of the inflammation. In exceptional cases we 
find very mild symptoms with a gangrenous appendix. 
The pain may be only a moderate sticking pain, or 
it may be severe and cramp like, requiring relief 
with morphine. The pain is usually felt in the right 
iliac region, but sometimes it is felt higher up. The 
pulse is more rapid in bad cases. A slow, weak, small 
pulse, with pallor cyanosis and low temperature, means 
sepsis. If the pulse is of normal quality and does not 
go above ioo°, the case is mild. As a rule, the higher 
the temperature the severer the case. 
Pulse and temperature rise when the patient is re- 
covering from the shock of perforation. 
Vomiting at the onset is present sometimes even in 
mild cases. When vomiting is repeated and persistent, 78 
CLINICAL PEDIATRICS 
it means severe infection, gangrene, perforation. 
There may be constipation, or diarrhoea. 
Objective symptoms: Mcßurney sign—Tenderness 
on deep pressure at a point midway between the um- 
bilicus and anterior superior spine, a little towards 
the centre. Meltzer sign—While exercising pressure 
over the Mcßurney point, the patient is requested to 
raise his extended leg. This brings about a contrac- 
tion of the psoas muscle. In the presence of appendi- 
citis, this contraction is very painful. 
A rectal examination will disclose the presence of 
a mass, or of tenderness. 
Where perityphlitis or abscess is present, we get a 
board-like rigidity of the right rectus muscle. The 
rigidity is in proportion to the amount of inflamma- 
tion present. 
In advanced cases, there is a hypersesthesia of the 
skin in the iliac region (head zone). 
There is tendency to flexion of the leg. Extension 
is painful. If abscess is present, we may feel a mass. 
Sometimes it is possible to feel the cord-like appendix. 
Catarrhal or mild cases may recover in a few days. 
It may result in empyema of the appendix, with re- 
current attacks, or persistent pain, with a slight rise 
in the temperature; or perforation. It may result in 
the formation of periappendical abscess, which may be 
absorbed and cicatrize, or perforate into the intestine, 
or into the peritoneum, causing peritonitis. 
The gangrenous form may result in sepsis. The 
blood is characterized by a polynuclear leucocytosis. 
Diagnosis: Pleurisy and pneumonia sometimes be- 
gin with pain in the region of the appendix. Typhoid 
fever may also begin with symptoms of appendicitis. GASTROINTESTINAL DISEASES 
79 
Other conditions that may simulate appendicitis are: 
Psoas abscess and perinephritis, intestinal tubercu- 
losis. 
Treatment: Ice bag to the iliac region, moist packs; 
enema; hypodermoclysis, or saline enema to stimulate 
leucocytosis. 
Diet should be very moderate and fluid. Morphine 
should be used as sparingly as possible. 
It is best to operate after the acute symptoms have 
subsided. 
When severe symptoms persist and the general con- 
dition of the patient is not too poor, operate without 
delay. If abscess forms, wait for adhesions. HERNIiE 
Umbilical hernia; Described elsewhere. 
Diaphragmatic hernia: There is a weak spot in the 
diaphragm, through which the abdominal contents are 
forced into the thoracic cavity. Percussion of the chest 
posteriorly gives a tympanitic note. 
Abdominal hernia.—Lateral: A weak spot, just 
above the crest of the ilium, between the transversalis 
muscle and the quadratus lumborum (Triangle of 
Petit), allows the escape of some of the abdominal con- 
tents. 
Ventral: There is a separation of the two recti 
muscles. It is best to operate. 
Femoral hernia: Midway between the spine of the 
ilium and the spine of the pubes, through the femoral 
ring. This form is rather rare in children. 
Inguinal Hernia.—Congenital form: There is a di- 
rect communication between the peritoneal cavity and 
the tunica vaginalis. In other words, the peritoneal 
covering of the cord, instead of becoming obliterated, 
remains patent. 
Upon standing, crying, coughing, or straining, the 
omentum, or intestines, easily find their way into the 
scrotum, causing the appearance of a swelling, which 
is readily reduced in the recumbent posture. This 
swelling is not translucent, and percussion gives a 
tympanitic note. If intestines are in the sac, reduc- 
tion is accompanied by a gurgle. 
80 HERNDE 
81 
This condition is frequently found in small and pre- 
mature babies. 
The majority of these close with palliative treat- 
ment. 
Congenital funicular form: This form is the same 
as the above, only the sac does not extend beyond the 
external ring. 
Infantile form: The hernial sac is located behind 
the tunica vaginalis, which in infants extends up as 
far as the internal abdominal ring. 
Encysted form: Here, the hernial sac is invaginated 
in the tunica vaginalis, both sacs extending as far as 
the internal abdominal ring. 
The acquired form in older children is the same as 
in adults. It may be direct (through the external 
ring), or indirect (through the internal ring and the 
inguinal canal). 
It is usually reducible, rarely irreducible (contents 
adherent). 
Symptoms: Usually there are no subjective symp- 
toms. In acquired cases there is a sharp pain in the 
inguinal region upon its first appearance. 
Physical signs; 
The presence of a lump in the inguinal region 
This lump appears upon standing, coughing, or 
straining. 
There is an impulse on coughing. 
Percussion note—flat or tympanitic. 
Not translucent. 
Disappears in recumbent posture. 
Sometimes the sac becomes overfull and tense and 
strangulation or incarceration is the result. This is 82 
CLINICAL PEDIATRICS 
accompanied by severe pain and symptoms of intesti- 
nal obstruction. 
Diagnosis: Hydrocele Translucent: Inguinal 
adenitis—Hard or fluctuating; aspirate. No intestinal 
obstruction. 
Hydrocele of the cord—Hard, painless lump in the 
inguinal canal, which is translucent. Aspirate. 
Undescended testicle—lts absence in the scrotum. 
The congenital form is differentiated from the ac- 
quired by the history. 
Treatment: Palliative—For infants, a skein of Sax- 
ony wool makes a good support. It is applied in the 
following manner: A skein of white Saxony is looped 
around the body just below the line of the crest of 
the ilium. The loop is adjusted so that it rests upon 
the external ring of the side affected. Tighten as 
well as possible and pull downward and backward 
along the inner aspect of the thigh on the same side. 
Then fasten to the horizontal turn of the w'ool pos- 
teriorly. 
In cases of double hernia two separate skeins may 
be used. These may be washed and changed as often 
as may be found necessary. 
In older infants and children we use a regular truss. 
If there is not a marked improvement after two or 
three years advise operation. 
In cases of strangulated hernia try ice and taxis for 
not longer than 6-12 hours. If unsuccessful, urge op- 
eration without delay. HYDROCELE 
Congenital form: There is a direct communication 
between the tunica vaginalis and the peritoneal cavity. 
Congenital funicular form: Same as above, but it 
does not extend beyond the external abdominal ring. 
Encysted hydrocele of the cord. Forms a cystic 
tumor in the inguinal canal. It is very hard and may 
easily be mistaken for a gland. 
Infantile form: The sac extends from the internal 
abdominal ring down into the tunica vaginalis. 
Acquired, or vaginal form: Distention by an ac- 
cumulation of serum in the tunica vaginalis proper. 
The most important point is fluctuation and trans- 
lucency of the tumor. 
Treatment: The congenital form is treated by 
means of a support or truss, just as if it were a con- 
genital hernia. 
The encysted form is treated by aspiration, which 
may be repeated, or supplemented by the injection of 
a few drops of Tr. lodine. 
The infantile form should be aspirated. After as- 
piration, rub the sac between the two fingers over the 
needle still in the sac, to roughen the surface of the 
walls of the sac. 
Aspiration may be repeated a few times, at intervals 
of two weeks. 
83 84 
CLINICAL PEDIATRICS 
It is rarely necessary to resort to operation, or even 
the injection of irritants. 
The vaginal form is the same as in adults and is 
treated by aspiration, injection or irritants, or opera- 
tion. ANIMAL PARASITES 
Nematodes 
Ascaris Lumbricoides (roundworm) : Round salmon- 
colored body, pointed at each end. The female pro- 
duces 40 to 60 million eggs (1/20 mm. long). Embryos 
develop within four to eight weeks. Found in dirt. 
The eggs after being swallowed develop in the in- 
testines. The worm that develops is usually 2-6 inches 
long, and of the thickness of an angle- 
worm. About six worms are usually 
present in the intestines at a time. 
The condition is recognized when the 
worms are found in the stools, or when 
a microscopical examination shows the 
presence of the eggs. 
Egg 
Symptoms: Abnormal cravings for unusual kinds 
of food, transient abdominal pains, vomiting, itching 
in the nose. The worms may migrate into the lungs 
and cause cough, atelectasis, and even pneumonia. 
Biliary ducts may be invaded and cause symptoms of 
biliary calculus. A large mass of worms may cause 
symptoms of intestinal obstruction. The mucous 
membrane of the intestines may become ulcerated, or 
infected with abscess formation resulting. The worm 
may migrate to other parts of the body. 
Other possible symptoms are: irregular pulse, urti- 
caria, diarrhoea, nervous twitchings, convulsions. 
85 86 
CLINICAL PEDIATRICS 
Treatment: Santonin, in lozenges, powder or 
tablets. Dose, 34 gr- t° 1 gr. three times a day 
for several days. Also purge with Castor oil or Ep- 
som Salts. 
P>lood count shows a large number of eosinophiles. 
May give 
Ext. Spigelia fl 15 c.c. 
Mist Rhei et Sodae ad 60 c.c. 
Sig. oi t i d p c. 
Examine for eggs after several weeks. 
Oxyuris Vermicularis (threadworm, pinworm) : 
The stool has the appearance of being covered with 
a great many white threads. The worm 
is 34"P2 inch in length and is spindle- 
shaped. A good many eggs are found in 
the faeces. They may also be found in 
the dirt under the finger nails. They are 
.05 mm. long. The principal symptom is 
itching around the perineal region. Irrita- 
Egg 
rp, 
tion may cause eczema. Ihe worms may 
migrate into the vagina. This condition may also 
be a cause of enuresis and masturbation. A rectal ex- 
amination will often bring out some of the worms. 
Treatment: Cleanliness and frequent baths. Ene- 
mata with infusion of Quassia, or 1 oz. of vinegar to a 
quart of water, or with limewater. These should be 
continued until the worms disappear from the stools. 
Internally we may give Santonin and Calomel aa gr. 
34 t i d p c. 
Trichocephalus Dispar (Whipworm) : This is a 
thready worm about 1 inch or more in length. The ANIMAL PARASITES 
87 
head and neck are thin, and take up two-thirds of 
the length of the body. The posterior third contains 
the sexual organs. 
The worm attaches itself firmly to the 
mucous membrane, and causes enteritis. 
The egg is characteristic. It is nar- 
rowed at each end, like a corked neck of 
a bottle. 
The infection is carried by dirty water, 
or earth dirt. 
Egg 
Treatment is the same as that of roundworm or 
threadworm. 
Anchylostoma Duodenale (Plookworm) (Uncina- 
ria) : This worm inhabits the duodenum, or upper ilium. 
It is most frequently found in 
those that work in excavation 
(tunnels, etc.). It is less than 
Yz inch in length. The mouth 
has hook-like teeth. Through 
the grayish body the intestinal 
tract, filled with blood, is per- 
ceptible. The eggs (found in 
jrGG 
the faeces) are characteristic. 
They are .05 mm. in length. 
The chief symptom is severe anaemia 
Treatment; Thymol V -XX gr., a saline cathartic 
being administered two hours before and after the 
dose. 
Trichina Spiralis: The source of infection is pork 
and sausages. The swine get it from infected rats. 
The worm is mm. wide and 2-4 mm. long. Tim 
encysted trichinae get into the intestinal tract. After 
two or three days the male and female meet. After 88 
CLINICAL PEDIATRICS 
four or five days the female begins to deposit embryos, 
and discharges about 1,500 of these during the follow- 
ing four or five weeks. 
These embryos are 1/10 mm. long and 1/200 mm. 
wide. 
They pass out in the faeces, or migrate directly to 
the muscles, or indirectly through the circulation, or 
lymphatics. In the muscles they grow to the size of 
1 mm. and become encysted, and either live for years, 
or die. The capsule becomes calcified. 
Symptoms—At first, there is diarrhoea, vomiting and 
a slight rise in temperature. Later, the temperature 
is high and the patient complains of pains all over the 
body. The muscles swell and are painful. The eyelids 
become temporarily oedematous, pupils dilated and 
fixed. 
The child becomes sleepy, rarely restless. 
The outcome is death, or protracted recovery. 
Diagnosis—We must distinguish from acute myosi- 
tis. Examine the stools. Sometimes it may be neces- 
sary to excise a section of the muscle. 
Treatment—Give Castor Oil repeatedly; then gly- 
cerin 3i-ii q. 3h. May give: 
Benzol . 1. 
Muc. Acaciae 12. 
Aq. Menthae pip. ad 60 
Sig. 3 i q. 2 h. 
Cystodes (Tapeworms) 
Taenia Solium (armed) : 6-12 ft. long. The head is 
of the size of a pinhead. It has four suckers and at 
the tip of the head there is a circular row of hooks. ANIMAL PARASITES 
89 
The eggs are round and .03 mm. in diameter. 
It is acquired through eating pork, containing living 
embryo cysts. 
Taenia Saginata (mediocanellata) : 18-24 ft. long. 
It is acquired through eating infected beef. 
The head may be 2 mm. thick, showing a brown 
pigmentation, four suckers and no hooks. The eggs 
are smaller than those of tsenia solium. 
Bothriocephalus latus (broad, the links are broad 
and narrow) : Length 30 ft., or longer. The head is 
wedge-shaped. The eggs are plentiful in the faeces 
(oval, .07 mm. long). 
The embryos swim in the water and are ingested by 
fish, and encysted in them. This variety is, therefore, 
contracted by eating fish. 
Taenia Cucumerina (dog, or cat tapeworm) : 4-12 
inches long. The worm is provided with a head and 
four suckers. Children who play with cats or dogs 
are apt to become infected. 
Taenia Nana: One inch long. Found in Italy. 
Children are sometimes infected. 
All tapeworms present a head, neck and links. The 
neck is never longer than 1 cm. The links contain 
the sexual organs, which are packed full of eggs. The 
body grows in segments, or links, from the head down, 
each succeeding link being broader than the one above. 
The head becomes attached to the mucous membrane 
of the intestines. 
Groups of segments are discharged in the stools. 
They are gray in color and are sometimes mistaken 
for false membrane (mucous colitis). The body con- 
tinues to grow as long as the head remains. CLINICAL PEDIATRICS 
There may be only one worm present in the intes- 
tinal canal, or there may be two or three and even 
more. 
Symptoms : Anaemia, dyspepsia, choreiform, or epi- 
leptiform symptoms. In rare cases of bothriocephalus 
latus, we may get a very severe and even fatal form 
of anaemia. 
The patients usually have a ravenous appetite, and 
may have indefinite nervous symptoms. Blood shows 
an increase in eosinophiles. 
Diagnosis: Examine the links and look for eggs 
in the stools. Give a cathartic, if necessary, to bring 
them out. 
Treatment: Give castor oil and bland diet. May 
add onions and garlic to the diet. The next day, give 
a cup of tea, followed an hour later by the Felix Mass 
mixture (7 Til of Felix Mass for each year of life, the 
dose not exceeding i 3). 
Felix Mass mixture; 
Res. Aspidium (Felix Mass) oss 
Sp. Chloroform fflxv 
Sp. Terebinthinse v 
Muc. Acaci oss 
Divide into 2 doses given 2 hours apart. Instead 
of Felix Mass we may give p2 lb. of pumpkin seed with 
pomegranate (gr. LXXV, macerated for 24 hours in 
6 oz. of water), made into a decoction and given in 
four doses during the day. 
Taenia Echinococcus: The infection comes from a 
dog fed on meat with echinococcus cyst. When the egg 
reaches the intestinal tract the embryo becomes free. 
Then through the lymphatics, or circulation, the em- ANIMAL PARASITES 
91 
bryo migrates to different organs in the body, prefer- 
ably the liver. There it becomes encysted and sur- 
rounded by a connective tissue capsule. When in the 
peritoneal cavity, no protective capsule is formed. 
Usually it gives no evidence of its presence until large 
enough to cause pressure. 
The main cyst has smaller cysts springing from its 
parenchyma. These are surmounted by booklets and 
four suckers. The daughter cysts may have grand- 
daughter cysts forming within them. 
The cysts may be multilocular. This means that a 
great number of cysts is imbedded in the large cyst. 
This cyst is about the size of an orange and is filled 
with a jelly-like substance. 
When fluid escapes into the peritoneal cavity, the 
patient may get persistent attacks of urticaria, or else 
may develop a fatal toxemia, or pyemia. 
Cysts may remain in the body for years without 
giving any symptoms, or they may dry up. 
Large cysts, giving pressure symptoms, must be op- 
erated upon. DISEASES OF THE PERITONEUM 
Acute peritonitis 
Pneumococcus: The infection enters through the 
peritoneal wall, the appendix, Fallopian tubes, circula- 
tion, or directly from the pleura, in cases of concomi- 
tant empyema of the chest. 
Symptoms: Abdominal pain, vomiting, diarrhoea, 
distention of the abdomen with presence of fluid. The 
pus usually becomes encapsulated, collecting in the 
antero-inferior part of the abdomen. If no incision 
is made it may ooze out through the umbilicus and 
even result in spontaneous recovery. 
The pus is thick and greenish. 
The blood picture is that of leucocytosis. 
If not operated, it generally results in the wasting 
of the patient, or pneumococcus septicaemia. 
Diagnosis: Appendicitis—symptoms are localized, 
and there is no fluid in the peritoneal activity. 
Typhoid—Widal reaction;, there may be other 
symptoms of typhoid. 
Tuberculous peritonitis—Slow onset and blood 
count shows no leucocytosis. 
Treatment: Incision and drainage. 
Streptococcus peritonitis: This form may be pri- 
mary, or may follow some infectious disease, particu- 
larly scarlet fever. 
The onset is severe with pain, fever, vomiting, severe 
92 DISEASES OF THE PERITONEUM 
93 
diarrhoea and distention. Usually fatal in seven days. 
The pus is thin and reddish yellow. The process 
rarely becomes encapsulated. 
Prognosis is very bad. 
Treatment: Incision and drainage. 
We may try polyvalent, or autogenous vaccine. 
Gonococcus peritonitis: This form is rare. It may 
be mild or severe. 
Vaginal discharge is present. 
Even bad cases may get well. 
Do not advise any operation, unless the case looks 
desperate. 
The case may look like appendicitis. 
Tuberculous peritonitis 
Serous: Onset is slow. The abdomen is distended 
with fluid. General health is not much affected at 
first. It may disappear and recur. The patient may 
get well permanently, or may in time become emaci- 
ated, with development of tuberculosis in other parts 
of the body. 
Sero-fibrinous: The tubercles become large and 
caseous. 
The omentum and intestines may become matted to- 
gether, and form distinct masses. 
Symptoms: Indefinite abdominal pain, nausea, di- 
arrhoea, emaciation. 
The physical signs depend on the presence of fluid 
and tuberculous masses. 
Treatment: For the serous variety, the surgical 
procedure of incision, evacuation and closure has re- 
sulted in some cures. CLINICAL PEDIATRICS 
94 
Treatment is otherwise the same as in tuberculosis 
elsewhere, i. e., climatic, dietetic, Thiocol, etc. Tuber- 
culin. 
Tumors of the peritoneum: May have; endothe- 
lioma, sarcoma, lymph cyst, chylous cyst, or dermoid 
cyst. DISEASES OF THE LIVER 
Jaundice: Catarrhal, or Infectious. 
Other causes: icterus neonatorum, congenital ob- 
struction of the biliary ducts, biliary calculus (rare in 
children), sepsis, malaria, infectious diseases (pneu- 
monia, scarlet fever), drugs (santonin, male fern). Cir- 
rhosis of the liver, haemolytic jaundice. 
Catarrhal jaundice; This is always associated with 
gastroduodenitis, which seems to be of infectious 
origin. 
Symptoms; Chills, fever, vomiting, gastric pain, con- 
stipation, or diarrhoea, light colored stools, dark urine 
with a trace of albumin. 
The liver and spleen are enlarged, the pulse is slow. 
The fever usually lasts a few days and recovery fol- 
lows. Jaundice disappears in two to four weeks. 
Epidemic jaundice (Weil’s disease) : This seems to 
be an epidemic infectious disease. 
The symptoms are similar to those of the catarrhal 
form, perhaps more severe and accompanied by hem- 
orrhages from the mucous membranes. 
Treatment: Initial dose of calomel, followed by a 
daily dose of sodium phosphate, given in water, every 
morning. When vomiting is severe we may use so- 
dium bicarb, and cerium oxalate aa 2-5 gr. q. 2 h. 
May also give a daily cold water enema. Later 
Mist, rhei et sodse may be given. Sometimes vomiting 
95 96 
CLINICAL PEDIATRICS 
is so persistent that it is necessary to give lavage be- 
fore it stops. 
Diet: At first only water; later, barley or oatmeal 
gruel, milk, zoolak. 
Acute yellow atrophy: Rare in children. Etiol- 
ogy is indefinite. It may be apparently primary, or 
may follow typhoid, general septic condition, or ery- 
sipelas, or phosphorus poisoning from matches. 
Symptoms: Jaundice, fever, somnolence, convul- 
sions, coma, hemorrhages, rapid diminution of the size 
of the liver in a few days to two weeks. Leucin and 
tyrosin crystals are found in the urine. The outcome 
is always fatal. 
Fatty liver: Present in acute, or chronic infectious 
diseases, also in atrophic infants. 
Amyloid liver: Found in cases of prolonged sup- 
puration. 
Abscess of the liver: In the tropical region, it may 
be associated with dysentery. Other causes: migra- 
tion of the round worm, appendicitis, trauma, typhoid 
fever, pyemia, influenza, tuberculosis. 
Symptoms: Swelling, pain, fever. 
The traumatic form may get well; the others are 
usually fatal. 
Treatment: Surgical. CIRRHOSIS OF THE LIVER 
Varieties: 
i. Atrophic (alcoholic) (rare) (Laennec’s cirrhosis) 
2. Hypertrophic (Hanot’s cirrhosis) 
3. Circulatory 
4. Congenital obliteration of the bile ducts 
5. Syphilitic 
Atrophic: The liver is small and contracted. The 
symptoms are: Dyspepsia, tympanitis, ascites, large 
spleen and a small hard liver, diarrhoea, loss of flesh, 
hemorrhage, oedema of the lungs. Slight jaundice. 
The course of the disease is subacute and shorter than 
in adults. 
Hypertrophic: This form is probably of infectious 
origin. The liver is large and of wooden consistence; 
the spleen is large. Ascites is usually not present, but 
may be marked in some cases. There may be attacks 
of fever with liver pain. Jaundice is marked. The 
growth of the child is arrested, this being more appar- 
ent owing to the large size of the abdomen, associated 
with joint deformities, especially the fingers and toes. 
Sometimes the spleen is very large and the liver is 
not so very large. The course of the disease is slow, 
dragging through years. The duration is shorter in 
infants. 
Cardiac, or cardio-tuberculous cirrhosis: This form 
is associated with pericarditis (rheumatic, or tubercu- 
lous). 
97 98 
CLINICAL PEDIATRICS 
The liver is large and fatty (smooth, slightly granu- 
lar), covered with thickened peritoneum. A cross-sec- 
tion of the liver shows it to be of nutmeg appearance. 
The spleen is enlarged and also covered by thickened 
peritoneum. The abdominal peritoneum may also be 
thickened. 
The ascites is uncontrollable and is not affected by 
digitalis. 
The course of the disease is progressive and termi- 
nates fatally. 
Hypertrophic cirrhosis due to congenital oblitera- 
tion of the bile ducts: This condition is caused by 
stagnation of the bile. 
The liver and spleen are enlarged and there is in- 
creasing jaundice from birth. There are hemorrhages 
from the umbilicus and the mucous membranes, fever 
and convulsions. Ascites develops, if the child lives 
long enough. Death usually occurs in fourteen days 
after birth. Some cases may drag out a few months. 
Treatment: Milk diet, mixed treatment (mercury 
and iodides). 
When ascites persists we may try Talma’s operation 
of venous anastomosis. 
Treat symptoms as they arise. 
Tumors of the liver: Angioma, cystic degenera- 
tion, adenocarcinoma, carcinoma, sarcoma, echinococ- 
cosis. DISEASES OF THE RESPIRATORY ORGANS 
Coryza: This is a catarrhal condition of the Schnei- 
derian membrane, caused by some form of acute in- 
fection. 
Predisposing causes are: warm clothing, cold and 
damp weather, adenoids. Exciting causes are: 
Streptococcus, or staphylococcus infection, influenza, 
measles, diphtheria, erysipelas. 
There is a swelling of the mucous membrane, fol- 
lowed by a discharge of mucus, seromucus, or mu- 
copurulent in character. There is an obstruction to 
nasal breathing and other symptoms, depending on 
the associated disease. 
Treatment: Treat associated disease. Locally, we 
may apply an instillation of i% silver nitrate, or 3% 
protargol, or 5% argyrol. 
Steam inhalation with Tr. Benzoin. When obstruc- 
tion to breathing interferes with nursing, use a spray 
of weak solution of cocaine and adrenalin. 
Chronic rhinitis: Causes: Adenoids, polypi, for- 
eign body in the nose, congenital deformity of the na- 
sal septum. 
There is a constant discharge of mucus from the 
nose and interference with nasal respiration. The con- 
dition improves in the summer. The irritation of the 
constant discharge causes eczema of the upper lip. 
Treatment: Removal of the causes and tonics. 
99 CLINICAL PEDIATRICS 
Chronic atrophic rhinitis follows chronic hypertro- 
phic rhinitis (CEzena). 
This affection is common in scrofulous and anaemic 
children. 
The nasal cavity is wide open. There is a foetid 
discharge, with a tendency to formation of crusts and 
slight bleeding. 
Syphilitic rhinitis: This is one of the earliest 
symptoms of the disease. It appears between the 3rd 
and the 6th week, rarely after the third month. It is 
present both early and late in the disease. 
Treatment: Antiseptic sprays. 
Usually there is only catarrh, but there may be mu- 
cous patches. The discharge is seromucus and 
slightly bloody. It improves with constitutional treat- 
ment. In neglected cases gummata form, with ulcer- 
ation and cicatrization and frightful deformities. 
(True cases of oezena.) 
Membranous rhinitis: This is a diphtheritic infec- 
tion. There is a mucopurulent bloody discharge with 
nasal obstruction. In the presence of such a discharge, 
always take a culture. The infection may spread to 
the throat. Usually there are no marked constitu- 
tional symptoms and cases are frequently overlooked. 
Treatment: Give antitoxin. Spray nose with a bi- 
chloride sol., 1-1000. May also give a 1% or 2% 
sol. of carbolic acid internally, 1 teaspoon q. 2 h. 
Epistaxis: Bleeding is most frequently from the 
anterior septum, but may come from any part of the 
nasal mucous membrane. 
Possible causes: Traumatism, coryza, picking of 
nose (scab), scurvy, haemophilia, purpura, severe 
anaemia, pertussis, diphtheria, typhoid. DISEASES OF RESPIRATORY ORGANS 
Treatment: With the aid of adrenalin try to find 
the bleeding point and touch with silver nitrate. If 
that is not possible, have the patient hold his head 
forward, allowing the blood to drip until a clot forms, 
then cut the clot even with the anterior nares. May 
also try the application of cold on the back of the neck, 
at the same time compressing the nose just below the 
bony bridge. If all these efforts fail, then we may 
pack the nose anteriorly, or by means of a posterior 
plug. This latter is done by introducing a string 
through the nose, with the aid of a catheter, until the 
string drops below the uvula; get hold of the string 
through the mouth, withdraw the catheter, then to the 
oral end attach a gauze plug, pulling this back into 
the posterior pharynx by drawing on the nasal end 
of the string. While drawing on the string, introduce 
your anterior packing. Order only cold fluid diet. Re- 
move plugs after 24 hours. 
Catarrhal spasm of the larynx (False croup) : The 
affection is rare under 6 months, common after that 
until the age of 3 years, but rare after the sth year. 
It is frequent in children with adenoids, long uvula, 
or rhinitis. Exciting causes are: cold, indigestion, 
constipation. 
Treat the general condition. 
Symptoms: Croupy cough, hoarseness, attacks of 
stridulous breathing, coming on at night (usually 
about 12 o’clock), lasting three or four hours, of vary- 
ing severity, prostration, fever (ioi°). These cases 
of croup are never fatal. Unless arrested by treat- 
ment, the attacks of stridor will be repeated the sec- 
ond and third night, though less severe than the first 
attack. 102 
CLINICAL PEDIATRICS 
It is often mistaken for diphtheria. Chloroform 
will relieve catarrhal croup, but not diphtheria (mem- 
branous croup). 
Treatment: During the attack administer some 
emetic, such as Syr. Ipecac 3i-ii, or Yin Antimony, 
TT[xv, which may be repeated once, or twice. We may 
use the inhalation of steam with Tr. Benzoin Comp. 
During the next day, give ipecac and antimony aa 
gr. i/ioo, q. 3 h., and at bed-time give antipyrine gr. 
ii, for a child 2 years old. 
In some severe cases, it is necessary to do an intu- 
bation to relieve the stridor. 
Acute catarrhal laryngitis: This may be caused by 
cold, irritative gases and eruptive fevers. The patient 
may not feel, sick, or have any fever. The tempera- 
ture may depend on the associated condition (influ- 
enza, etc.). Symptoms are hoarseness, loss of voice, 
croupy cough. We may get attacks similar to laryn- 
geal spasm. 
Duration of the affection is one week, or longer, de- 
pending on the-associated condition. 
Must be differentiated from diphtheria. Sometimes 
it is safer to administer diphtheria antitoxin before ar- 
riving at a definite diagnosis. 
Treatment: Cold compress to the neck. Medica- 
tion, the same as in catarrhal croup. 
Membranous laryngitis (Laryngeal diphtheria, True 
croup, Membranous croup) ; This may be primary, 
or secondary to diphtheria of the pharynx. 
The onset is the same as in catarrhal croup, only 
slower. Temperature is ioo°-ioi°. In 12 hours the 
symptoms become worse and in 24 hours they become 
fully developed. There is stridulous breathing, with DISEASES OF RESPIRATORY ORGANS 
103 
retraction of the chest and supraclavicular spaces, and 
cyanosis. 
The local symptoms are severe, before the general 
symptoms have a chance to develop. In bad cases 
death may occur in 24-36 hours. 
The child may develop bronchopneumonia, which is 
a frequent cause of death. We must differentiate from 
retropharyngeal abscess, foreign body, pneumonia with 
laryngitis. 
Treatment: Antitoxin, intubation (if stridor con- 
tinues to increase). 
Tracheotomy, if intubation fails, or is not available. 
We may also try the inhalation of calomel fumes 
(gr. xv), with tent over the bed. Protect the face, air 
the room after inhalation for 15-20 minutes. 
Submucous laryngitis (oedema of the larynx) : 
Causes: Inhalation of steam, or some irritating gas, 
acute laryngitis, retropharyngeal abscess, erysipelas. 
There is an inspiratory dyspnoea with attack of suf- 
focation. We may recognize the oedema by digital 
examination. 
Treatment: Ice, swallowed and applied externally. 
Scarification of the oedematous parts. As a last resort, 
do a tracheotomy. 
Chronic laryngitis: Most frequently caused by 
adenoids. 
Syphilitic laryngitis: Rarely found in children 
New growths of the larynx: Papilloma is not un- 
common in infants. At first, we get symptoms of 
laryngitis, paroxysmal cough and hoarseness; later, 
dyspnoea. Prognosis is not favorable, owing to ten- 
dency to recurrence. 
It is a small whitish growth, sessile, or peduncu- 104 
CLINICAL PEDIATRICS 
lated. If pedunculated, it may be removed by the 
oral route, but, if sessile, it is necessary to perform a 
thyroidotomy. 
Congenital stridor: This is caused by an anomaly 
of the epiglottis. There is an almost constant inspira- 
tory crowing sound, heard soon after birth. This 
gradually disappears during the first two or three 
years of life. 
Air goitre: This may be spontaneous or traumatic. 
There is an air cyst on the side of the neck (subcuta- 
neous emphysema). 
Foreign body in the larynx; This is manifested by 
a sudden paroxysm of coughing and dyspnoea. The 
foreign body may be arrested in the larynx or may be 
carried down into the trachea and bronchi, especially 
the right bifurcation. The symptoms require urgent 
treatment. Turn the patient upside down, at the same 
time striking him on the back. We may have to do a 
bronchoscopy, tracheotomy, or laryngotomy without 
delay. 
If the foreign body is in the bronchus, we get cough, 
pain in the chest, absence of breathing in one section 
of the lungs, or in the entire lung. It may cause the 
formation of an abscess, with hectic fever and death 
after a few weeks, or months; or a great paroxysm of 
coughing may expel the foreign body. The condition 
is sometimes diagnosticated as tuberculosis. DISEASES OF THE LUNGS 
Acute catarrhal bronchitis: Predisposing causes: 
Malnutrition, rickets, warm rooms, influenza, other in- 
fectious diseases, adenoids. Exposure to cold acts as 
an exciting cause. 
Mild cases: Duration is about one week. There is 
a slight rise in temperature, 101-102°, for two or three 
days; later, ioo°. It is often preceded by coryza and 
pharyngitis. Mucus is coughed up, or swallowed, or 
sometimes vomited. Upon auscultation, we hear 
coarse and sonorous rales. Breathing is somewhat in- 
creased in frequency. Sometimes there is also vomit- 
ing and diarrhoea. The attacks are often recurrent. 
Severe cases: These may resemble bronchopneu- 
monia. 
Fever is 103-104° at the onset, going down to ioo° in 
36 hours. There is dyspnoea, cyanosis, dullness, apa- 
thy, stupor. These symptoms may come on very sud- 
denly and cause death within a few hours. Dyspnoea 
is caused by a collapse of the lungs, due to obstruction 
of the bronchi by mucus. 
Physical signs: Percussion note may be tympan- 
itic; auscultation gives coarse, sonorous rales; also 
subcrepitant rales, which disappear on coughing. 
In older children the symptoms are not so severe. 
If the child is kept out of doors, the case may become 
subacute or chronic. 
Rarely, the cases may run into bronchopneumonia, 
105 CLINICAL PEDIATRICS 
especially when associated with measles or pertussis. 
Treatment: The room should be well ventilated. 
Keep the child in bed, with care to keep the feet warm. 
Locally—Mustard paste over the entire chest, 5-8 
minutes, every 3 hours. Or Priesnitz compress (tepid 
wet pack to the chest, one hour on and two hours off). 
Antipyrin or phenacetin, with aspirin, or sodium sa- 
licylate aa gr. i (for 1 year old) q. 4 h. 
Internally—cathartic—castor oil, or calomel. 
Or, sol. Ac. carbolici 1-3%, for child 1-3 years re- 
spectively, dose 3i q. 2 h. 
Expectorants may be used later, if necessary. These 
may be a combination of Syr. Ipecac, Yin Antimony, 
Syr. Senega, Syr. Squills, with Potas. citrate, or Am- 
monium muriate. Also: 
Thiocol (Roche) 2.00 5 ss 
Tr Opi Camph 10.00 3 iiss 
Syr Tolu 30.00 § i 
Syr siml. ad 60.00 § ii 
Misse et Sig. 3i q. 4 h. (for child 2 yrs.) 
For cyanosis spanking and mustard baths. 
Fibrinous bronchitis: This form of bronchitis may 
be caused by diphtheria, but there is another form, 
acute, or chronic, with obscure etiology. 
The characteristic symptoms are the expectoration 
of bronchial casts, with severe dyspnoea. Otherwise, 
the symptoms are the same as in ordinary bronchitis. 
The tube casts may be entire, or they may come out 
in little balls, which unfold in water. 
Prognosis is bad, there being a mortality of 75% in 
acute cases. DISEASES OF THE LUNGS 
107 
Chronic cases may last for months, or years, with- 
out affecting life. 
Treatment: Steam inhalations, pilocarpine. In 
chronic cases we may give potassium iodide. 
Chronic bronchitis: Rickets, malnutrition, lymphat- 
ism; poor environment may cause an acute attack to 
persist. Other causes are: measles, whooping cough, 
tuberculosis, heart disease, late manifestation of syph- 
ilis, interstitial pneumonia with or without bronchiec- 
tasis, deformities of the chest. 
Symptoms: Cough, with expectoration of variable 
quantities of mucopus, especially at night. Very 
large quantities of sputum at one time means the pres- 
ence of bronchiectasis. 
Afternoon temperature and emaciation mean tuber- 
culosis and repeated examinations of the sputum for 
tubercle bacilli should be made. 
Treatment: Improve the environment, if possible. 
Avoid sedatives. Give cod-liver oil, creosote, tere- 
bene, potassium iodide. 
Nervous cough (reflex cough) : This cough may be 
associated with elongated uvula, nasopharyngitis, 
dyspepsia, or cardiac disease. 
It is usually a persistent night cough, causing in- 
somnia. 
Tuberculous bronchial glands and abscess following 
Pott’s disease may also cause a cough. In rare cases 
otitis will cause a cough. Treat the cause. We may 
give antipyrine and bromides at night. 
Asthma: This is very similar to the adult condi- 
tion, but is uncommon before the age of seven years. 
It accompanies, or is followed by bronchitis. Etiology CLINICAL PEDIATRICS 
is the same as in adults: heredity, locality, irritating 
vapors, heavy underclothing. 
The symptoms are similar to those of capillary 
bronchitis, with fever, fine rales, dyspnoea, but, instead 
of running the regular course, the symptoms disap- 
pear in 24 hours. The attacks will recur. There may 
be attacks of suffocation, which in infants may turn 
out fatal. Cases usually follow bronchitis, and are 
frequently found in rachitic children. 
Asthma may last two to six weeks, or may persist 
for months, and yet complete recovery, without recur- 
rence, is possible. 
Physical signs; During dyspnoea the respirations 
are 50-60. 
We get sibilant, sonorous and stridulous breath- 
ing. The child appears cyanotic. The percussion note 
is somewhat tympanitic, indicating the presence of 
some emphysema. This emphysema may disappear, 
when the child recovers. Asthma may not affect gen- 
eral health. The accompanying cough is usually only 
moderate, with very little expectoration. 
Hay fever, which is frequently associated with asth- 
ma in adults, is rare in children before the age of 10 
years. 
Asthma may cause thoracic deformity (barrel- 
shaped chest). 
Prognosis is better in younger children. It is best 
in catarrhal asthma. 
Treatment: Treat local condition; removal of ade- 
noids, if present, is especially important. During the 
acute attack, we may use inhalation of fumes of nitre 
paper, or stramonium leaves; or adrenalin (-1-1000), 
1-5 drops hypodermatically. Internally, administer: DISEASES OF THE LUNGS 
109 
Potassium lodide 3.00 gr. 45 
Atropine Sulph 002 gr. 1/30 
FI. Ext. Grindelia Robusta.... 5.00 iU 75 
Syr. Pruni Virgin 30.00 1 oz. 
Aquae q s ad 60.00 2 oz. 
Dose 1 teaspoon q. 4 h. for 5 year old child 
In bad cases we add morphine, or chloral. 
Between attacks we may give cod liver oil and 
creosote. Change of climate is beneficial. 
Bronchopneumonia: Bronchopneumonia may be 
primary or secondary. 
Secondary case may follow measles, pertussis, 
diphtheria, bronchitis, influenza. 
Primary cases are caused principally by the pneu- 
mococcus. In secondary cases, there is a mixed in- 
fection. The bacteria found are streptococcus, sta- 
phylococcus, bacillus of Friedlander. Streptococcus 
plays the most important role in secondary cases. 
Symptoms: There is no typical course, but the dis- 
ease may be grouped into several types. 
Acute congestive type: The onset is sudden, with 
death in 12 to 24 hours. 
There is extreme prostration, cyanosis and dyspnoea. 
The temperature is io4°-7°, rising before death. The 
pulse is very rapid. There is usually stupor and some- 
times convulsions before death. 
There are usually no physical signs, except perhaps 
roughened or diminished breathing on one side. 
The symptoms are caused by the pneumococcus in- 
fection and the congestion of the lungs. 
If the child can overcome the severe onset, it may CLINICAL PEDIATRICS 
recover after three or four days, or it may develop the 
regular bronchopneumonia. 
Acute disseminated bronchopneumonia (capillary 
bronchitis) : These cases are as severe as the pre- 
ceding. The patient usually recovers except in cases 
of great feebleness. 
Temperature is 102°, respiration 80-100. There is 
also cyanosis, dyspnoea, prostration, and excessive 
cough. x 
Physical signs: Percussion note may be exagger- 
ated. Breathing may be feeble and diminished or 
sibilant. We also usually find subcrepitant and coarse 
rales. There are no signs of consolidation. 
Death may occur in three or four days, or improve- 
ment and recovery at the end of a week, or develop- 
ment of consolidation of the lung. 
The common type: Only 10% are preceded by 
bronchitis. 
The onset is usually sudden. Temperature is high 
(104°). Sometimes there is vomiting and sometimes 
covulsions. Prostration is not very marked at first. 
Respiration 80-100. Pulse 140-160. The patient looks 
cyanotic. 
Cough is more constant than in lobar pneumonia. 
The temperature is usually remittent. Sometimes 
the temperature is low, particularly in weak children. 
Pain is not a common symptom. 
Convulsions are not as common as in lobar pneu- 
monia, but frequent in cases following pertussis, 
usually with a fatal outcome. 
Delirium may be present at any stage of the disease. 
Sometimes the case may look like meningitis (men- 
ingism), DISEASES OF THE LUNGS 
Gastroenteritis is not uncommon, making- the case 
more serious. 
Gas in the stomach may interfere with respiration, 
and cause cyanosis. 
The urine shows a trace of albumen, if the temper- 
ature is very high. 
Physical signs: A. No consolidation—slight dull- 
ness, or no change in percussion ; rales—coarse, or fine; 
diminished breathing. 
Duration of the disease is one to four weeks. 
B. Incomplete consolidation—Percussion slightly 
dull or tympanitic, or normal, no increased fremitus, 
diminished, or broncho-vesicular breathing, increased 
voice. 
C. Complete consolidation—Dullness may or may 
not be marked. 
Pure bronchial breathing and voice, blending at the 
edges with fine rales. Rales all over. Later the phys- 
ical signs may simulate those of lobar pneumonia. 
The signs are usually found in the back, extending for- 
ward as far as the axillary line. Breathing may be 
diminished or absent, unless inspiration is forced, and 
then it is bronchial. 
Fremitus is increased. Friction sounds may be 
heard. 
In some cases signs of consolidation are absent, 
when areas of consolidation are small and central. 
Protracted cases: These may be primary, but they 
are not uncommon after pertussis, or scarlet fever. 
At first the case appears like a regular broncho- 
pneumonia for two or three weeks. Then the temper- 
ature comes down to 100-103° and the lung does not 
resolve; in fact, the consolidation spreads. There is 112 
CLINICAL PEDIATRICS 
indigestion and asthenia, and there may be an exac- 
erbation of the acute condition. Breathing is bron- 
chial (like cavernous) and friction and bronchial rales 
may be heard. Punctate hemorrhages may appear 
on the abdomen and extremities, which generally mark 
the case as fatal. Death usually follows after four or 
five weeks. Recovery is possible and may be com- 
plete. The child may never become actually strong. 
Relapses may take place and the case looks like tu- 
berculosis. 
Consolidation may disappear after a few weeks, 
but rales and friction sounds persist for a long time. 
Convalescence is very slow. 
Secondary pneumonia complicating pertussis: The 
course of the disease is slow. Recovery is slow. Con- 
solidation may persist for weeks or months, and yet 
be followed by recovery. Sometimes there may be 
cerebral symptoms, and then the case is fatal. 
Pneumonia complicating diphtheria: It usually ap- 
pears two days after laryngeal diphtheria. Generally 
we find it associated with bronchial diphtheria. Signs 
may be obscured by laryngeal breathing and death oc- 
curs before the development of consolidation. 
Pneumonia complicating measles: This may ap- 
pear at invasion, but is more common with the erup- 
tion. 
Pneumonia complicating influenza: In some cases 
there may be fever and prostration a few days before 
the physical signs, and then pneumonia may run a 
regular course. In other cases, pneumonia may last 
two to four days, with very severe symptoms and 
high temperature and recovery may follow. 
Pneumonia following ileocolitis: Slow cases, some- DISEASES OF THE LUNGS 
times not noticed. There is rapid respiration, dyspnoea, 
cough and pain. May vary in severity. 
Complications: Pleurisy, empyema, abscess of the 
lung, pericarditis, endocarditis, nephritis (rare), men- 
ingitis (rare), gastroenteritis, stomatitis. 
Prognosis is grave, especially in secondary cases. 
Continued high temperature is more favorable than 
remittent temperature, as it implies pneumococcus in- 
fection : In rickets and poorly nourished babies, prog- 
nosis is bad. The younger the child the more serious 
the prognosis. If the stomach is in good condition, 
prognosis is favorable. Nervous symptoms (convul- 
sions, stupor, etc.) are not serious at the onset, but are 
very grave at the end. 
Treatment: Bed, fresh air, mustard pack, or Pries- 
nitz compress. Regular feeding and in reduced quan- 
tity. Give plenty of water to drink. 
Stimulation should be judicious. We should not 
overstimulate. It is frequently unnecessary to use any 
stimulants, particularly when the temperature is very 
high. 
Brandy §ss-i, a day, for i-year-old baby, is of spe- 
cial value just before and during collapse. Instead of 
brandy, we may use Tokay or sherry wine. Camphor 
gr. 1-5 in asther or oil is a valuable stimulant. A 
10% solution should always be on hand, to give hypo- 
dermatically, in the emergency. Caffeine sodium ben- 
zoate, 25% Sol. should also be kept on hand (Dose, 
gr. 1-4). Digalen and Tr. Digitalis will be found 
useful where early stimulation is required. Strych- 
nine and nitroglycerin may sometimes be useful adju- 
vants, but are not as important as the above. 114 
CLINICAL PEDIATRICS 
Hydrotherapy—Tepid sponge or pack will be found 
refreshing and stimulating. 
If the child suffers a great deal of pain, we may give 
y2-i gr. antipyrine. 
Attacks of collapse—These are not serious in the 
beginning of the disease, but are extremely grave later. 
Give a hot mustard bath with vigorous friction; also 
Camphor and £Ether, strychnine, nitroglycerin and 
oxygen. 
For protracted cases: Diet and tonic treatment: in- 
halation of creosote (aa creosote, alcohol and chloro- 
form). 
We may suspect tuberculosis, but non-tuberculous 
cases are more common. If there is no temperature, 
advise change of climate. 
Lobar pneumonia: Lobar pneumonia is an infec- 
tious disease, caused by the invasion of the body by 
the pneumococcus (micrococcus lanceolatus). 
It is found most frequently in children between the 
ages of 2-6 years. Male children are more frequently 
affected. It is most common in the spring and winter 
months. It may affect children who are in perfect 
health. The lower left lobe is most frequently in- 
volved ; next in frequency is the upper right lobe and 
lower right lobe. 
Symptoms: Typical course—There is general ma- 
laise for a few hours, which is. followed by a sudden 
rise in temperature. There is prostration, vomiting. 
The pulse is full, 120-130, sometimes a sharp pain in 
the side, restlessness (delirium), dyspnoea, cough, 
thirst, etc. On the second day, patient is no better, 
but on the third day he is more comfortable. DISEASES OF THE LUNGS 
The symptoms continue for six or seven days and 
then, after a long and natural sleep, the child awakens, 
feeling much improved, with a pulse of 90 and normal 
respiration. In one week the child is out of bed, and 
inside of a month out of doors. 
Sometimes the attack is of very short duration, last- 
ing three or four days. 
Abortive type: It begins like the ordinary form, 
but on the second or third day the temperature comes 
down, and the physical signs disappear. The case 
probably does not go beyond the stage of congestion. 
It means that the patient has a strong power of re- 
sistance. 
Prolonged type: Usually lasts 10-15 days. It may 
or may not be due to spreading of the disease. 
At the onset, vomiting is common. In the summer 
diarrhoea is frequent. Sometimes we get convulsions. 
Cough varies in intensity. Chill at the onset is rare 
in children under the age of 5 years, and even in older 
children it is uncommon. Pain may last throughout and 
be the most prominent symptom, or may moderate and 
be only at the onset. Pain may not be felt in the chest, 
but may then be referred to the iliac region, thus re- 
sembling appendicitis; or it may be felt in the epigas- 
trium. Respiration is rapid and jerky and expiration 
is accompanied by a grunt. Pulse is usually full at 
first, 110-140, but later it may become very rapid and 
feeble, or imperceptible and irregular. 
Temperature is 102° in the" morning and 104-5° in 
the afternoon. 
At the crisis the temperature drops to normal or 
subnormal in 24 hours. 
The remittent type is not uncommon in children. CLINICAL PEDIATRICS 
The temperature may come down by lysis. 
There may be a pseudocrisis, followed by a rise, 
which remains for two or three days, and the true 
crisis follows. 
Nervous symptoms: At the onset these may be se- 
vere and the case appears like a meningitis (menin- 
gism). This condition may last two or three days and 
pneumonia may not even be suspected, necessitating 
a lumbar puncture to aid diagnosis. Then suddenly 
the nervous symptoms disappear and the physical 
signs in the lungs develop. 
Convulsions at the onset frequently take the place 
of a chill, and are not of serious import, but if they 
occur at the end, the outlook is very poor, as it means 
either exhaustion, or meningitis. Convulsions are 
more frequent in children under 5 years of age. 
The usual nervous symptoms are restlessness, 
sleeplessness, headache, sometimes delirium (low 
muttering, or wild and active). 
Urine—High colored, sometimes containing a trace 
of albumen and a few hyaline casts. 
Skin—The face is flushed, sometimes only one side. 
There is no cyanosis, except at the end, when there 
is failure of respiration. Herpes on the lip is frequent. 
Auscultation—Diminished breathing, bronchovesic- 
ular breathing, bronchial breathing and voice. Some- 
times the bronchial breathing is distant. 
Physical signs: Percussion—Dullness, or flatness. 
Palpation—lncreased fremitus. 
Over the normal lung areas the breathing is ex- 
aggerated. 
Sometimes the physical signs cannot be detected 
until the sth or 6th day. That is probably due to the DISEASES OF TEIE LUNGS 
fact that the pneumonic spot is in front of the vertebral 
column, or the scapula. Look for it high up in the 
axilla, or over the apex in front. 
Complications: Pleurisy (dry, or one or two ounces 
of fluid), empyema, meningitis (rare), pericarditis 
(rare), sometimes gastro-enteritis, peritonitis (with 
pleuropneumonia). 
Course and termination: Pneumonia may end in 
death or recovery. Delayed resolution is rare. Tu- 
berculosis and chronic pneumonia are rare. Empyema 
is common and frequently comes immediately after 
pneumonia, the temperature remaining high. The 
empyema may be encapsulated. 
Death results from exhaustion with cardiac failure, 
with or without respiratory failure. Cardiac failure is 
accompanied by a rapid compressible pulse, pallor, 
weakness, but usually no cyanosis. Respiratory fail- 
ure is accompanied by blue lips and finger tips, and 
sometimes a leaden hue of the whole body. There are 
usually tracheal rales and recession of all the soft 
parts of the chest on inspiration. 
Death is most frequent at the crisis, but sometimes 
on the fourth day. Complications may cause death 
in two weeks, and sometimes longer. 
Prognosis: Usually good, even when the tempera- 
ture is very high. When complications are present, 
prognosis is not so good. If meningitis develops, the 
outlook is very bad. When the temperature persists 
after the tenth day, the case is unfavorable. For, 
though the crisis may be delayed until the tenth day, 
the temperature usually means that some complica- 
tion has set in. CLINICAL PEDIATRICS 
Treatment the same as that of bronchopneumonia. 
Stimulation is often unnecessary. 
Pleuropneumonia: There is an exudate of pus and 
fibrin upon the pneumonic area. The symptoms of 
pleurisy are simultaneous with those of pneumonia. 
The case looks one of severe pneumonia. Friction 
sounds are more prominent in the beginning. We get 
moist crackling pleuritic rales. Breathing and voice 
may be diminished, or distant bronchial. Fremitus is 
diminished. There is marked dullness. Empyema 
is usually suspected; we may even get a few drops 
of pus from one of the pockets with an aspirating 
needle. 
Prognosis is not good. Young children usually die 
during the second week and in severe cases on the 
fourth or fifth day. 
Convalescence is slow and may be interrupted by 
a recurrence of the pleurisy. Adhesions cripple the 
lung for years, more so than in empyema. 
Hypostatic pneumonia: This is frequent in chil- 
dren who die of marasmus. The only physical sign 
is moist rales posteriorly. 
Chronic bronchopneumonia: (Interstitial pneu- 
monia, Bronchiectasis). This disease is frequently 
tuberculous, but may be caused by a nontuberculous 
infection. 
After an attack of bronchopneumonia the child does 
not seem to recover entirely, slight rise in the tem- 
perature continuing and physical signs persisting. 
Then the fever goes down and the appetite returns, 
but still the physical signs do not clear up. There is 
dullness, diminished, or bronchovesicular breathing. DISEASES OF THE LUNGS 
119 
There is a dry cough and occasional pain in the chest. 
Dilated bronchi (as in adults) are seldom seen in 
young children. Several exacerbations of the bron- 
chopneumonia may follow, each time leaving the lung 
more crippled. The second attack may not be as 
severe as the first, but it drags out for a few weeks 
with a slight rise in temperature. The child is usually 
very weak and may die from some intercurrent dis- 
ease. With good care, recovery may be complete, or 
the child may remain delicate throughout life. 
These cases are frequently diagnosticated as tuber- 
culosis. Examine the sputum. Cases of non-tuber- 
culous bronchiectasis are often characterized by club- 
bing of the fingers. 
Gangrene of the lungs: This is a rare condition, 
but is more frequent in children than in adults. 
The most frequent cause is bronchopneumonia. 
Other causes are tuberculosis, foreign body in the 
bronchus, embolism, which is the immediate cause of 
all cases. 
Gangrene may be circumscribed, or diffuse. 
The condition is usually fatal, but it is possible for 
older children to cough up the necrotic masses, and 
cavity to cicatrize. 
There is a bad breath and coughing up of necrotic 
masses, with hemorrhage. 
Death usually takes place before these symptoms 
have a chance to appear. 
Treatment: Inhalation of creosote and turpentine. 
Acquired atelectasis (collapse of the lung) : Such 
a condition may be caused by pleuritic effusion, peri- 
carditis, hypertrophied heart, mediastinal tumor, de- 
formity of Pott’s disease, or rickets. 120 
CLINICAL PEDIATRICS 
The lungs may expand again, unless pleuritic ad- 
hesions form. 
Atelectasis may also be caused by an obstruction of 
a bronchus, its extent depending on the size of the 
bronchus. 
Bronchitis, or stenosis of a bronchus, is more likely 
to cause emphysema. In rachitic children, we may 
get a postero-inferior lobular pneumonia, with areas 
of atelectasis. The symptoms are inspiratory dys- 
pnoea, with recession of the soft parts, rapid respira- 
tion and slight cyanosis. The physical signs are in- 
definite. We may get dullness, moist rales and dimin- 
ished respiratory murmur. 
Emphysema: There is a dilatation of the air vesi- 
cles. The percussion note is tympanitic. 
i. Compensatory—Found in pneumonia, tubercu- 
losis, pressure of Pott’s disease or rickets. 
2. Caused by stenosis of the larynx, bronchitis, or 
pertussis, where there is forcible expiration. 
Pleurisy: Primary pleurisy is rare. It occurs most 
frequently after pneumonia, and next in frequency 
after tuberculosis. Empyema is common, but pleurisy 
is rare. In older children pleurisy may possibly be 
caused by exposure or rheumatism. It is more fre- 
quent in males between the ages of 1-5 years. It may 
occur in the course of infectious diseases. 
Pleurisy with effusion: In primary cases the symp- 
toms at the onset are like those of pneumonia, but 
milder. There is not much prostration. The tempera- 
ture is remittent, 100-103°, pulse frequent and full, 
dyspnoea and pain in the chest are present. There are, 
indeed, some cases that seem exactly like pneumococ- DISEASES OF THE LUNGS 
121 
cus infection, only attacking the pleura instead of the 
lung, the onset and course being just as severe as that 
of lobar pneumonia. There are some cases in which 
the onset of the disease is very insidious. 
Physical signs: Over the fluid—Flatness, breath- 
ing diminished, or absent, or bronchial (when the 
quantity of fluid is large and the lung is com- 
pressed), voice is diminished, absent, or bronchial; 
f/emitus is diminished. Over the lung area—Exag- 
gerated, bronchial, or cavernous breathing and bron- 
chial voice, the signs depending on the amount of 
fluid present, causing lung compression. At the level 
of the fluid, we get segophony (a peculiarly shrill bron- 
chial voice). 
Aspiration will show the presence of clear serum. 
The serum, if not interfered with, will remain in 
the chest three weeks, or several weeks, or may turn 
into empyema. 
Treatment: Rest in bed, sedatives, salicylates. 
Do not aspirate unless the quantity of fluid is so 
great as to interfere with breathing and if it remains 
in the chest longer than three weeks. As soon as the 
temperature is normal, the patient should sit up. 
There should be no exertion, as deaths have been re- 
ported. 
Empyema: The most frequent cause of empyema 
is pneumonia, which may be masked by the signs of 
fluid giving the empyema the appearance of a pri- 
mary disease. Empyema following tuberculosis of the 
lungs is rare in children under five years of age. In 
children seven years of age or more, the disease is 
more frequent. It may complicate measles, scarlet, or 
any other infectious disease. It may be caused by 122 
CLINICAL PEDIATRICS 
pyemia, from any cause such as infection of the um- 
bilicus, suppuration of the joints, osteomyelitis, sup- 
purative peritonitis. Local causes may be abscess of 
the chest wall, mediastinum, traumatic subphrenic 
abscess, necrosis of the ribs, perinephritic abscess, 
new growth of the lung, or actinomycosis. Bacterio- 
logically we may find the pneumococcus alone, strep- 
tococcus and pneumococcus, streptococcus and 
staphylococcus (pyemia), or staphylococcus alone. In 
tuberculous empyema it is often difficult to demon- 
strate the tubercle bacillus. When no bacteria are 
found, suspect tuberculosis. 
Symptoms: Physical signs are similar to those of 
pleurisy with effusion. In empyema following pneu- 
monia, the disease is ushered in by a rise in the tem- 
perature, after the crisis. The temperature remains 
high and the child does not seem to improve in the 
normal way. The physical signs do not clear up and 
the condition is frequently mistaken for delayed reso- 
lution. A careful examination and the aspirating 
needle will determine the condition. If the child is 
seen for the first time, it often seems like a pneu- 
monia, only the patient does not seem sick enough for 
the extensive physical signs. 
Prognosis depends on the age of the patient, dura- 
tion of the disease and the treatment. In babies under 
one year of age, there is mortality of 50%. In older 
children, with proper treatment, recovery is invariable. 
If treatment is not delayed, recovery is perfect without 
any deformity. Spontaneous recovery is rare, but pos- 
sible. This may be either by absorption or rupture, 
externally, or into a bronchus. The pus may burrow 
in all directions, into the mediastinum, oesophagus, DISEASES OF THE LUNGS 
123 
peritoneal cavity, or may burrow down and appear 
as a psoas abscess. 
Without treatment, the patients are worn out by 
suppuration, or die of amyloid degeneration, or tuber- 
culosis. 
Treatment: Surgical. Thoracotomy should be 
done as soon as the diagnosis is made. In infants, 
incision and drainage is sufficient. In older children, 
a section of one or two ribs may be removed to avoid 
compression of the drainage tube. The incision 
should be below the angle of the scapula. Cases of 
moderate severity heal in four to six weeks. Severe 
cases may last for weeks or months. DISEASES OF THE HEART 
Congenital anomalies of the heart: These are caused 
by imperfect development, foetal endocarditis, or a 
persistent foetal condition. The most frequent defect 
is a patent interventricular septum; next in frequency, 
a patent foramen ovale. These conditions are asso- 
ciated with a stenosis of the pulmonary artery or pat- 
ent ductus arteriosus. Pulmonic insufficiency is rare 
and mitral and aortic lesions still more so. 
Symptoms: Most cases show symptoms soon after 
birth. Some cases may show signs later during the 
first year of life. There are still other cases which 
do not give any symptoms till after puberty. 
The most common and prominent symptom is 
cyanosis, which is most frequently associated with 
pulmonic stenosis. It is not always present, and is 
most prominent after exertion, crying and coughing. 
Sometimes there is dyspnoea and swelling of the lower 
extremities, fluid in the serous cavities, haemoptysis, 
epistaxis, clubbing of the fingers. Physical examina- 
tion usually shows an enlargement of the right side 
of the heart, with the presence of a loud systolic mur- 
mur heard all over the chest and loudest over the 
pulmonic valve. 
The following variations in symptoms and corre- 
sponding conditions may be found; 
Systolic murmur at the base with cyanosis—Pul- 
monic stenosis, usually associated with defec- 
tive septa and patent ductus arteriosus. 
124 DISEASES OF THE HEART 
125 
Systolic murmur without cyanosis—Patent ven- 
tricular septum, or tricuspid insufficiency. 
Systolic murmur at the apex with cyanosis—Pat- 
ent auricular septum with patent ductus ar- 
teriosus, or transposition of great vessels. 
Cyanosis without murmur—Atresia of the pul- 
monary artery and transposition of great ves- 
sels. 
Diastolic murmur—Pulmonic insufficiency. 
Absence of cyanosis and murmur—Atresia of the 
aorta, both vessels arising from the right ven- 
tricle, the interventricular septum remaining 
patent. 
Diagnosis: Must be distinguished from acquired 
condition by the history, cyanosis character of the 
murmur and its location, the presence of clubbed fin- 
gers, and enlargement of the right heart. 
Prognosis: Sixty per cent, die before 5 years; 16% 
die after 16 years; 8% after 30 years. 
Treatment: Symptomatic. 
Pericarditis: Causes—Pleurisy, pleuropneumonia, 
rheumatism (after the age of four years), endocarditis, 
scarlet fever (usually associated with neuritis and joint 
affections), typhoid fever, tuberculosis (associated 
with tuberculosis of the lungs in children over two 
years), pyemia in the newborn, from the umbilicus, in 
older children from bone or joint infection, traumatism, 
foreign body in the oesophagus, rupture of a bone ab- 
scess or bronchial gland abscess. 
There may be an inflammation of the external sur- 
face of the pericardium, which will give a friction sound 126 
CLINICAL PEDIATRICS 
which increases with each systole. Posteriorly this 
inflammation (mediastinitis) will cause pressure on 
the large bloodvessels with oedema of the face or 
lower extremities, or ascites. 
Only the internal inflammation is classed as peri- 
carditis. 
This condition may last three months to three years. 
It may be fibrinous, serous, purulent, or hemor- 
rhagic. 
Symptoms: Pain in the precordium, palpitation and 
a rapid, irregular pulse. There is a double friction 
sound not dependent on respiration. When fluid col- 
lects the friction sound disappears and the apex be- 
comes muffled and diffuse. Signs of fluid: Flatness, 
absence of breathing, murmur and fremitus. Fre- 
quently signs come on in the course of pleuropneu- 
monia and are not noticed. 
Duration is one to three weeks. 
Dry pericarditis is followed by a chronic inflamma- 
tion. 
In the serous form, in which the fluid disappears, we 
get adhesions and friction sound. 
The purulent variety is usually fatal, but if it 
opens spontaneously or is opened, recovery is possible. 
Prognosis: Depends on the cause. If caused by 
pleurisy, or pleuropneumonia, prognosis is bad, as 
also in cases of pyemia. If rheumatic, which condi- 
tion is frequently unrecognized, prognosis is better. 
Treatment: Hot poultice, mustard plaster, or ice- 
bag. 
Rapid heart action may be controlled by aconite, 
or opium. 
If rheumatism, we use salicylates. DISEASES OF THE HEART 
127 
Serous effusions usually disappear under tonic treat- 
ment. 
Sometimes too much pressure by fluid will cause 
syncope, cyanosis, irregular heart action, feeble pulse, 
dyspnoea, or orthopnoea. 
In these cases, give oxygen; aspirate to relieve pres- 
sure. 
If pus is found, open and drain. For aspiration we 
may choose one of three points; Fourth or fifth inter- 
space, one inch to the left of the sternum; just at the 
right of the sternum; or just inside the line of dull- 
ness. 
Chronic pericarditis with adhesions: The youngest 
case on record was sixteen months of age. It is fre- 
quently unrecognized. Sometimes it is of tuberculous 
origin. There is a thickening of the pericardium, 
which may be one-eighth to one-quarter of an inch 
in thickness. It will cause dilatation of the heart, 
sometimes with sudden death. 
There is a characteristic drawing in of the chest 
with each systole, which may be better felt than seen, 
and which may also be seen in the subscapular re- 
gion (Broadbent sign). 
There is an area of dullness, with a forcible apex 
impulse. 
The disease is often associated with endocarditis. 
We may find that during diastole there is a collapse 
of the veins of the neck. 
Acute simple endocarditis: In the foetus it may af- 
fect the valves of the right heart. In infants it is ex- 
tremely rare. Between the ages of three and five, 
it is not uncommon, but after that it is quite frequent. 128 
CLINICAL PEDIATRICS 
Primary endocarditis is probably rheumatic fever, 
of which it is the first symptom. It is often associ- 
ated with or preceded by tonsillitis, joint affection and 
chorea. 
Infectious diseases, especially scarlet fever, influ- 
enza, may cause endocarditis. 
Other causes may be pleurisy and pneumonia, of 
which it is sometimes a complication (pneumococcus, 
or staphylococcus infection). 
Endocarditis is more frequent in children than in 
adults. 
Symptoms: May be preceded by tonsillitis, or joint 
symptoms. It is usually ushered in by a temperature 
of io2°-ios° F., rapid heart action, and dyspnoea. On 
the third or fourth day a murmur appears. The mitral 
valve is most frequently affected. The murmur is, 
therefore, systolic, heard over the apex and transmit- 
ted to the left. 
Febrile symptoms usually subside after a few days, 
and cardiac symptoms slowly diminish. The disease 
may terminate after a few weeks with death caused 
by an acute dilatation of the heart, or complicating 
pneumonia. Emboli, lodging in the spleen, may cause 
enlargement of that organ, lodging in the kidney may 
cause hsematuria. 
The duration of the disease is one to three weeks. 
In some mild cases, the murmur may disappear after 
a few weeks. In the great majority of cases, the 
murmur persists. The attacks frequently recur and 
ultimately a chronic lesion develops. 
Diagnosis: We must distinguish from pericarditis, 
or congenital anomaly, by the character of the mur- 
mur and the history of the case. Functional murmurs DISEASES OF TEIE HEART 
129 
are heard best over the pulmonic region, in the left 
second interspace, and are transmitted upward to the 
neck. 
Prognosis: The danger to life is not great and 
depends on the severity of the case and the amount of 
dilatation of the heart. 
Treatment: Rest in bed, opium, salicylates. Digi- 
talis is rarely required. The patient should remain 
in bed at least four weeks and should have very little 
exertion for a few weeks after that. 
Malignant endocarditis (septic) : The disease is 
very rare in very young children, most cases occurring 
after the age of 10 years, and frequently in congeni- 
tally abnormal hearts. It is very rarely primary. It 
may follow pneumonia, rheumatism, meningitis. It 
is usually caused by a pneumococcus, streptococcus, 
or staphylococcus infection. In 75% of the cases the 
infection is grafted on an old valvular lesion. Strepto- 
coccus viridans is most frequently found. 
Symptoms: There is a remittent fever, rigors, 
sweating, delirium, stupor and coma. There is also 
cough, sometimes pneumonia, and sometimes hsema- 
turia. Sometimes the symptoms may resemble those 
of meningitis, with hemiplegia (caused by embolism), 
and petechial spots. Spleen is usually enlarged, this 
being caused by repeated embolic process. The heart 
is characterized by a murmur. Death may be due to 
embolic process, or exhaustion. 
Blood culture is positive. 
Duration of the disease is a few days to a few 
weeks. 
Prognosis is very bad; the outcome is almost in- 
variably fatal. CLINICAL PEDIATRICS 
130 
Transfusion may be tried, as well as vaccines. 
Chronic valvular disease: This is usually the re- 
sult of acute endocarditis. The degenerative changes 
found in adults are not seen in children. 
There seem to be more females than males affected. 
Most cases are traced to an attack of rheumatism. 
The disease is frequently associated with chorea. Oc- 
casionally the condition may be traced to influenza, 
scarlet fever, and rarely to other infectious diseases. 
Symptoms: The onset is insidious. During the 
period of compensation there may be no symptoms 
except dyspnoea on exertion. The disease may be dis- 
covered by accident. It is usually progressive but 
may remain stationary for a long time. 
Compensation may fail for the following reasons: 
Acute endocarditis, excessive muscular exertion, inter- 
current disease (pneumonia, scarlet, typhoid), rapid 
growth at puberty. 
We get increase in dyspnoea, cough with marked 
palpitation, pain in the chest, congestion of the lungs 
(subcrepitant rales), vertigo, fainting spells, head- 
ache, dropsy, fluid in the serous cavities, enlargement 
of the liver and spleen, scanty urine and albuminuria, 
clubbing of the fingers, cyanosis and dilatation of the 
superficial veins, epistaxis. 
It is unusual to see all the symptoms of decom- 
pensation before the age of 10 years, but at puberty it 
is quite common. 
Death may occur from sudden cardiac failure, or 
from intercurrent nephritis, pneumonia, embolism, in- 
fection of the serous membranes, or oedema of the 
lungs. DISEASES OF THE HEART 
131 
The physical varieties are the same as in adults. 
Thus; 
Mitral stenosis—enlargement of the right heart, 
presystolic thrill .and murmur, small pulse. 
Mitral insufficiency—Enlargement of the right 
and left heart, systolic murmur, transmitted to 
the left and back. The quality ‘of the pulse 
depends upon the degree of compensation. This 
condition is frequently associated with mitral 
stenosis and we get a double murmur (presys- 
tolic and systolic). The second pulmonic 
sound is accentuated. 
Aortic insufficiency—Enlargement of the left 
heart, diastolic murmur, transmitted downward, 
toward the apex, water hammer (Corrigan) 
pulse. 
Aortic stenosis—Enlargement of the left heart, 
systolic murmur at the base, transmitted up- 
wards, small pulse. 
Dilatation of the left ventricle, with aortic lesion, 
will cause insufficiency of the mitral valve, although 
the valve may not be diseased. With loss of com- 
pensation in mitral disease, the right ventricle may 
become dilated and the tricuspid valve may become 
incompetent. 
Prognosis : Very few children with valvular disease 
reach adult life in good condition. The demands on 
the heart at puberty are great. There is also danger 
from intercurrent diseases. The pericardial adhe- 
sions, which are frequent, are a handicap. The ad- 
vantages over the adult are in the absence of disease 132 
CLINICAL PEDIATRICS 
of coronary arteries, and the fact that the disease is 
more easily overcome by compensation. 
In giving a prognosis, consider the progress of the 
disease, the child’s condition, and the amount of dila- 
tation. 
Treatment: The child must be watched to note 
progress. We must make a careful examination at 
least four times a year. Watch for anaemia, and if it 
appears treat energetically. Direct exercise, such as 
walking, skating and horseback riding. No exercise 
that requires too much running should be allowed. 
The amount of exercise should be regulated accord- 
ing to the child’s condition. We may use tonics, such 
as strychnine, cod liver oil and iron. If compensa- 
tion fails, put the child to bed and give codeine and 
digitalis, if necessary. If dropsy develops, give salines 
and diuretics. If sudden heart failure should occur, 
give hypodermatically: Camphor and aether, caffeine 
sodium benzoate, digalen, strychnine and nitroglyc. 
Myocarditis: It is of rare occurrence in children. 
Positive diagnosis is impossible. It has been known 
to occur even in the foetus. Occurs after diphtheria, 
scarlet fever, influenza, or typhoid. Frequently there 
are no symptoms. Sudden death may occur even from 
so slight a cause as sitting up in bed. If symptoms 
are present, they are dyspnoea, pallor, syncope, ir- 
regular feeble heart action. Later, dropsy, fluid in 
serous cavities and dilatation may develop. 
Treatment: Rest, no exertion after diphtheria, etc. 
Tonics, strychnine and cod liver oil. When there are 
symptoms of impending heart failure, morphine has 
a striking effect. DISEASES OF THE HEART 
133 
Anaemic murmurs: This is of quite frequent oc- 
currence in children and often mistaken for valvular 
disease. The murmur is heard usually loudest over 
the pulmonic valve, at the base of the heart, and is also 
heard over the carotids. Sometimes it may be heard 
at the apex, but is not transmitted. The murmur 
may be of blowing character, or it may be musical. It 
may disappear with change of posture. There is no 
cardiac hypertrophy or accentuation of the second 
sound found in mitral diseases. The murmur disap- 
pears with improvement of the child’s condition. 
Functional disorders of the heart: This affection 
is very rare in infants and young children. In older 
children it is more common. 
Causes: Indigestion, overpressure in school, pu- 
berty with rapid growth, masturbation, coffee, tea, 
cigarettes. It may follow typhoid, exanthemata, bron- 
chitis or pneumonia. 
Symptoms: The most prominent is palpitation, 
less frequent is bradycardia, or tachycardia. During 
the attacks of palpitation there may be dyspnoea, which 
may be quite severe, with a sense of oppression. 
The apex impulse may be felt over the entire heart 
area; the carotids pulsate forcibly; pulse is irregular in 
force and rhythm; the face is pale or flushed. There 
may be headache, vertigo, spots before the eyes, cold 
hands, cyanosis and general perspiration. 
The attack may last a few minutes or a few hours. 
Examine carefully before excluding organic dis- 
ease. 
In girls it frequently disappears when menstruation 
begins. 
Treatment: During the attacks, we may give bro- 134 
CLINICAL PEDIATRICS 
micles, or valerian, and sometimes it is necessary to 
give strychnine or camphor. Between the attacks 
when the pulse is irregular, we may give small doses 
of digitalis. It is most important to attend to the 
general condition. Exclude coffee, tea, tobacco, regu- 
late out-door exercise and sleep, as well as hours for 
study. Regulate diet. 
Small Arteries: Sometimes it may be only the 
aorta, but sometimes all the arteries are small (two- 
thirds or three-fourths normal size). 
Phis condition may interfere with development and 
may cause hypertrophy of the heart. 
Atheroma of the aorta and aneurism: Very rare 
in children, but cases have been reported. 
Causes: Syphilis, tuberculosis, erosion of bone, 
abscess, embolism. DISEASES OF THE GENITO-URINARY 
SYSTEM 
Cyclic (orthostatic) albuminuria: This affection is 
of rather frequent occurrence in children between the 
ages of ten and sixteen years, associated with curva- 
ture of the spine. There is no albuminuria in the 
morning, but the afternoon urine shows the presence 
of albumin. 
Treatment should be directed to orthopedic con- 
dition. 
Hasmaturia: Causes—New growth of the kidney, 
calculus, nephritis (especially complicating scarlet 
fever), vesical calculus, local injury, infectious dis- 
eases, such as scarlet fever, malaria, typhoid, variola, 
influenza, also purpura. 
Haemoglobinuria: Causes—Winckel’s disease, poi- 
soning by carbolic acid, or potassium chlorate, typhoid, 
scarlet fever, malaria, syphilis, erysipelas. Paroxysmal 
hemoglobinuria is rare in children. 
Glycosuria: Found in some children who have a 
disturbance of digestion or are fed with excess of milk 
sugar. 
Pyuria: Pus may come from any part of the genito- 
urinary tract. It is most frequently traced to the 
kidney. There may be a rupture of an abscess (peri- 
nephritic or appendicial) into the tract. 
If it comes from the kidney it is caused by pyelitis, 
pyelonephritis, tuberculosis, renal calculus. The urine 
135 136 
CLINICAL PEDIATRICS 
is acid and contains pus cells, albumen, transition cells. 
If it comes from the bladder, there is not much pus 
mixed with the mucus, the urine is alkaline and there 
is marked vesical irritation. 
Lithuria: The proportion between urea and uric 
acid varies. An increased secretion of uric acid means 
an increased destruction of the nuclein principle 
(white blood cells). The quantity of uric acid may 
be determined by means of Haycroft’s test. If there 
is an excess of amorphous urates, uric acid is in excess, 
if the sp. gr. is not higher than 1.025. A brick-red 
deposit in the urine does not mean an excess of uric 
acid secretion. 
Lithuria is present in anaemia, malnutrition, chorea, 
rheumatism and chronic dyspepsia. 
Treat the cause. 
Uric acid crystals forming a brick red deposit indi- 
cates decreased solvent power of urine, rarely found 
in children. It means gouty diathesis and is found 
in children with gouty antecedents. It is usually as- 
sociated with digestive disturbances and frequently 
causes irritation of the urinary passages. 
Treatment: Cut off nitrogenous diet; give sugar 
and starches and alkaline waters. 
Indicanuria; Caused by putrefactive changes in 
the intestinal tract, also when there is suppuration 
without drainage, as in empyema and cavities in tu- 
berculosis of the lungs. We find it in intestinal indi- 
gestion, obstinate constipation, putrefactive diarrhoea. 
Acetonuria; Found in small quantities in healthy 
children. In larger quantities it may be found in fe- 
brile conditions, just before a coma in diabetes, starva- 
tion, cyclic vomiting, autointoxication. In autoin- DISEASES GENITOURINARY SYSTEM 
137 
toxication there may be high temperature, drowsiness, 
and brain symptoms, with an excessive amount of ace- 
tone present in the urine. Starchy diet with bicarbo- 
nate of sodium given by mouth and by rectum usually 
clears up the condition of acidosis. 
Anuria: No excretion from the kidney. In the 
newborn it may be due to malformation of the kidney, 
or uric acid infarction. This latter condition is shown 
later by the fact that when the urine does start, it is 
high colored and contains masses of uric acid crystals 
which may often be appreciated with the naked eye. 
Sometimes anuria cannot be explained. It is not 
unusual for the newborn to go 10 to 36 hours without 
passing urine. 
Treatment: Hot poultice over the kidney region. 
Also may give potassium citrate gr. i and Sp. setheri 
nitrosi Hi in oz. of water every hour until the 
urine is passed and is normal in color. 
Malformation of the kidney; Fusion of the kidney, 
cystic degeneration, single kidney, the other being 
rudimentary. 
Hydronephrosis: This condition is frequently as- 
sociated with cystic kidney and nephritis. If present 
on both sides, the infant dies during the first year. If 
it is unilateral, prognosis is better, but the affected side 
must be removed, as too much fluid collects and pye- 
litis is sure to develop. In infants it cannot be felt, 
but between the ages of three and ten years it is not 
difficult to palpate. It may cause a distention of the 
intestine. The bladder is frequently hypertrophied. 
Uric acid infarction: Uric acid crystals and amor- 
phous urates collect in the straight tubules. This is 
due to the presence of uric acid in the kidney before 138 
CLINICAL PEDIATRICS 
there is enough water to dissolve it. It is of com- 
mon occurrence in the newborn, and causes scanty 
urine or anuria for one or two days. 
Sometimes may form a focus for a calculus in the 
kidney or bladder. Usually it is washed away by more 
freely running urine. It may cause pain and irritation 
upon micturition and leaves dark stains on the nap- 
kin. 
Treatment: Hot poultice to the kidney, also potas- 
sium citrate gr. i and sweet spirits of nitre H I in 
water every hour until the urine flows freely. 
Causes: Ingestion of certain poisons, infectious dis- 
eases. 
Acute congestion of the kidney: 
Symptoms: The urine is scanty and contains al- 
bumen, some hyaline casts, and some blood. It may 
cause headache and pain in the back. This congestion 
may pass off or may be the beginning of a nephritis. 
Treatment: Hot poultices over the kidney, hot 
packs, or vapor baths. Also give saline cathartics. 
Chronic congestion of the kidney is caused by heart 
disease, pleurisy, pressure by tumors on the vena cava. 
There is a trace of albumen and hyaline casts found 
in the urine. 
Degeneration of the kidney (parenchymatous ne- 
phritis) : 
Causes: Introduction of certain poisons into the 
body (phosphorus, arsenic, mercury), infectious dis- 
eases (diphtheria, typhoid, etc.). 
The amount of degeneration depends on the viru- 
lence of the poison. The cells are swollen, more 
opaque and granular. If the poison is very intense, DISEASES GENITOURINARY SYSTEM 
139 
nephritis develops, otherwise the cells gradually go 
back to normal. 
Symptoms: Diminution or suppression of urine. 
The urine contains albumen casts and blood. If the 
degeneration continues, as in cases of severe poison- 
ing, the patients pass into a comatose or typhoid state 
and soon die. In acute degeneration associated with 
infectious diseases, the only symptom present is al- 
buminuria, which disappears as soon as the patient 
improves. 
Acute degeneration of the kidney may be distin- 
guished from other forms of kidney disease by the 
fact that it is evidently caused by the invasion into 
the circulation of some severe poison, and that it is 
not accompanied by dropsy, contraction of the ar- 
teries, or other of the renal symptoms. 
Treatment: Treat the cause. When the urine is 
scanty we may give hot air baths, or hot packs. Of 
late years, in cases of acute poisoning by mercury, 
attempts have been made to save the patients by a 
surgical operation of incision and flushing the kidney. 
Acute exudative nephritis: This is an acute inflam- 
mation of the kidney, characterized by congestion, de- 
generation of epithelium, exudation of serum and dia- 
pedesis of red blood corpuscles. 
Causes: Scarlet fever, diphtheria, influenza. Some 
cases are apparently primary, following exposure. 
Nephritis may develop in the course of any severe in- 
fectious disease. 
Symptoms: Some cases are so mild that they may 
be easily overlooked. There may be just a little ma- 
laise with headache and pains in the limbs. It may 
seem no different than an ordinary cold. The child 140 
CLINICAL PEDIATRICS 
does not seem to respond to ordinary treatment and 
seems to look poorly. There may be a little rise in the 
temperature. These symptoms may last two weeks 
and be followed by recovery. The urine, if exam- 
ined, will be found of normal sp. gr., and containing 
a moderate quantity of albumen with hyaline granular 
and epithelial casts, and sometimes pus and red blood 
cells. In some cases the amount of blood in the urine 
attracts the patient’s or mother’s attention. The urine 
gradually returns to normal state after a period of 
four or five weeks. 
In cases of moderate severity the symptoms are 
as follows: Fever, some prostration, headache, stupor, 
sleeplessness, restlessness, muscular twitchings, gen- 
eral convulsions, dyspnoea, loss of appetite, nausea, 
vomiting, pulse of high tension, exaggerated heart 
action with hypertrophy of the left ventricle, dropsy 
and anaemia. 
The urine: At first reduced in quantity, or sup- 
pressed ; later the quantity increases, but still remains 
a little below normal. The specific gravity may be 
normal at the outset, but as the quantity of urine in- 
creases, it drops to a little below normal. The urine 
contains a large quantity of albumen as well as all 
kinds of casts, blood and pus cells. All these may be 
in proportion to the severity of the disease. 
There are other cases, which are characterized by 
an excessive production of pus cells. These cases act 
like a severe infection, and may look like meningitis. 
There is sudden onset with high temperature, and 
marked prostration. Restlessness, headache, stupor 
and delirium are soon developed and continue through- 
out the attack. The patients rapidly pass into the DISEASES GENITOURINARY SYSTEM 
141 
typhoid state. Dropsy may be slight, or absent alto- 
gether. The urine is not necessarily diminished in 
quantity, and the specific gravity is normal. The 
urine contains albumen, casts, many blood and pus 
cells. All these may not be present early in the dis- 
ease. 
The ordinary duration of an exudative nephritis is 
about four weeks, but some cases may last as long 
as eight weeks. 
The recovery is usually complete. Chronic nephri- 
tis does not usually follow. 
Prognosis is usually good in ordinary cases. Cases 
with persistent brain symptoms are very serious. 
Cases with excessive formation of pus are usually 
fatal. 
Treatment: Rest in bed, milk diet. Hot packs. 
Kemp’s irrigation for y2-1 hour every three hours. 
This is a double current rectal irrigation with water 
at 104° F. When the nephritis is not too acute, digi- 
talis may have a good effect on the circulation. Use 
digalen or digitalin, or digipuratum, or Tr. Digitalis. 
Also give saline cathartics such as magnesium sul- 
phate, drachm every hour until the bowels move, 
or until eight doses have been given. For suppres- 
sion of urine, we should avoid the use of diuretics, 
which would only increase the congestion. Dropsy 
disappears with improvement. Hot packs, rectal ir- 
rigation and digitalis may be sufficient to obtain this 
result. We may have to resort to other drugs, par- 
ticularly if the blood pressure goes above 180, which 
may be ascertained by the use of a sphygmoman- 
ometer; also in the presence of marked cerebral symp- 
toms. These drugs may be; 142 
CLINICAL PEDIATRICS 
Morphine 1/120-1/50 gr. of the sulphate q. 6 h. 
Nitroglycerin 1/300-1/50 gr. at regular intervals. 
Chloral hydrate 1-5 gr. q. 3 h. 
Tr. Aconite 1-3 drops, or acontin 1/300-1/100 gr. 
Sodium nitrite 3/2-2 gr. t i d. 
In bad cases, especially in full-blooded children, we 
may get relief by means of venesection, taking off 10 
to 20 ounces of blood. 
If vomiting is troublesome, we may give cerium 
oxalate and sodium bicarb, in the milk every 2 or 3 
hours. 
As the nephritis subsides the milk is gradually re- 
placed by solid food. 
During convalescence we may aid recovery by giv- 
ing tonics. 
Acute diffuse (productive) nephritis: This is an 
acute inflammation of the kidney with degeneration 
exudation #nd the formation of connective tissue in 
the stroma of the kidney. This nephritis is most com- 
monly found late in scarlet fever. 
Symptoms: Fever, prostration, headache, stupor, 
restlessness, sleeplessness, muscular twitchings and 
general convulsions, pulse high tension, heart action 
exaggerated and left ventricle may be hypertrophied, 
dyspnoea, loss of appetite, nausea and vomiting. 
Urine: Scanty, or suppressed, containing much 
albumen, many casts, pus cells and blood cells. 
Patients are usually sicker than in the exudative 
variety and are more likely to die. 
Such a nephritis may run its course in four or five 
weeks and the patient may make an apparently com- 
plete recovery. He may remain well for weeks, 
months or years, but sooner or later he gets another DISEASES GENITOURINARY SYSTEM 
143 
attack of acute nephritis, or chronic nephritis may de- 
velop gradually. 
The more ordinary cases have a gradual invasion 
and run a subacute course. In some cases at first there 
are only loss of appetite, headaches, and increasing 
pallor, dropsy developing very much later. In other 
cases dropsy of the legs seems to be the only symptom 
for a long time, the child feeling well otherwise. 
In most of these subacute cases, headache, anaemia, 
dropsy of the face and legs, sleeplessness, nausea and 
vomiting develop at the same time. The urine is 
somewhat diminished in quantity, with normal or 
somewhat reduced sp. gr., containing a large amount 
of albumen and very many casts. 
The course of these subacute cases varies. There 
are cases in which recovery follows after a few weeks, 
but the patients seem susceptible to fresh attacks, and 
sooner or later, perhaps after a few years, they de- 
velop chronic nephritis. There are other cases in 
which the recovery is apparently complete and the 
patients live in comparative comfort for years. The 
chronic nephritis is progressive, though very slow in 
development, after the acute attack, as evidenced by 
a gradual reduction of the specific gravity and the 
presence of a trace of albumen in the urine. If not 
taken off by some intercurrent disease they usually 
die of an acute exacerbation of the disease or in a 
condition of chronic uraemia. In still other cases the 
patient gets an acute attack every few weeks or 
months, seeming apparently well between the attacks. 
Finally he gets an attack that proves fatal. 
The worst cases are severe and continuous, with bad 
dropsy and uremic symptoms. Treatment in these CLINICAL PEDIATRICS 
144 
cases is of no avail; death is the usual outcome after 
weeks or months. 
Prognosis: This depends on the severity of the 
case. Absolute and permanent recovery is rare but 
possible. 
Treatment: Bed, milk diet, hot packs, Kemp’s ir- 
rigations, digitalis. Also a daily dose of some saline 
cathartic (magnesium sulphate, or Husband’s mag- 
nesia). During the subacute stage we may aid by the 
employment of diuretics. Thus : caffeine, strophanthus, 
diuretin, acetate of potash and squills. 
In the presence of extreme dropsy, we may have to 
tap the serous cavities and puncture the skin of the 
tegs, or drain by means of Southey’s tubes. As the 
patient improves, diet should be gradually increased, 
but should be salt free. 
During convalescence iron should be given. 
When dropsy is very persistent, and resists all treat- 
ment, the patient may be improved by Edebohl’s oper- 
ation of decapsulation of the kidneys. 
Tuberculosis of the kidney: We usually find mili- 
ary tubercles in cases where the tuberculosis is gen- 
eral. Large tuberculous deposits are rare in children. 
Cases in which the tuberculosis is limited to the kid- 
ney have been reported. Other parts of the genito- 
urinary tract may be affected. The bladder frequently 
escapes. 
The symptoms are pain in the back, vesical irri- 
tation, and pus in the urine. Examine the urine for 
tubercle bacillus, also cystoscope and segregate the 
urine. If diagnosis is positive and only one kidney 
is affected, advise nephrectomy. DISEASES GENITOURINARY SYSTEM 
145 
Malignant tumors of the kidney: This is most fre- 
quently sarcoma, but may be carcinoma. 
It may form from the pelvis, cortex, or the adrenals. 
The growth is very rapid. In three months it may 
attain the size of a fist or may be so large as to fill the 
entire abdomen. 
The symptoms are tumor, hsematuria, cachexia. 
The tumor must be distinguished from large spleen, 
retroperitoneal sarcoma, hydronephrosis, tumor of the 
liver, tumor of the abdominal wall, dermoid cyst of 
the ovary. When the tumor is large it may cause hy- 
dronephrosis by pressure on the ureter. It may also 
cause thrombosis of the vena cava and oedema of the 
legs. Pressure may also cause gastric or intestinal in- 
digestion, or dyspnoea. 
Secondary growths may be found in the liver or 
lungs, causing cough and haemoptysis. Retroperito- 
neal glands are usually involved. 
Treatment: Surgical, if seen early. 
Death usually occurs in three to ten months. 
Fibroma, fibrocystoma, and adenoma are benign tu- 
mors, which may sometimes be found. 
Pyelitis: Causes: Infectious diseases, such as in- 
fluenza, scarlet fever, diphtheria, malaria, typhoid, tu- 
berculosis, pyemia, renal calculi. Sometimes pyelitis 
is apparently primary. 
It is a frequent cause for obscure temperature, and 
it is best to examine the urine in every case in which 
fever cannot be otherwise accounted for. It may also 
be caused by a congenital malformation of the kidney 
and ureter, tumors of the kidney, and rupture of a 
perinephritic abscess into the pelvis of the kidney. 146 
CLINICAL PEDIATRICS 
Symptoms: Chill, fever and pyuria. The fever is 
remittent and irregular. It may be high in the morn- 
ing, go down in the middle of the day and go up again 
in the evening, or it may be normal in the morning, 
high in the afternoon and down again in the evening. 
The fever may be intermittent. There may or may 
not be pain in the back and bladder symptoms. 
The chill may or may not be repeated. 
The pus may form from 1 to 50% of the urine. 
Urine: Acid reaction, containing pus cells and 
blood cells and albumen in proportion to the amount 
of nephritis present, or the amount of pus present. 
Duration of the apparently primary cases and those 
following infectious diseases is from three to five 
weeks, or longer. Prognosis in these cases is good. 
In cases with calculus, or pyelonephrosis, the patients 
often die from exhaustion before any serious degree 
of nephritis develops. 
Treatment: Rest in bed, milk diet, potassium ci- 
trate 12-24 gr. daily to an infant. If the urine is al- 
kaline we may give urotropin or benzoic acid. Pyelo- 
nephrosis requires surgical treatment. 
Renal calculus: Small calculi are common in in- 
fancy, but they do not usually give any symptoms. 
Large stones with symptoms, as in adults, are very 
rare. 
Traumatic hydronephrosis: This condition may 
appear two weeks to two months after injury of the 
kidney. It may disappear spontaneously. Usually 
it is necessary to aspirate or open and drain. 
Perinephritis: It may be primary or secondary to 
calculus, pyelitis, or tuberculosis of the kidney. DISEASES GENITOURINARY SYSTEM 
147 
The primary variety is common in children and 
may be caused by injury or exposure. It may resolve 
or suppurate. 
It occurs most frequently between the ages of three 
and six years. It may burrow between the lumbar 
muscles and appear in the ileocostal space. It may 
burrow between the abdominal muscles and appear 
above Poupart’s ligament. Rarely it may work along 
the psoas muscle and appear on the inner aspect of the 
thigh. 
It may open into the peritoneal cavity. 
Symptoms are usually acute or subacute, rarely 
chronic. 
There is a chill, followed by a rise in temperature 
(io2°-io4°), prostration, pain in the loin, sometimes 
in the groin or inner aspect of the thigh or even in the 
knee. There is a stiffness of the spine and tendency 
to flexion of the thigh on the body, with lameness. 
These symptoms may be present for two or three 
weeks before the swelling appears. 
A fullness becomes apparent in the ileocostal space, 
which later becomes a distinct mass. Some cases will 
show a swelling on the inner aspect of the thigh. The 
inflammatory mass suppurates, and the sac contains 
three ounces to a pint of pus. Tenderness over the 
affected region increases as the disease progresses. 
There is a characteristic concavity of the spine toward 
the affected side, and the thigh is flexed at right angles. 
Urinary symptoms may be entirely absent or there 
may be frequency of urination, pain referred to the 
bladder, pus in the urine (pyelitis). 
The patient may pass into a typhoid state. 
The usual duration is from three to eight weeks. 148 
CLINICAL PEDIATRICS 
With resolution there is a subsidence of all the 
symptoms but the lameness, which may persist for 
several months. 
Diagnosis: We must think of coxitis and Pott’s 
disease. 
Treatment: Rest in bed, icebag to the loin. When 
suppuration seems inevitable, use hot poultice and 
incise early. 
General oedema, not dependent on renal disease: 
This condition may be secondary to marasmus, anae- 
mia. There is sometimes serum in the cavities. The 
urine does not contain albumen. 
It is possible for the child to recover, but death is 
the usual outcome. 
Addison’s disease: The disease is usually associ- 
ated with a tuberculous inflammation of the adrenal 
glands. 
The characteristic signs are: Bronze discoloration 
of the skin and later severe gastric symptoms, with 
gradually increasing asthenia. 
Obstipation has been mentioned as a possible cause, 
and hopeful results have been obtained by the use of 
Russian mineral oil, given in generous daily doses. 
This treatment overcomes the stagnation of foecal sub- 
stance and the resultant autointoxication. 
The duration of the disease is indefinite; it may be 
a few months or a few years. The outcome is fatal. DISEASES OF THE GENITAL ORGANS 
Malformations; Epispadias—absence of the superior 
wall of the urethral canal. 
Hypospadias—absence of the inferior wall of the 
urethra. 
The urethral opening may be at the junction of the 
penis and scrotum. 
Extrophy of the bladder—absence of the anterior 
covering and bladder wall, with eversion of the vesical 
mucous membrane. Surgical interference must be 
resorted to. 
Adherent prepuce occurs very frequently. Some- 
times remains adherent a long time, causing the in- 
carceration of smegma, and resulting in swelling with 
pain and irritation. Upon separation of the prepuce, 
the smegma is easily evacuated. 
Phimosis: The prepuce is long and the opening is 
so small that it is impossible to draw it back over 
the glans penis. 
It may not cause any symptoms. It may cause: 
balanitis, hernia, hydrocele, painful urination, incon- 
tinence, spasm of the vesical sphincter with retention, 
prolapse of the rectum. It may be the irritating cause 
in convulsions, epilepsy, hysteria, pseudoparalysis 
with spasm of the muscles about the hip (resembling 
hip disease), night terrors, priapism, masturbation. 
Treatment: Stretching or circumcision. 
Undescended testicle:,, Testicle may be in the ab- 
149 CLINICAL PEDIATRICS 
dominal cavity or in any part of the inguinal canal. 
It usually descends in the first week of life. It may 
be helped along by manipulation. Sometimes it may 
not descend until puberty, or may not descend at all. 
If not in the canal it should be left alone. If in the 
canal an attempt may be made to pull it down and 
fasten it by means of a surgical procedure. If painful 
it should be removed. 
Balanitis: Infection of the glans by smegma, in- 
jury or masturbation. 
Treatment: Wet dressing. Sometimes it may be 
necessary to slit the prepuce. We should not do a 
circumcision until the inflammation subsides. 
Meatitis erosiva puerorum: This is an erosion of 
the meatus, causing painful urination and even reten- 
tion of urine. It is usually found in little boys with a 
very small urethral opening. The irritating cause is 
probably friction of a rough napkin. 
Treatment: Cauterization with a silver nitrate 
stick. Sometimes it is necessary to slit the opening 
to allow an easier flow of urine. 
Urethritis: Simple or gonorrhoeal. 
Simple vulvo-vaginitis catarrh: Caused by dirt in- 
fection. Wash with a weak permanganate solution 
and keep clean. 
Gonorrhoeal vulvo-vaginitis: This is of frequent oc- 
currence. The infection may be caused by attempted 
rape or it may come from the parents by the use of 
infected towels, etc. It is very commonly found in 
institutions and hospitals. 
There are usually no constitutional symptoms. 
Locally we find redness and a thick yellow discharge. 
Microscopical examination discloses the gonococcus. DISEASES OF GENITAL ORGANS 
151 
Treatment: During- the very acute stage we may 
irrigate the vagina with a weak solution of potassium 
permanganate (1-4000). 
Later, best results are obtained by the use of silver 
nitrate solutions. These are used in the following 
manner: 
During the Ist week—1% sol. every day. 
During the 2nd week—2% sol. every 2 days. 
During the 3rd week—3% sol. every 3 days. 
During the 4th week—4% sol. every 4 days. 
After that a 5% sol. once a week. 
Continue the last for a few weeks and then stop. 
If the treatment is continued too long, we may in- 
duce simple catarrhal condition as a result of the treat- 
ment. 
The technique is as follows; 
Fill two 1 or 2 oz. syringes, one with sterile distilled 
water, and the other with the silver nitrate sol. 
After washing the external parts, introduce a small 
catheter through the opening in the hymen, about ij/2 
inches into the vagina. 
Then attach the syringe containing the water and 
inject, at the same time holding the labia close to- 
gether so as to balloon out the vagina, thus putting 
the mucous membrane on a stretch. 
Withdraw all the water that may remain in the va- 
gina and repeat the same procedure with the silver 
nitrate sol. 
Another form of treatment is to make direct appli- 
cation to the mucous membrane with tr. iodine by 
means of an endoscope. 
Gonococcus vaccine may be tried. It is given hypo- 152 
CLINICAL PEDIATRICS 
dermatically. Give dose every 3or 4 days. Start with 
50 million, and gradually go up to a billion. 
Herpes of the vulva: Usually disappears after a 
few days. It may be mistaken for mucous patches. 
Gangrenous vulvitis (Noma) : This is the same 
form of infection as cancrum oris. It occurs after 
some infectious diseases, particularly measles, when 
vitality is much reduced. It is usually fatal. 
Recovery results in great deformity. May cause 
fistulse, or atresia, or stenosis of the vagina. 
Enuresis, Causes: Organic nervous diseases. 
Inflammations of the genito-urinary tract: Ure- 
Calculus, renal, ureteral or vesical. 
Tumors of the bladder or kidney. 
thritis, cystitis, pyelitis. 
Malformations: extrophy of the bladder, epispa- 
dias, hypospadias, phimosis, small meatus, ad- 
herent clitoris. 
Constipation, fissure in ano, pinworms. 
Masturbation. Diabetes mellitus. Diabetes in- 
sipidus. 
Adenoids. 
Scrotal hernia, undescended testicle 
Functional disturbance of vesical sphincter ac- 
tion. 
Enuresis may be diurnal, nocturnal, or both. 
It is frequently caused by improper early training. 
The involuntary act has never been properly changed 
into a voluntary one, so that enuresis may be placed 
in the category of habit twitch. 
The affection usually continues up to the 6th or 7th 
year. Sometimes it may continue until puberty. DISEASES OF GENITAL ORGANS 
153 
Prognosis is better at 4 years than at 8 years. 
The children usually recover unless the condition 
is due to some organic disease. 
There is never any dribbling of urine; the evacua- 
tion is sudden. 
Treatment: Ascertain the cause and treat accord- 
ingly. 
Begin to train babies early. It is best to start when 
the baby is 9 months old. The child should be placed 
on the commode at regular intervals, both in the day 
time and at night. 
The evening meal should be light. Do not allow 
coffee or tea. 
The child must be aroused once or twice during the 
night so as to forestall the accident. 
The method of treatment that is most important is 
that of re-education. The child is urged to micturate 
in the presence of the parent or nurse and instructed 
to pass water in little jets, a small amount at a time, 
each time suddenly arresting the flow. As in the habit 
twitch (Tic. convulsif), the idea is to convert the in- 
voluntary act into a voluntary one. 
Of drugs, not much may be expected. Bromides 
have been used. Atropine has yielded the best results. 
It should be given in slowly ascending doses. 
Atropine Sulph. gr. ss to Water §i 
One drop is equivalent to 1/1000 gr. 
Give TTt i t. i. d. and increase gradually as follows: 
Ist day i-i-i 
2nd day 1-1-2 
3rd day 1-2-2 
4th day 2-2-2 etc. 154 
CLINICAL PEDIATRICS 
Continue up to 10 drops, t. i. d., then go down again. 
Vesical calculus: Usually originates in the kidney. 
It is most frequently of uric acid origin. It is rather 
rare in children and has often been overlooked. 
Symptoms: Tenesmus, incontinence and pain, es- 
pecially after urination. There may be a sudden stop- 
page of the flow during urination, which is a char- 
acteristic sign. Hsematuria is rare, but we usually find 
pus and mucus in the urine. 
Prolapse of the rectum and rectal tenesmus are com- 
mon ; so that in persistent prolapse of the rectum, sus- 
pect vesical calculus. 
Sometimes it is possible to feel the stone by a rectal 
examination. A positive diagnosis is made by means 
of a sound introduced into the bladder or by means 
of a radiograph or cystoscope. 
Treatment: If the stone is small we may remove 
the stone by crushing. If the stone is large we must 
remove through a suprapubic incision. DISEASES OF THE THYMUS GLAND 
Hyperplasia: This is very indefinite, owing- to the 
wide range of size and weight (2-30 gm.). Clinically 
the thymus occupies the triangular space the base of 
which corresponds to a line drawn between the ster- 
no-clavicular joints and the apex pointing downward 
and extending down to the level of the second rib. 
If on percussion we find that there is no area of res- 
onance between the thymus and the hpart, we may 
consider the thymus gland enlarged. 
When percussing have some one hold the child with 
the body inclined forward. The same dullness on per- 
cussion may be caused by the presence of large medi- 
astinal glands. 
A radiograph may show a shadow extending as far 
as the heart. 
Pressure of this gland on the trachea will cause thy- 
mic asthma, which disappears as the child grows older 
and trachea becomes firmer. 
The hyperplastic thymus gland is not appreciable 
on percussion after the 6th year of life. 
Status lymphaticus: Characteristics: Large lymph 
glands, and lymph nodes, large spleen, large thymus, 
anaemia, weakness of the muscles, weak heart muscle 
with dilatation, sudden death. 
The child is usually small, fat and pale. It may 
frequently succumb to a slight intercurrent disease, 
even eczema. 
155 156 
CLINICAL PEDIATRICS 
The child may have rickets, spasmophilia or tuber- 
culosis (scrofula). 
Other affections of the thymus are rare. These may 
be syphilis, tuberculosis, acute inflammation or new 
growth. DISEASES OF THE THYROID GLAND 
Abscess of the thyroid: Acute inflammation, re- 
quiring the usual surgical treatment. Prognosis is 
good. 
Goitre: There is a partial hyperplasia, with cir- 
cumscribed tumors, infiltrating the gland. It is more 
frequent during the first year than the second, and 
then it increases in frequency up to the 15th year. 
It is more frequent in females. Sporadic cases are 
rare. 
Endemic cases are usually associated with cretin- 
ism, cases in which the whole thyroid is involved in 
the goitre. 
Where the whole thyroid is not involved, the func- 
tion will not be interfered with. 
Drinking water is probably an important factor in 
the etiology of endemic cases. 
Symptoms depend on the size of the tumor and the 
amount of pressure on the trachea. 
The patients usually have a short fat neck and may 
suffer from dyspnoea, cough and inspiratory whistle. 
In sporadic cases look for heredity. 
Treatment: Thyroid ext. and potassium iodide. 
Congenital goitre: In these cases heredity is an 
important factor. It is usually associated with a large 
thymus. 
The goitre gradually decreases in size and rarely 
157 158 
CLINICAL PEDIATRICS 
becomes permanent. It may cause sudden death by 
pressure on the large vessels in the neck and trachea, 
with secondary bronchopneumonia. 
The treatment is the same as above. We may give 
thyroid extract to the mother. 
Cretinism: This is a disease due to the absence of 
thyroid secretion. The characteristics do not show 
at birth, but at the age of I year. Heredity plays an 
important role. There is a degeneration of the thyroid 
gland with hyperplasia. The thyroid gland may be 
replaced by a small fat cushion. Eighty per cent, of 
the cases also have goitre. 
The body is short, stumpy and fat. The extremi- 
ties are short, the skull is flat and broad, lips are thick. 
The tongue is large, the nose is broad and saddle- 
shaped, the skin is dry; hair is dry and bristly; the 
hands are spade-like, with short, stumpy fingers. The 
intellectual development is slow and may vary from 
defective to idiocy. The voice is hoarse. Hair on the 
genitals is slow in appearance. 
The abdomen has a tendency to be balloon shaped 
and umbilical hernia is common. 
Treatment: Thyroid extract in gradually increas- 
ing daily doses. 
We may begin with *4 gr. a day and increase the 
dose every week or every month, depending on the 
results obtained. The maximum dose necessary is 
usually 5 gr. daily. 
With the administration of the thyroid extract, the 
patient improves rapidly. 
The mental and physical development become more 
nearly normal. 
There are various degrees of improvement. The DISEASES OF THE THYROID GLAND 
159 
most favorable cases differ very slightly from the nor- 
mal child. 
These patients must take their thyroid for the rest 
of their lives, otherwise symptoms of myxoedema will 
develop. 
Myxoedema: The same as in the adult. The con- 
dition is due to deficient function of the thyroid. The 
symptoms are similar to those of cretinism. 
Infantile myxidiocy: This is a congenital affection. 
The thyroid may be absent or intact (with arrested 
function). 
There is marked myxoedema, with arrested mental 
and physical development. The condition is some- 
what improved by thyroid therapy. 
Congenital myxidiocy: The myxoedema is appar- 
ent in the first months of infancy. 
Infantilism: This is a continuance of the infantile 
state of the mind and body, with an undeveloped state 
of the genitals. 
Acquired myxidiocy: Appears later in infancy. 
It may be a mild form of myxidiocy. 
There are two types: 
1. Myxoedema type—with short extremities, and 
fat appearance (Brissaud type). 
2. Thin long face with thin long extremities (Lor- 
Thyroid extract may sometimes improve the first 
type. 
raine type). 
Basedow’s disease (Graves’ disease) ; This condi- 
tion is rare in children. The cardinal symptoms are 
the same as in adults; large thyroid, exophthalmos, 
tachycardia, tremor and anaemia. The first two are 
often absent. CLINICAL PEDIATRICS 
Mongolism: Mongolism is recognized at birth by 
the characteristic facies. 
There is a downward sloping of the inner canthus of 
the eyes. 
It seems to be an arrested form of foetal develop- 
ment. 
Mental development is very slow. The babies are 
small and delicate, but show no dwarfism. 
Other characteristic signs are: Tongue sucking, 
loose joints, long tapering fingers, chicken breast (due 
to associated rickets), tendency to hernise, blephari- 
tis, bronchitis and pneumonia. 
The children usually die in infancy with pneumonia 
or some other intercurrent disease. 
Ossification is not delayed as in the cretin. 
If they grow up to adult age, they do not show any 
dwarfism, but a slow and imperfect mental develop- 
ment. Speech is imperfect and the voice is harsh. 
Treatment is of no avail. Thyroid extract is usually 
given. 
Micromelia (Achondroplasia, chondrodystrophy) : 
Characteristic signs: long body, short extremities, 
saddleshaped nose, normal intelligence. 
It is due to a non-development of cartilage in the 
long bones. DISEASES OF THE BLOOD AND BLOOD- 
PREPARING ORGANS 
Symptomatic or secondary anaemia: Causes; Hem- 
orrhage, illness, malnutrition, improper hygienic en- 
vironment. In this group we may also mention anae- 
mia of school children, which is caused by overheat- 
ing and improper ventilation of school rooms, to- 
gether with insufficient out-of-door exercise and im- 
proper diet. 
These anaemias improve upon removal of the cause. 
School children should be removed from school for a 
few weeks and given plenty of fresh air and outdoor 
exercise. Food should be simple and given at regular 
intervals. Eating of candy, etc., between meals is a 
very important factor in the causation of loss of ap- 
petite, indigestion, with secondary malnutrition and 
anaemia. 
Treatment: Regulation of diet and exercise are 
most important. 
Tonics may be used as an aid. Thus we may give: 
Maltine and iron, Liq. Ferri Peptomangan or the 
Anaemia pseudoleukaemia infantum (Von Jaksch): 
From the seventh month to the second year we often 
see severe anaemias with grave blood pictures. 
Syr. of iodide of iron. 
Among the chief causes for this condition we may 
mention: Poor heredity, poor environment, bad arti- 
ficial feeding, gastroenteritis, rickets, etc. 
161 162 
CLINICAL PEDIATRICS 
In mild cases we find continued pallor and weak- 
ness. 
In severe cases the pallor assumes a yellowish tint. 
The child is irritable and cries continuously, especially 
upon attempts to move it (probably on account of 
rickets). 
Diarrhoea is often present and bronchopneumonia 
frequently develops. 
There may be hemorrhage from the skin or the mu- 
cous membranes. 
The retina is not affected. 
The spleen may be slightly enlarged, or very much 
enlarged and hard. 
The glands in the axilla, neck, as well as the epi- 
trochlear and inguinal glands may be somewhat en- 
larged. 
The liver is usually normal in size but may extend 
two fingers’ breadth below the free border of the ribs, 
and is soft. This, probably, is due to associated 
rickety condition. 
The blood condition varies with the severity of the 
case. The characteristic points are: Red blood cells 
—reduced in number, with a reduced quantity of 
haemoglobin. We usually find poikilocytes (irregular 
shaped and pointed erythrocytes), normoblasts, and in 
severe cases megaloblasts. The cells may vary in size 
from very small to very large. Lymphocytes are nu- 
merous (50%), polynuclears—30%, myelocytes and 
mast cells are also usually found. 
The total white blood cell count varies from 10,000 
to 50,000. 
The diagnostic points of the disease are large 
spleen, normal liver, large number of normoblasts (nu- DISEASES OF THE BLOOD 
163 
cleated red blood cells) and lymphocytes: It must be 
differentiated from leukaemia, pernicious anaemia and 
rickets with simple anaemia. 
Treatment: Give breast milk, if obtainable, or 
careful artificial feeding. Stop pasteurizing or boiling 
the milk. In older children give a mixed diet, con- 
sisting of meat juice, cereals, spinach, potato, aspara- 
gus tips, carrots and raw fruit juice. 
Medication: Fowler’s solution, or oil of phosphorus 
(1%) drops, t. i. d. in emulsion of cod liver oil. 
We may also try bone marrow stirred up in egg and 
spread on bread. 
Transfusion will be beneficial; 60-200 c.c. may be 
transfused. This is facilitated by the use of Sodium 
citrate. This added to the blood drawn from the do- 
nor (1 gr. to the ounce) will retard coagulation three 
or four days (Lewisohn). 
Chlorosis: Chlorosis develops during the second 
decade in female children. The probable causes are 
constipation, intestinal intoxication, insufficient out- 
door exercise, too much study, poor nourishment, and 
possibly internal secretions of the internal sexual or- 
gans (Van Noorden). 
The blood shows a reduction of the number of red 
blood cells to a slight degree, but the reduction of 
haemoglobin is very great, and shows under the mi- 
croscope by the pale appearance of the corpuscles, 
these being colorless in the centre. 
Symptoms: Pallor, weakness, vertigo, attacks of 
syncope, dyspnoea, headaches, amenorrhoea, indiges- 
tion, and sometimes symptoms of gastric ulcer, epi- 
staxis. 
Treatment: Fresh air, change in environment, if 164 
CLINICAL PEDIATRICS 
possible; rest and simple good food. Iron is very 
valuable in these cases. 
The following preparations may be used: 
Maltine and iron or Neoferrum, Dose 5i 
Liq. Ferri Peptomangan, Dose 3i 
Syr. Ferri lododi, Dose lUvxx 
Ferri Sulph. exsic., Dose gr. ss-iii 
Iron Tropon, Dose gr. v 
We may also give arsenic. 
Pernicious Anaemia: This affection is rare in chil- 
dren. There seems to be a consensus of opinion that 
pernicious anaemia is a severe form of secondary anae- 
mia. 
Causes: Chronic poisoning (carbon monoxide or 
coal gas), tumors, tumors of the bone marrow, infec- 
tious diseases (sepsis, syphilis, malaria), bodily or 
mental injury, autointoxication, worms (ankylostoma 
duodenale, Bothriocephalus latus, Ascaris lumbri- 
coides). 
There is a destruction of the blood, and affection of 
the bone marrow. There is gastric pain and anorexia. 
Retinal hemorrhages appear early. We also get hem- 
orrhages from the intestines and sometimes from the 
kidneys. The spleen is enlarged. Other signs: Pul- 
sating carotids, diastolic murmur, venous hum, rapid 
pulse and respiration. The temperature is normal or 
slightly raised. There is a disturbance of digestion 
and increasing weakness, which in bad cases is fol- 
lowed by coma and death. 
Blood: Number of blood cells is very much re- 
duced ; haemoglobin is also reduced, but the blood cells 
retain their normal color and may even be of a deeper DISEASES OF THE BLOOD 
165 
shade than normal. We also find poikilocytes, micro- 
cytes, normoblasts, megaloblasts. The white blood 
cells are reduced in number, the lymphocytes predomi- 
nating (60%). 
Prognosis is bad unless the cause can be removed. 
Treatment: Treat cause and give arsenic. Early 
splenectomy has given good results; especially if pre- 
ceded and followed by transfusion. 
Leukaemia: There are two forms, lymphatic and 
myelogenous. 
The lymphatic form is usually acute, but may be 
chronic. 
The myelogenous form is usually chronic, but may 
be acute. 
No uniform cause has yet been recognized. Any 
disease that is a drain on the system may be a pre- 
disposing cause. 
It is possible that it may be of infectious origin 
owing to the enlargement of the glands. 
Symptoms: Acute or chronic. 
It begins with pains in the limbs, with weakness and 
anorexia, and sometimes pains in the region of the 
spleen. 
There may be a slight rise in the temperature. 
There is increasing pallor and dropsical manifesta- 
tions, septic involvement of the tonsils, stomatitis. 
Hypostatic pneumonia usually precedes death. Glands 
all over the body are enlarged (about the size of a 
hazel nut). The spleen is enlarged. We get hemor- 
rhages into the skin and from mucous membranes. 
Retinal hemorrhages appear early and are seldom ab- 
sent. The liver is enlarged (usually studded with 
white specks of lymphoid cells). 166 
CLINICAL PEDIATRICS 
Blood; Lymphatic form—A large number of large 
and small lymphocytes (100,000-500,000). The ratio 
as compared with the red blood cells is 1-20 to 1-1. 
In the myelogenous form, we find a great many 
myelocytes (neutrophile and eosinophile large mono- 
nuclears), also mast cells (basophile polynuclears), 
atypical forms of polynuclears, small or large, with 
very little or’no granulation (karyokinesis). 
Red blood cells—two to three million, with micro- 
cytes (small), megalocytes (large), poikilocytes (ir- 
regular in shape), normoblasts (nucleated). 
Course: From three weeks to four years. 
Treatment: Iron, arsenic, iodine, radiotherapy, 
Benzol (Gtt i-x, in ascending drop doses). 
Transfusion seems beneficial. 
Pseudoleukaemia (Hodgkin’s disease) : This disease 
is usually found in young people, but children may be 
affected. The lymphatic glands are very much en- 
larged. The cervical glands are most frequently in- 
volved. These glands are often found to be tubercu- 
lous. The disease is probably akin to leukaemia, only 
the marrow of bones and spleen are not involved. 
Symptoms: There is a marked enlargement of the 
lymphatic glands, especially the cervical glands. 
These grow to good sized tumors, exerting pressure 
on the trachea and oesophagus, causing difficulty in 
swallowing and respiration. Glands in the other parts 
of the body, including the internal organs, gradually 
become affected. The spleen is large, sometimes at- 
taining enormous proportions. The liver is also large. 
We may also have fever, anaemia, cachexia, amyloid 
degeneration, septic infection and pneumonia. 
Blood: Diminution of the number of red blood DISEASES OF THE BLOOD 
167 
cells and haemoglobin; no grave change; white blood 
cells are slightly increased in number; lymphocytes 
are somewhat increased in number. When tubercu- 
losis is present the polynuclears are increased in 
number. 
Prognosis is uncertain. The disease usually drags 
on for years, with periods of improvement. An at- 
tack of measles or varicella has been known to effect 
a transitory improvement. 
Treatment: The same as in leukemia. 
Enlargement of the spleen: Causes; 
Infectious diseases (typhoid, malaria). 
Leukaemia, pseudoleuksemia, Von Jaksch anaemia. 
Echinococcosis of the spleen. 
Splenoptosis, frequently associated with enterop- 
tosis. 
Rachitis (the enlargement is probably due to sec- 
ondary anaemia, and pressure downward by 
contraction of the chest, Harrison’s groove). 
Syphilis. 
Hanot’s cirrhosis of the liver. 
Banti’s disease: Begins with enlargement of the 
spleen, followed by secondary anaemia (with lympho- 
cytosis, splenic anaemia). After a number of years cir- 
rhosis of the liver develops, causing ascites, etc.; also 
leucopenia. 
Extirpation of the spleen is sometimes curative. 
Gaucher’s splenomegaly: This form seems to be a 
familial type of splenomegaly. The spleen usually 
grows to enormous size. There are no special blood 
changes. The patient seems to be in good health until 168 
CLINICAL PEDIATRICS 
the spleen gives pressure symptoms. The disease be- 
gins before 13 years and lasts about 25 years. 
Splenectomy should be advised if spleen becomes 
too large. Death from intercurrent disease may occur. 
Haemolytic jaundice: Familial; liver and spleen 
enlarged (spleen first) ; gradually increasing jaundice; 
sometimes hemorrhages from mucous membranes. 
Urine contains urobilin, but no bile. Early splenec- 
tomy gives good results. There may be attacks of 
liver pain and tenderness. Differs from Hanot’s cir- 
rhosis : Spleen large first; fragility of red blood cells. HEMORRHAGIC AFFECTIONS 
The following conditions are associated with hem- 
orrhage : 
Infectious diseases 
Syphilis 
Sepsis 
Blood diseases (leukaemia, anaemia) 
Haemophilia 
Purpura (simplex, rheumatica, hemorrhagica, 
fulminans) 
Scurvy 
Melaena neonatorum 
Paroxysmal haemoglobinuria 
Weil’s disease 
Cirrhosis of the liver. 
Haemophilia: A hereditary affection. It is more 
common in boys. Girls may not be affected and still 
carry affection to their children. 
A male haemophilic may with a healthy woman have 
a normal child. 
Haemophilic women produce children that are af- 
fected. 
Symptoms: There is bleeding from the skin and 
mucous membranes upon the slightest provocation. 
We may also get hemorrhages, which are subcutane- 
ous, interstitial, intramuscular or into the joints. 
These are of varying severity. The hemorrhages may 
169 170 
CLINICAL PEDIATRICS 
form large haematomata which upon absorption cause 
scar formation, with stiffening of the joints and 
muscles. 
A large number of haemophilics succumb to internal 
or external hemorrhages in early childhood. 
Purpura: All forms seem to be associated, the dif- 
ference being in severity. There is tendency to hemor- 
rhage, which may be subcutaneous, into the joints or 
organs or from mucous membranes. Thus a great 
variety of pictures are presented. 
The cause may be infection, or toxaemia, which ef- 
fects a change in the walls of blood vessels. There is 
no change in the coagulability of the blood itself, but a 
change in blood platelets may be at the basis of the 
disease. 
Purpura simplex: At the onset we usually get 
headache, lassitude and vomiting. This is followed 
by small subcutaneous hemorrhages, resulting in the 
formation of petechias and wheals, which do not dis- 
appear on pressure. Sometimes it is associated with 
true urticaria and exudative eczema. 
It may come out all at once and disappear in twelve 
days, or it may come out in successive crops, lasting 
for months. 
The spots appear on the extensor surfaces of the 
arms and legs and on the trunk. The face and hands 
remain free. 
Prognosis is good. 
Purpura rheumatica (Peliosis rheumatica, Schoen- 
lein’s Disease) : This disease may run an acute 
course in fourteen days or more frequently it takes a 
paroxysmal course. HEMORRHAGIC AFFECTIONS 
171 
The symptoms are similar to the simple form, but 
are more severe. 
There are pains in the joints, owing- to serious in- 
filtration of the periarticular tissues or hemorrhages 
into the joints. 
The disease sets in with fever anorexia, vomiting 
and diarrhoea. 
The purpuric eruption may be associated with ery- 
thema nodosum, erythema multiforme, urticaria and 
exudative eczema. 
The outcome is favorable. 
Purpura hemorrhagica (Morbus maculosus Werl- 
hofii) : Subcutaneous hemorrhages are like those of 
simple purpura, but more extensive. There are also 
hemorrhages from the mucous membranes of the nose, 
stomach, from the kidneys, etc. 
It occurs in patients who are apparently healthy 
and usually runs an acute course. At the start there 
is a little rise in the temperature, with weakness and 
subcutaneous hemorrhages. Joints are not affected. 
Subcutaneous hemorrhages may be very large. 
Prognosis is good. Death may occur as a result of 
too much loss of blood. 
Abdominal purpura (Henoch’s): This form begins 
like purpura rheumatica. This is followed by colic 
and intestinal hemorrhage, vomiting of blood and diar- 
rhoea with black stools. The abdomen is distended 
and sensitive. These symptoms appear in.paroxysmal 
attacks at intervals of days, months or even a year. 
The attacks diminish gradually in severity. Progno- 
sis is doubtful, on account of possible affection of the 
kidney. 
Purpura fulminans: This is like purpura simplex, 172 
CLINICAL PEDIATRICS 
but is characterized by very severe subcutaneous hem- 
orrhages. 
It takes a very rapid and fatal course in 12 hours to 
four days. 
Paroxysmal haemoglobinuria: Predisposing causes: 
hereditary syphilis, malaria, scarlet fever. 
The immediate cause is exposure to cold. 
Each paroxysm lasts 13/2-2 hours. It comes on at 
varying intervals following exposure. 
Symptoms; There is lassitude, yawning, chill, cya- 
nosis, followed by heat and perspiration, associated 
with haemoglobinuria. 
The skin may show hyperaemic spots, or wheals, 
which may become gangrenous. The urine is dark 
red or brown. Microscopically, the urine shows 
masses of pigment but no red blood cells. 
It must be differentiated from haemoglobinuria oc- 
curing after burns or poisoning with phosphorus, 
mushrooms, potassium chlorate, phenol, etc. 
Treatment: Haemophilia—Prohibit marriage of 
haemophilics, especially in the cases of women coming 
from haemophilic families, even if they themselves are 
not bleeders. For bleeding we may use the subcuta- 
neous injection of 10% solution of Russian gelatin, 
the quantity employed being 20-30 cc. Elevate the 
bleeding part. 
The coagulability of the blood may also be increased 
by transfusion or the injection of human serum or 
horse serum. Before using any serum or blood, al- 
ways ascertain as to haemolysis and anaphylaxis. We 
may try intramuscular injection of whole blood 6 cc. 
Purpura: Rest in bed, 10% sol. of gelatin by hypo- 
dermoclysis (20-30 cc.) and 200 cc, daily by mouth. HEMORRHAGIC AFFECTIONS 
173 
Henoch’s purpura: Rest in bed, icebag to the ab- 
domen, cold bland diet, gelatin. No coffee, tea or 
alcohol. 
For local bleeding we may use adrenalin solution, 
sol. of ferric chi. coagulen, pressure and elevation. 
Hsemoglobinuria: Rest in bed and warmth. A 
bland diet, plenty of water. Treat the cause if found. 
DIABETES 
Diabetes mellitus: This is more frequent in chil- 
dren than was formerly believed. 
Two and one-half per cent, of the cases occur dur- 
ing the first decade. 
Young children also show more tendency to tran- 
sitory glycosuria than adults. Diabetes is a metabolic 
disease. Heredity and consanguinity may be etiologi- 
cal factors. Concussion of the brain may be a cause. 
The disease is common among the Jewish race (con- 
sanguinity). 
Usually, several members of the family are affected. 
The pancreas appears to be normal. 
Symptoms: The most important symptom is gly- 
cosuria. 
At first it may be slight, disappearing upon reduc- 
tion of carbohydrates in the diet. The glycosuria 
may, however, at any time become so bad that even a 
carbohydrate free diet will not affect it. 
When glycosuria is due to some slight change in 
the pancreas, it is generally transitory, disappearing 
after a few weeks. 
There are patients who have a limited tolerance of 
carbohydrates which persists throughout life. 174 
CLINICAL PEDIATRICS 
The majority of cases gradually become worse. 
As soon as diet has no effect on the glycosuria, the 
children become more and more emaciated, languid 
and weak. 
Diabetic acidosis, sooner or later, develops, gener- 
ally followed by coma. Sometimes we find that even 
in bad cases the percentage of sugar in urine is un- 
usually low. This may be due to the fact that all the 
sugar is not excreted. An examination of the blood 
will disclose a state of hyperglycasmia (normal per- 
centage of sugar in the blood is .06%). 
Acidosis really means a reduction of the normal 
akalinity of the blood. The normal sodium bicar- 
bonate content of the blood should be .36%. If that is 
reduced to .20% it means acidosis. 
Acidosis is, generally, recognized by the presence 
of acetone breath and acetone, diacetic and oxy-buty- 
ric acid in the urine. 
Sometimes, owing to defective excretion, examina- 
tion of the urine may mislead us as to the actual aci- 
dosis of the blood. 
Carbonic acid, present in alveolar air, is in propor- 
tion to the amount of sodium bicarbonate in the blood. 
Thus acidosis of the blood may be determined by 
means of an apparatus (Van Slyke), which indicates 
the quantity of carbonic acid in alveolar air and varia- 
tion from normal. 
Nitrogen ratio is, normally, 2.8 to each gramme of 
sugar. Increased nitrogen means hyperglycsemia. 
Prognosis in diabetes of children is bad. 
Treatment: The most important part of the treat- 
ment is the diet. 
The regulation of the diet depends entirely on the DIABETES 
175 
effect produced. It is best to begin with a strictly 
carbohydrate free diet, until the urine is free from 
sugar. Then gradually add carbohydrates to ascertain 
the patient’s tolerance. The greater the tolerance the 
more favorable the case. 
In bad cases it is necessary to adhere to a strict diet 
for a long time. Watch for acidosis, and if present, 
add 30 to 60 gm. of carbohydrate daily for a few days. 
Physical exercise increases carbohydrate tolerance. 
Every once in a while it may be advisable to give 
the patient a day when his diet consists of eggs and 
vegetables; also a starvation day, when he is allowed 
only tea and a little vegetable. During starvation 
keep child in bed. In some cases diet has no effect on 
the glycosuria. Acidosis is also frequently present in 
these cases, and development of diabetic coma is im- 
minent. 
These cases are best managed by instituting star- 
vation with rest in bed for a few days until glycosuria 
disappears. It is important in these cases to examine 
alveolar air repeatedly in order to keep posted as to 
the alkalinity of the blood. Acidosis may decrease in 
the course of this treatment or it may increase. If 
the acidosis increases we have to postpone starvation 
for a few days, putting the patient on a protein-fat diet. 
As soon as acidosis is markedly diminished, we may 
again try starvation, carefully watching the patient’s 
condition. As soon as glycosuria disappears, give the 
patient a protein-fat diet, with gradually increasing 
quantity of carbohydrate. 
At the same time it is important to have the patient 
take a good deal of physical exercise. 
This treatment has been found remarkably sue- 176 
CLINICAL PEDIATRICS 
cessful in some cases. If acidosis develops while the 
patient is on a protein-fat diet, add carbohydrate; also 
give 15-90 gr. of sodium bicarbonate daily. In the 
presence of diabetic coma, give infusion of a 3% so- 
lution of sodium bicarbonate, intravenously, and by 
rectum. 
Diabetes insipidus; As in true diabetes a large 
amount of urine is passed. The urine is light colored 
and of a low specific gravity. The urine does not con- 
tain either sugar or albumen. 
The condition is often associated with affection of 
the brain, and may frequently follow some infectious 
disease. 
Sometimes no definite cause can be found. 
The child may pass three to eight quarts of urine 
in 24 hours. 
There is great thirst, perspiration is reduced and 
there may be trophic disturbances of the skin and 
nails. 
In bad cases there may be considerable exhaustion, 
sometimes even causing death. 
The child may get well or the condition may con- 
tinue throughout life. 
Treatment: Reduce fluids and try a salt free diet. 
Drugs have not given satisfactory results. We may 
use belladonna, strychnine, ergotin, antipyrin, salicy- 
lates. 
SCROFULA 
This is a disease of childhood and puberty, char- 
acterized by low resistance to infection and tendency 
to development of tuberculous adenitis, tubercu- SCROFULA 
177 
lous otitis, eczema, tuberculides (skin tuberculosis). 
There is usually a persistent discharge from the 
nose, causing an excoriation of the upper lip. The 
eyes are frequently affected with blepharitis, phlyc- 
tenular conjunctivitis, or keratitis with photophobia 
Otitis media with persistent discharge is common. 
Adenoids are always present. 
Cervical adenitis frequently becomes very large, re- 
sulting in rupture and fistulse. Sometimes we get a 
mixed infection and acute suppuration. 
Tuberculous ostitis in any part of the body may de- 
velop. Dactylitis is commonly encountered. There 
may be spondylitis, coxitis, tuberculosis of the knee, 
elbow, etc. 
Treatment: Fresh air, good food, maltine and cod 
liver oil. 
For glands—local application of io% potassium 
iodide in lanolin base. 
For eczema we may use some tar preparation. The 
excoriations may be touched with 5-10% silver ni- 
trate. 
Do not incise unless there is suppuration. 
Adenoids should be removed. 
Eyes—Hydrarg. lodidi flav. gr. 2 in 2 drachms pe- 
trolatum, applied to the eyelids. For phlyctenular 
conjunctivitis, immerse the child’s head in cold water 
every morning. If keratitis dilate the pupil with atro- 
pine. 
Otitis—usual treatment and cleanliness. 
Bone tuberculosis; Immobilization, Bier treatment. COMMUNICABLE OR INFECTIOUS DISEASES 
Measles (Rubeola) : An intensely contagious dis- 
ease. The contagion is probably carried by discharges 
from the nose, throat and eyes. 
Children are more susceptible than adults to the in- 
fection. 
Period of incubation, 10-14 days. 
Invasion; There is fever, sneezing, cough. This 
usually lasts 3-4 days, but may last 12 hours to 6 days. 
Koplik spots appear during this period. These consist 
of red spots on the buccal or labial mucous membrane, 
yk~Y\ inch in diameter, with a central grayish spot. 
The symptoms during invasion may sometimes be 
very severe. There may be chill, convulsions, head- 
ache and vomiting. 
Eruption then appears on the face, neck, trunk, ex- 
tremities and mucous membranes. The eruption is 
maculo-papular, with a tendency to crescentic forma- 
tion. The patches are light or dark red and are scat- 
tered or confluent. Sometimes it may be hemorrhagic 
or vesicular. It reaches its full development in two 
to four days. After one week we see a fine desquama- 
tion. The temperature rises with the appearance of 
the eruption until it is complete and then it drops. 
With the high temperature we also get restlessness, 
sleeplessness, stupor and delirium. 
The mucous membranes are inflamed. Thus, there 
is conjunctivitis with pain and photophobia, pharyn- 
gitis, bronchitis, laryngitis, gastritis and enteritis. 
178 COMMUNICABLE DISEASES 
179 
The eruption and fever subside in two to seven 
days. Convalescence is established in ten to fourteen 
days after the appearance of the eruption. Possible 
complications: Bronchopneumonia, otitis media, 
adenitis (simple or tuberculous), nephritis, cancrum 
oris or vulvae. 
The course of the disease may be mild, severe or 
malignant. The malignant cases are called black 
measles. The eruption in these cases is not well de- 
veloped, but is very dark in color or hemorrhagic. 
Prostration is extreme, heart action very feeble, skin 
cold, tongue dry and brown. There are also marked 
cerebral symptoms, and hemorrhages from the mu- 
cous membranes. Convalescence may be delayed by a 
persistence of conjunctivitis, pharyngitis, otitis media, 
bronchopneumonia, gastritis, tuberculous adenitis, 
cervical or mediastinal. The child may remain anae- 
mic for a long time. 
Treatment is symptomatic. The temperature of the 
sick-room does not have to be too warm. The room 
should be darkened. For a child 2 years of age we may 
give 1 or 2% Sol. of Carbolic acid, a teaspoonful every 
2 hours. 
Prognosis is usually good. 
Scarlet fever: A contagious disease characterized 
by sore throat and a scarlet eruption. The discharges 
from the throat and nose seem to be the source of in- 
fection. 
Incubation—Seven days. No symptoms are present. 
Invasion—l 2-48 hours. There is fever with chills, 
vomiting, sore throat, headache, prostration and some- 
times convulsions, delirium and stupor. The symp- CLINICAL PEDIATRICS 
Toms vary in intensity. They may be very severe or 
very mild. 
Tongue—There is swelling of the papillae (straw- 
berry tongue). This may not be apparent till the dis- 
ease is well developed. 
Throat—Angry red appearance; usually tonsillitis 
present; sometimes streptococcus diphtheria, rarely 
diphtheria. 
The eruption appears with the temperature rising. 
It appears in the form of minute red points. These 
become very numerous and confluent. The eruption 
appears first on the neck and shoulders and extends 
down the trunk and extremities. It reaches its full de- 
velopment in from one to four days, when the skin is 
uniformly red and swollen, and tense. 
The regular cases are easily recognized, but atypical 
cases are frequently a source of doubt. Thus the erup- 
tion may appear in one part of the body and never 
extend. The eruption may be only a few hours in 
duration and may never be seen. 
The duration of the regular eruption is 3-10 days. 
As the eruption disappears desquamation begins, 
and may last three to eight weeks. Desquamation 
may be delayed until the end of third week. 
Cases where no eruption was seen are first recog- 
nized when desquamation begins, unless suspected by 
the appearance of the tongue and throat or kidney 
complication. 
Atypical cases: 
1. Regular course, except for the temperature, 
which instead of subsiding on the seventh day, con- 
tinues one or two weeks longer. COMMUNICABLE DISEASES 
181 
2, Mild, scanty and short-lived eruption, but with 
desquamation and tendency to complications. 
3. Regular course, except that the eruption is ir- 
regular in appearance, duration and extent. 
4. The only symptoms seem to be fever, sore throat 
and desquamation. 
5. Severe and prolonged cases, lasting two to three 
weeks, with no complications, sometimes cause death. 
6. Malignant cases. Patient seems to be suffering 
from the intense poison of the disease; the eruption is 
irregular and dark, sometimes petechial. The temper- 
ature is high or sometimes subnormal. The throat is 
dark red, ulcerated, or membranous; foul breath, cer- 
vical glands are very much enlarged. The tongue is 
thickly coated and later dry and brown. The eyes are 
congested. Cerebral symptoms are marked. There is 
hemorrhage from the mucous membranes, vomiting, 
diarrhoea and feeble heart action. 
Death is the inevitable outcome and occurs in eight 
hours to two days, with the child in a state of coma. 
7. Associated with diphtheria. 
8. Instead of a catarrhal inflammation of the tonsils 
and pharynx, we get a streptococcus inflammation. 
This may vary in intensity. In bad cases the cervical 
glands are very much enlarged, the throat becoming 
necrotic during the second week of scarlet fever; there 
is a yellow and bloody discharge from the mouth and 
nose, unhealthy fissures form at the edges of the nose 
and corners of the mouth. Lymphatic glands of the 
neck may become necrotic with ulceration of the skin, 
sometimes causing erosion of the large bloodvessels 
with formation of septic thrombi. This is usually fol- 
lowed by pyemic infection, involving joints and serous 182 
CLINICAL PEDIATRICS 
cavities. The temperature is very high. There is a 
rapid loss of weight. Death occurs in three to five 
weeks. 
9. Otitis media is a frequent complication and may 
come on with symptoms simulating meningitis, which 
continue until the drum ruptures. 
10. Cervical adenitis, which suppurates during the 
second week, is a prominent symptom. 
11. Endocarditis or pericarditis may develop at any 
time during the disease. 
12. Inflammation of the joints and muscles occurs 
as the eruption is subsiding. Hands and feet and 
muscles of the neck may be affected. There is usually 
some rise in temperature. 
13. Nephritis is a frequent complication. 
A. Acute degeneration—mild during the first or 
second week. 
B. Acute exudative nephritis—During the second 
week or third week. 
The urine is scanty or suppressed, specific gravity 
is unchanged, albumen is present in large quantity, 
also casts and blood. The temperature runs up to 
105°, with prostration, headache, nausea and vomiting, 
as well as dropsy. In some cases there is contraction 
of the arteries, disturbance of heart action, convulsions, 
delirium and stupor. 
In most cases recovery follows after four weeks. 
Some cases are fatal. 
C. Acute diffuse nephritis—This form belongs to the 
third week or the period of convalescence. It may be 
acute or subacute. 
The urine is diminished in quantity and contains a COMMUNICABLE DISEASES 
183 
great deal of albumen and very many casts, but no 
blood. There is no fever and anaemia and dropsy de- 
velop gradually. 
In all cases of acute diffuse nephritis the disease is 
apt to continue rapidly, or slowly, or at intervals, until 
the patient dies, or develops chronic nephritis. 
14. General oedema without nephritis may develop 
during the third week. 
15. Meningitis, pleurisy, bronchopneumonia and 
peritonitis are comparatively rare complications. 
Myocarditis and multiple neuritis are sometimes en- 
countered. 
In mild cases convalescence is prompt. The child 
often appears well before the end of the first week. 
Later, the only evidence of the disease is the desqua- 
mation, particularly on the palms of the hands or soles 
of the feet. In bad cases and those with complications 
convalescence is slow, and may leave the child weak 
and anaemic for weeks and months. 
Treatment is symptomatic. It is safest to have the 
child remain in bed for at least 3 weeks, even though 
no complication may appear and the patient seems 
well. Keep the patient on a milk diet. For the throat 
condition give a Solution of Carbolic acid, 5i q. 
2h. After the third week if no contraindications pre- 
sent themselves, a daily warm bath will soften the skin 
and hasten desquamation. The diet, providing that 
the examination of the urine is negative, should be 
unrestricted. 
German measles (Rubella) : A mild contagious dis- 
ease. The contagion is not easily disseminated and 184 
CLINICAL PEDIATRICS 
it is short lived. The source of contagion is not defi- 
nitely known, but is probably the nose, throat and 
eyes. 
Incubation—14 to 21 days. No symptoms. 
Invasion. Sometimes there are no symptoms. We 
may have fever, headache, convulsions, vomiting, con- 
junctivitis, pharyngitis, laryngitis. There is a swell- 
ing of the cervical glands, particularly the posterior 
chain. 
The symptoms are usually very mild. 
Eruption: Very often it is the first sign of the dis- 
ease. It appears first on the forehead and temples and 
extends rapidly downward. It is in the form of pink- 
ish points, which may form blotches very much like 
those of true measles; or they may become confluent 
and look somewhat like scarlet. In some cases the 
macules become papular, or even vesicular and pustu- 
lar. The eruption is also seen in the mouth in the form 
of small red points, not surmounted by a gray spot, as 
in true measles. The duration of the eruption is one 
to seven days. In its progress down the body it often 
fades in one region before it appears in another. 
There is usually no desquamation following the erup- 
tion. 
During the period of eruption there is usually some 
rise in temperature, a coated tongue, conjunctivitis, 
pharyngitis, swelling of the glands in the posterior cer- 
vical and other regions. 
Other possible complications are: Synovitis of the 
small joints, inflammation of the muscles of the neck, 
bronchitis and bronchopneumonia. 
The cases rarely run a severe course. COMMUNICABLE DISEASES 
185 
Variola (small-pox) ; A very contagious exanthe- 
matous disease. 
The contagion is carried by direct contact, clothing; 
also in the nose and throat of healthy carriers. 
One attack protects against subsequent attacks. 
Incubation—lo-15 days. No symptoms or slight 
general malaise. 
Invasion—2-4 days. Chills, with rapid rise in tem- 
perature (103-107°). The pulse is rapid and full, 
breathing is rapid; there is vomiting and prostration, 
the tongue is coated, there may be convulsions and 
delirium. Severe pains in the head and back are char- 
acteristic. The mucous membranes are congested. 
Death may occur during this period. 
During invasion, we may have the appearance of 
a variolous rash, which is not the eruption proper. 
This may be in the form of points or streaks or 
blotches, which are red, purple or brownish red. Over 
these, there may be scattered purpuric or urticarial 
spots. This eruption may disappear in one spot and 
appear in another. 
Eruption: It first appears on the face and scalp 
and then extends to other parts of the body and to 
the mucous membranes. 
At first there is an appearance of macular spots, 
which on the second day become papular. On about 
the fourth day the papules become vesicular and on 
the eighth day they become pustular. The vesicles 
are umbilicated and the pustules are indurated. As 
the eruption appears the symptoms of invasion sub- 
side. 
Simultaneously with the appearance of pustules the 
temperature rises, and we usually get prostration, de- 186 
CLINICAL PEDIATRICS 
lirium and stupor. The patient suffers a great deal 
from the inflamed condition of the skin and mucous 
membranes. This condition remains for three to eight 
days. 
The pustules may become confluent and symptoms 
are then more severe and prostration greater, with 
possible complications in the pericardium, lungs, 
pleura, gastrointestinal tract and kidneys. 
Malignant form may cause death in one to two 
days. It is characterized by a purplish hue of the 
skin, with purpuric papules, and hemorrhage from 
the mucous and serous membranes. The papules may 
be large and confluent, and later hemorrhagic. In 
other cases only a few vesicles appear, but there is 
extreme prostration, and the same disposition to bleed- 
ing. 
The malignant cases are usually fatal. 
The disposition to bleeding is sometimes found in 
ordinary cases. 
Vaccination will modify small-pox, making it 
milder. These mild cases are just as readily com- 
municable. 
Convalescence may be interrupted by boils; ery- 
sipelas, gangrene of the skin, laryngitis, pleurisy, 
pneumonia, myelitis, septicaemia, loss of sight, or 
hearing. 
Mortality depends on the severity of the case. The 
average case is not fatal. 
Treatment: Proper nursing and stimulation. Wet 
packs to the skin with boric acid solution or weak car- 
bolic acid solution or Liq. Aluminii Acet. The child 
may be immersed in a warm bath for a few hours 
every day. COMMUNICABLE DISEASES 
187 
Vaccination: Inoculation of cow-pox. This seems 
to give immunity for four or five years. If infection 
with smallpox takes place in spite of the vaccination, 
the disease runs a very mild course. 
A clean vaccination should not give any symptoms 
except a slight rise in temperature on the seventh or 
eighth day, sometimes associated with the appearance 
of a few vesicles about the vaccination, and perhaps a 
few on the body (vaccinia). Too much inflammation 
and induration following vaccination is the result of 
mixed infection. 
In instructing as to the care of the vaccination, ad- 
vise that the sleeve be lined with linen. The sleeve 
of the undershirt should be loose. 
The use of vaccination shields is injurious. 
Varicella, Chicken-pox: A mild contagious disease, 
usually confined to children. It is very rare in adults. 
It is moderately contagious, the contagion originating 
from the skin lesions. 
Incubation: Two weeks or longer. 
Invasion: About two days, with malaise and fever 
(101°). 
The eruption appears in the form of macules, which 
develop into papules and later vesicles. The vesicles 
are always found on the scalp and usually on the roof 
of the mouth, this being a diagnostic point, as the dis- 
ease may be confused with papular urticaria. 
The vesicles sometimes become pustular. At the 
end of a few days, the vesicles become dry and scab 
formation results. Scabs dropping oflf often leave a 
few scars, similar to those of small-pox. The skin 188 
CLINICAL PEDIATRICS 
usually becomes clear two or three weeks after the 
onset of the disease. 
Nephritis is a possible complication. 
The serum from the vesicles has been collected and 
used as vaccine for prophylactic injection to prevent 
the spread of the disease in institutions. Reports as 
to the success of this measure are favorable. 
Streptococcus diphtheria: This is membranous in- 
flammation of the nose, throat, or larynx most fre- 
quently associated with scarlet fever and measles. 
It is of common occurrence in asylums and institu- 
tions, where there is a great deal of dust. 
Streptococcus is the offending organism. 
Symptoms: Nasal obstruction, pain on swallowing. 
If the membrane is in the larynx we get cough and 
stridor. There is usually a slight rise in the tempera- 
ture. There is no appearance of intense poisoning 
and the disease is not serious unless laryngitis or 
bronchopneumonia develops. Some cases are associ- 
ated with necrosis of the adjacent tissues, as we some- 
times find in bad cases of scarlet fever. Such patients 
become septic. 
Treatment: Frequent irrigation of the nose and 
throat with hydrogen peroxide, or weak bichloride so- 
lution. We may also give a 2% solution of carbolic 
acid, one teaspoonful swallowed every 2 hours. 
True diphtheria: A membranous inflammation of 
the pharynx, nose or larynx, caused by the infection 
with Klebs-Loeffler bacillus. The infection is carried 
by particles of the false membrane. The bacillus is 
not destroyed by drying and may float in the air. The 
patient’s breath is not infectious except when cough- COMMUNICABLE DISEASES 
189 
ing or sneezing. Children are more susceptible than 
adults. 
The bacillus disappears from the throat and nose 
about three weeks after the disappearance of the mem- 
brane, but it has been known to remain as long as 
nine weeks. 
We may also have healthy carriers who carry the 
germ in the throat without developing the disease. 
Bronchopneumonia is not an uncommon complica- 
tion. 
The cervical glands are enlarged. 
Nephritis is also a possible complication. This may 
be in the form of acute degeneration, acute exudative 
nephritis or diffuse nephritis. The nerves may become 
the seat of degeneration. 
Symptoms: Sore throat, nasal obstruction or laryn- 
geal stridor, depending on the location of the mem- 
brane. The mucous membrane is swollen and red and 
is covered by a dirty gray membrane, which cannot 
be brushed off without causing the surface to bleed. 
It usually appears on the tonsil at first in spots, 
which later become confluent, the membrane extend- 
ing beyond the tonsil. Sometimes the entire pharynx 
is covered. 
Sometimes there is only redness of the pharynx, and 
the membrane is limited to the larynx or the nasal 
cavity. 
Laryngeal diphtheria (croup) causes a gradually in- 
creasing stridor, with labored breathing, and retrac- 
tion of the supraclavicular spaces during inspiration. 
In bad cases there is marked cyanosis. 
The breath is foul, and there is difficulty in swallow- 
ing. 190 
CLINICAL PEDIATRICS 
Nasal diphtheria is frequently overlooked. This is 
due to the fact that the general condition remains 
good. Suspicion is aroused by the presence of a pro- 
fuse purulent and bloody discharge. 
Bronchopneumonia may develop on the fifth to the 
seventh day. It is usually fatal. 
Invasion of diphtheria may be sudden with chills, 
convulsions, sore throat and high temperature. Fever 
may be absent. The child looks pale and sick, with a 
temperature of 99-100°. 
Vomiting may be troublesome at any time of the 
disease. Diarrhoea is occasionally present. 
The heart action is rapid and we may get an attack 
of heart failure at any time of the disease or con- 
valescence, even as late as three or four weeks after 
the onset. The heart stops suddenly or may gradually 
fail. Kidneys may give symptoms in proportion to 
the intensity of the inflammation present. These may 
be nil or those of a severe nephritis. 
Course: 1. Malignant cases—A. Severe onset, 
glands swollen, severe inflammation of the mu- 
cous membrane with false membrane, stupor, 
delirium, death in three to five days. 
B. Invasion slow, skin pale and cool; dirty 
brown fluid exudes from the mouth and nose. 
The patient dies in collapse in three to four 
weeks. 
2. Ordinary cases. 
3. Very mild cases, but dangerous to the com- 
munity. 
4. At first mild, but suddenly becoming severe. 
These cases are sometimes serious. COMMUNICABLE DISEASES 
191 
5. Larynx first affected. Often fatal. 
6. Protracted cases. The membrane disappears, 
only to reappear again after a few days. Re- 
covery is the usual outcome. 
7. Cases look like a simple inflammation, but the 
bacteriological examination shows the presence 
of the Klebs-Loeffler bacillus. 
Convalescence is usually slow. Some children are 
apparently well after one week. We must always 
bear in mind the possibility of myocarditis. 
Sequelae: Multiple neuritis is frequent complica- 
tion. There is difficulty in swallowing, with regurgi- 
tation of food through the nose, nasal speech, brassy 
cough. 
The muscles of the arms, legs and back may be af- 
fected. 
The muscles of the eyes are frequently involved. 
Duration may be weeks or months. 
Myocarditis is a frequent cause of sudden heart 
failure. 
Chronic nephritis may follow acute diffuse nephritis. 
Treatment: Diphtheria antitoxin should be in- 
jected as early as possible. Large doses (10,000-20,000 
units) seem to give better results than smaller quan- 
tities. In bad cases it is advisable to repeat the dose 
in 12 hours. In some children the injection will be 
followed by symptoms of anaphylaxis, which may con- 
sist of fever, delirium, pains in the joints and the ap- 
pearance of an erythematous or urticarial rash. 
Locally, there seems to be nothing better than the 
internal administration of carbolic acid, 1-2% sol., one 
teaspoon every 2 hours. In cases of laryngeal diph- 192 
CLINICAL PEDIATRICS 
theria, where the symptoms are urgent, it may be nec- 
essary to do an intubation or tracheotomy, preferably 
the former. 
For the rest, careful nursing is most important. 
The heart action should be watched very closely. 
Even in mild cases it is advisable to keep the child 
quiet and resting in bed for at least three weeks. 
It is advisable to give a prophylactic dose of anti- 
toxin (500—1,000 units) to other children in the fam- 
ily, unless they give a negative Schick reaction. 
This reaction is positive only in children who are 
susceptible to diphtheria. 
Schick reaction: A needle (about the size of a 
hypodermic needle) is sterilized and dipped into stand- 
ard diphtheria antitoxin (100%) ; the point of the nee- 
dle is then forced into the skin intradermally (not 
subcutaneously) (Koplik method). The flexor surface 
of the forearm is used, and should be cleansed with 
ether, in preparation for the test. 
A positive reaction means the appearance of a red 
indurated papule (frequently surmounted by a vesicle) 
after a lapse of 24, 48, or 72 hours. 
Typhus fever: An infectious disease characterized 
by a typical eruption. The specific bacillus causing 
the disease has recently been identified by LI. Plotz. 
The infection seems to be carried by the body louse. 
The disease is rare in children under 12 years of age- 
Symptoms: First week—Sometimes the onset is 
preceded by a prodromal period with general malaise, 
headache, vertigo and loss of appetite. The invasion 
is usually sudden, with chills, fever, headache, loss 
of appetite, pains in the back and limbs, restlessness, COMMUNICABLE DISEASES 
193 
sleeplessness and prostration. Sometimes there is 
marked delirium (mania) and stupor. 
The eruption appears between the fourth and sev- 
enth days. It makes its appearance in one crop on the 
arms and legs and trunk. It is in the form of round 
pinkish blotches, somewhat resembling measles. These 
spots gradually become darker, or may be dark from 
the start. There is also a deep mottling of the skin, 
or general rash. After the eruption has disappeared 
there is more or less desquamation. 
Constipation is the rule, but sometimes there is diar- 
rhoea. 
Temperature rises rapidly, and reaches the highest 
point between the fourth and seventh day, which is 
104-106°. During the first week the temperature is 
continuous; during the second week it becomes re- 
mittent. In favorable cases the temperature drops 
suddenly at the end of the second week. 
The tongue is coated and moist at first; later it be- 
comes dry and brown. The pulse is about 100 at the 
onset; later it usually is rapid and feeble. It may 
be rapid and feeble throughout. 
Respiration is rapid. During the second week it 
may be rendered worse by the development of hypo- 
static congestion, or bronchopneumonia. 
Kidneys may develop degeneration or acute exuda- 
tive nephritis. 
During the second week the condition is marked by 
alternating delirium and stupor, typhoid state, feeble 
heart and sometimes coma vigil. 
In favorable cases, at the end of the second week 
the patient falls into a normal sleep, which is fol- 
lowed by recovery. 194 
CLINICAL PEDIATRICS 
Acute meningitis is a dangerous complication. 
There may be bleeding from the mucous mem- 
branes. Bleeding from the stomach is particularly 
dangerous. 
Thromboses often develop 
Prognosis is unfavorable. Brill’s disease, which 
has been identified with typhus fever, is a particularly 
mild form of the disease. 
Treatment is symptomatic. 
Typhoid fever: An infectious disease, characterized 
by the growth of specific bacteria, by fever, and the 
development of lesions in the lymph glands of the 
intestines and mesentery. 
Lesions are found in the Peyer’s patches, mesentric 
glands and the spleen. Ulceration of the Peyer’s 
patches may result in perforation and peritonitis. The 
liver usually shows some degeneration, or acute ex- 
udative nephritis; the heart, myocarditis; the lungs 
may show hypostatic congestion, or pneumonia; the 
pharynx and larynx, catarrh; the nervous system, 
neuritis and sometimes meningitis; the muscles, de- 
generation and sometimes rupture; the femoral veins 
and sinuses sometimes show thrombosis. Some of 
these inflammations are caused by the typhoid bacilli; 
others by other bacteria. 
The typhoid bacilli are found in the faeces, urine, 
blood. The excreta are therefore the source of in- 
fection. 
The infection is spread by infected water, milk, 
vegetables washed with infected water, oysters, etc. 
Symptoms: In infants the onset is sudden, with 
high temperature, which remains high during the first COMMUNICABLE DISEASES 
195 
week. During the second week the temperature be- 
comes remittent. The duration of the disease is us- 
ually two weeks. Together with the sudden onset, we 
also get an early blood reaction (Widal reaction), 
eruption and large spleen. The first week looks like 
the second week in adults. The blood count is char- 
acterized by hypoleucocytosis. 
In early childhood the symptoms of the first week 
last about three or four days. 
In later childhood the course is the same as in 
adults. 
The disease is as a rule not so severe in young chil- 
dren, the cases usually being mild. 
Temperature: First week—A gradual rise, a little 
higher in the evening. 
Second week—Continuously high. It may be re- 
mittent, or even higher in the morning. 
Third week—Remittent. 
Fourth week—A gradual decline in the temperature. 
Complications may change the course of the tem- 
perature. 
Hemorrhage from the bowel is usually followed by 
a drop in the temperature. 
In fatal cases the temperature may continue high 
until death. 
Pulse: During the first week the pulse is slower 
than would be expected according to the temperature. 
Later it may become feeble, dicrotic and intermittent. 
Cerebral symptoms: Severe headache and restless- 
ness belong to the first week; apathy to the second 
week; delirium and stupor to the third week. We 
may get delirium during the first few days. 
Eruption: Small, rose-colored lenticular spots, 196 
CLINICAL PEDIATRICS 
slightly elevated and disappearing on pressure. These 
are found on the front of the chest and abdomen and 
on the back. Usually only a few spots are found. 
The eruption appears between the seventh and tenth 
day; earlier in infants and young children. There 
may be successive crops. 
Duration of the eruption is 7-21 days. With each 
relapse we get a fresh crop. In some cases no erup- 
tion appears. 
Tongue: At first white and moist and coated in 
the center; later it becomes dry, brown and fissured. 
It may be red, glazed and fissured. 
Vomiting: Often present during the first week. 
Later it is caused by tympanitis or peritonitis. 
Tympanitis often present. Extreme distention in- 
terferes with the heart action. 
Diarrhoea is often present. The stools have a char- 
acteristic pea-soup appearance. Sometimes we get 
constipation instead of diarrhoea. 
Epistaxis may be an early symptom or it may 
appear late in the disease. Sometimes bleeding is 
excessive. 
Hemorrhage: Intestinal. Early in the disease it 
may be due to the extreme congestion of the mucous 
membrane. Later in the third week it is due to ul- 
ceration of the Peyer’s patches and may be excessive 
and fatal. 
Eyes; During the third week the eyes may be- 
come insensible, with dilated pupils. 
Ears: During the first week there may be ringing 
and buzzing in the ears. During the third week there 
may be deafness. 
Muscles: During the third week we often get sub- COMMUNICABLE DISEASES 
197 
sultus tendinnm, tremors, picking at the bedclothes. 
Urine; May contain albumen and casts, depending 
on the condition of the kidneys. 
Complications: Bronchitis, pyelitis, bronchopneu- 
monia, pharyngitis, laryngitis, suppurative infection 
of the parotids. During the third week, we may get 
thrombosis of the femoral veins, or cranial sinuses. 
This is accompanied, respectively, by pain and ten- 
derness of the vein, with oedema of the leg, or loss of 
consciousness and hemiplegia, depending on the loca- 
tion of the thrombus. The former may be followed 
by recovery, but the latter is invariably fatal. 
Perforation of the intestine; Shock, followed by 
symptoms of general peritonitis. Usually, the per- 
foration is most likely to occur during the third or 
fourth week, but may occur earlier or later. 
Peritonitis may occur without perforation, produced 
by inflammation of the mesenteric glands or infarcts 
of the spleen. It is invariably fatal. 
Relapses are very common. There may be two or 
three relapses. Each is accompanied by a fresh erup- 
tion and recurrence of the same symptoms that ac- 
companied the original attack. Relapses may last 
seven to thirty-five days. 
Treatment: Rest in bed; ice-coil to the abdomen. 
If the temperature runs above 103°, give cool sponge 
every three hours; for headache, ice-bag to the head; 
daily low saline enema. 
Diet: In young infants, milk in reduced quantity, 
bottle or breast, at intervals of four hours. 
In older infants, milk in reduced quantity, barley 
gruel, beef juice, puree of potatoes, the yolk of an egg. 
In older children, we may give small quantities of 198 
CLINICAL PEDIATRICS 
milk, as large quantity may produce tympanitis. The 
diet may consist principally of barley gruel, with the 
juice of half a pound of steak, and the yolk of one 
egg. This may be repeated every four hours. The 
diet may be varied with potato soup, to which tomato 
may be added. 
For perforation, operate as soon as possible. 
For hemorrhage, ice bag to the abdomen and mor- 
phine hypodermatically. 
As a rule, we must not allow the patient to get out 
of bed until the temperature has been normal for a 
few days. 
All excreta should be disinfected with 5% sol. of 
carbolic acid. 
Linens should be boiled and dried in the sun. 
Drugs are of very little value in the treatment of 
typhoid fever. 
The heart action should be carefully watched and 
stimulants used as the occasion arises. Of these, 
camphor, caffeine, and digalen are most reliable. Al- 
coholic stimulants are also of great value. 
High caloric feeding seems to be beneficial in some 
cases. 
Dysentery (colitis) : An inflammation of the lower 
bowel, caused by infection. The organisms princi- 
pally responsible for colitis are: streptococcus, Shiga, 
or Flexner bacillus, or amoeba coli, bacillus aerogenes 
capsulatus (gas bacillus). 
The disease varies in severity according to the in- 
tensity of the infection. It may be acute, subacute, or 
chronic. COMMUNICABLE DISEASES 
199 
The infection has its origin in contaminated water 
or food. 
Symptoms: Acute symptoms are fever, prostration, 
septic appearance, frequent small mucous and bloody 
stools. 
At the outset, we have vomiting, colicky pains, and 
tenesmus. 
There is a rapid loss of flesh. The outcome may be 
fatal in a few days, or the case may pass into the 
subacute stage. Later it may become chronic. In 
the chronic cases we find that the patients are anaemic, 
poorly nourished; there is a slight rise in temperature, 
the . appetite is poor and there are frequent mucous 
and sometimes bloody stools. 
The amoebic form is very rare. Abscess of the liver 
may be a complication of this form. Amoeba coli is 
found in the stool. It may be fatal in a few days or 
it may become chronic. 
Treatment: Administer a cathartic. Starve with 
only water for two or three days. Then add small 
quantities of food gradually. We give milk or barley 
water. It is advisable to avoid carbohydrate food 
in all cases, except those in which the Shiga, or Flex- 
ner bacillus are found. 
Irrigation of the bowel with warm saline solution, 
or silver nitrate 1-5000. Internally we may give Salol 
gr. 1-2 with Castor oil TUv-x, q. 3 Ir. 
In amoeba cases administer a large dose of ipecac. 
It should not be given in doses large enough to cause 
vomiting. Start with gr. i and increase every 2 hours 
by one or two grains until we reach ten grains. 
Instead of ipecac, we may use emetine, the active 
principle. It may be given in doses of %-i gr. a day. 200 
CLINICAL PEDIATRICS 
Influenza: Infectious disease caused by the pres- 
ence of the influenza bacillus (of Pfeiffer) in the body, 
which is usually associated with other bacteria. The 
onset is marked by headache, prostration, pains in the 
back and limbs, sometimes chills; also coryza and sore 
throat. It may be ushered in by vomiting. 
Examination of the patient usually discloses nothing 
but the temperature, coryza and redness about the 
pillars of the fauces. 
The attack varies in severity. The infection may 
find its way into the circulation and induce various 
complications. 
If the temperature persists in spite of treatment, it 
usually means the development of some complication. 
Complications: Bronchitis, bronchopneumonia, 
tonsillitis, otitis, sinusitis, adenitis, meningitis, pyelitis, 
nephritis, gastroenteritis, neuritis. A prolonged ca- 
tarrhal condition following an acute attack usually 
means influenza. 
Treatment: Phenacetin 
Aspirin aa gr. i-ii 
Sacchar. lactis gr. v 
Misse Ft pulv. D. T. D. No XV 
Sig. One q. 2 h. 
Also give cathartic; Calomel in small divided 
doses, followed by a saline seems to be the best. 
The improvement is usually very prompt. 
Continue the powders for two to four days, grad- 
ually lengthening the interval between the doses. 
Temperature remains normal, unless some compli- 
cation develops. 
Instead of the powders, we may use 1-5% sol. of COMMUNICABLE DISEASES 
201 
carbolic acid for children from 1-5 years of age. The 
dose is one teaspoonful every two to three hours. The 
danger to the kidneys is very slight, not great, as is 
generally believed. 
Whooping cough: An infectious disease character- 
ized by inflammation of the respiratory tract and 
paroxysmal cough. The inflammation is caused by 
the presence of a specific bacillus (Bordet-Gengou). 
There is catarrhal inflammation of the nose, larynx, 
trachea. Sometimes bronchopneumonia develops. 
The infection is carried from one child to another by 
means of droplets of sputum, created by coughing. 
One attack protects against subsequent infection. In- 
cubation is two weeks. The invasion is marked by 
a catarrhal condition of respiratory tract for two 
weeks before the paroxysmal cough begins. The par- 
oxysm consists of a succession of short coughs, last- 
ing one to five minutes, followed by a long stridulous 
inspiration. Frequently the child vomits before the 
inspiration. 
The characteristic whoop may not always be pres- 
ent. At the end of each spasm the patient becomes 
cyanotic. When the attacks of coughing are frequent, 
the child may vomit all its food, inanition resulting. 
The worst cases are those complicated by broncho- 
pneumonia. Cases vary in severity. Some are very 
mild, with hardly any catarrhal symptoms. In bad 
cases we often find subconjunctival hemorrhage, or 
petechial spots about the neck. 
A severe paroxysm may cause cerebral hemorrhage 
or interstitial emphysema. A sublingual ulcer of the 
frenum is frequently found. CLINICAL PEDIATRICS 
202 
Treatment: Plenty of fresh air. The paroxysms 
recur less frequently in the open air. Of drugs, none 
have been satisfactory. Antipyrine reduces the num- 
ber of attacks. We may give gr. i-v t. i. d.; also bella- 
donna in gradually increasing doses. Vaccine made 
from the Bordet bacillus has been successful in the 
hands of some investigators in shortening the course 
of the disease. When vomiting is excessive, we should 
advise feeding in very small quantities frequently 
repeated. 
Parotitis (mumps) : An infectious disease, charac- 
terized by constitutional symptoms and inflammation 
of the salivary glands, particularly the parotid gland. 
Incubation: 14-21 days. 
Symptoms; Fever, pain and swelling in the region 
of the parotid gland. The normal depression behind 
the inferior maxilla is obliterated, owing to the swell- 
ing of the parotid. We may have headache, nausea, 
restlessness and prostration. In the mouth we notice 
that the opening of Steno’s duct is surrounded by a 
red area a quarter of an inch in diameter. 
The inflammation reaches its height in three to six 
days, remains stationary for one or two days and then 
subsides. 
If only one parotid, or both simultaneously are in- 
volved, the duration of the disease is seven days. If 
the two glands are affected successively, the duration 
is ten days to two weeks. 
Complications: Metastatic involvement of the testes 
or mamma. 
Most of the cases run a mild course. We may, how- COMMUNICABLE DISEASES 
203 
ever, have excessive high temperature, feeble heart 
action, or delirium. 
Treatment: Isolation; wet dressing to the parotid. 
Malaria: An infectious disease due to the growth 
of the plasmodium in the blood. The infection is dis- 
seminated by a mosquito (Anopheles). The earliest 
form of the plasmodium is found soon after the chill. 
This appears in the shape of a small hyaline body 
lodged in the red blood cells, which stains with methy- 
lene blue. This gradually becomes larger, containing 
an increasing amount of pigment, until toward the 
end of 48 hours, when the body becomes segmented, 
and finally bursts into spores. This is simultaneous 
with the chill. This is the earliest and simplest form 
of plasmodium and is called the Tertian type. Double 
tertian constitutes the quotidian type. 
The quartan parasite is slower in development, the 
cycle extending over 72 hours. It is also characterized 
by the formation of fewer segments. 
The aestivo-autumnal parasite: The spore first ap- 
pears as a knob attached to the periphery of an ery- 
throcyte, lending it the appearance of a signet ring. 
After 24 hours, the organism disappears from the cir- 
culation, collecting principally in the spleen and the 
marrow of bones. After three or four days it appears 
again in the shape of a crescent, attached to the pe- 
riphery of a red blood cell. 
This form is apt to be resistant to treatment. 
The first two forms cause intermittent fever, the 
last form causes remittent fever. 
In the intermittent fever, each paroxysm consists of 
a chill, lasting ten minutes to two hours; fever, which 204 
CLINICAL PEDIATRICS 
rises in the course of the chill and remains rip for 
two to five hours; lastly, we get the stage of sweating, 
lasting two to four hours, in the course of which the 
temperature falls and all symptoms subside. In the 
course of the attack the patient suffers from head- 
ache, vertigo, nausea and vomiting; sometimes rest- 
lessness, delirium and apathy. Between the attacks, 
the patient appears normal. 
In the remittent fever, the invasion is marked by 
one or more chills. The temperature begins to rise 
during the chill. There is remission of the tempera- 
ture in the evening or in the morning. This fever 
lasts five to twenty-one days, terminating in recovery 
or death, or is followed by the intermittent variety. 
Pernicious type: Very severe, associated with 
severe prostration; hemorrhage from the mucous mem- 
branes ; severe cerebral symptoms; marked gastroin- 
testinal symptoms; congestion of the lungs; hemoglo- 
binuria. 
Hemoglobinuria may occur in mild cases. 
Malarial cachexia: Severe anemia, with a large 
spleen, with asthenia, found in patients who have had 
repeated attacks of malaria. 
Treatment: Quinine Sulph. gr. i-v, according to 
age. This may be given in the form of powders, cap- 
sules, or best in solution in Syr. Yerba Santa arom. 
The dose may be given four times a day. 
Sometimes in young children we may use Euchinine 
in place of quinine. Arsenic is a valuable aid in 
chronic cases. 
Acute articular rheumatism (rheumatic fever) ;An 
infectious disease with predilection for tonsils, joints. COMMUNICABLE DISEASES 
205 
serous membranes, endocardium, pericardium and 
nervous system. 
We frequently find the following affections asso- 
ciated: Tonsillitis, arthritis, endocarditis, chorea. 
Tonsillitis is very often a forerunner of rheumatic 
arthritis. 
A mild form is of very common occurrence in chil- 
dren. 
It is most frequent between the ages of 6 and 14 
years and is more commonly found in females. 
At the onset there may be chills and fever, with 
pain in one or two of the joints. The inflammation 
may be very slight, so that the child may be able to 
walk about; or it may be so severe that the slightest 
motion may cause excruciating pain. 
It is best classified into mild and severe cases. 
Mild cases: Children usually give a history of sev- 
eral attacks of tonsillitis. They are thin and anaemic, 
and complain of pains in the joints. There is no 
swelling of the joints, and there is little limitation of 
motion. The temperature is about 99° or ioo°. The 
children may improve under treatment, or may de- 
velop a heart murmur, which is usually caused by an 
affection of the mitral valve. 
These children are never very sick, and with rest 
in bed and proper care the cardiac condition does not 
become serious, although a slight murmur often per- 
sists. 
Severe cases; There are severe constitutional symp- 
toms and much prostration. The joints are inflamed 
and swollen. Several joints may be affected. The 
temperature runs ioo° and 104°. In some cases we 
get hyperpyrexia. 206 
CLINICAL PEDIATRICS 
The heart usually becomes involved and also the 
pericardium. There is congestion of all the organs 
and general oedema. Congestion or degeneration of 
the kidneys, or various forms of nephritis may be 
complications. 
If the heart is not involved, the child may get well 
in one or two weeks. The usual course of the severe 
cases in children is to drag out for weeks and months 
with complications. 
The acute condition becomes subacute and chronic 
with exacerbations. Finally the endocarditis becomes 
quiescent, leaving the heart with damaged valves and 
compensatory hypertrophy. This condition is called 
chronic valvular disease. 
Treatment: Rest in bed and salicylates, of which 
aspirin and novaspirin are best preparations. We may 
give 2-5 gr. q. 30r4 h. If the joints are swollen and 
painful, we may apply ice-bags. 
Diet: During the acute stage the exclusive milk 
diet is best. 
Treatment of the heart condition is described under 
the head of endocarditis. 
Septic arthritis: Under this heading we may also 
mention scarlatinal and pneumococcic arthritis. 
The joint inflammation is a part of the general 
sepsis. 
Suppuration usually follows and the case requires 
surgical intervention. 
Syphilitic arthritis: The joint particularly prone 
to this form of inflammation is the knee. Both are 
generally involved. The joint is filled with serofibrin- 
ous fluid. COMMUNICABLE DISEASES 
207 
There are usually other signs of syphilis, such as 
keratitis. 
The condition is not very painful and there is no 
suppuration. 
Gonorrhoeal arthritis: It may affect one or more 
joints. The joints most frequently affected are the 
sternoclavicular, the ankle, the knee joint. Look for 
source of infection. It is a very painful condition. 
Treatment: Treat the original condition; rest in 
bed; at first ice; later heat and passive motion. 
Chronic arthritis: It may follow acute arthritis or 
may be primary. It is similar to the adult condition, 
and usually affects the small joints. There is gen- 
erally no heart lesion present. Autointoxication may 
be an etiological factor. Cases seem to improve with 
the use of Russian mineral oil. We may give one 
tablespoonful in the evening and one first thing in the 
morning. 
Still’s disease: There is a painless thickening and 
stiffening of the joints, with fever either continuous 
or periodical. The knee is first affected and then the 
wrists and the cervical portion of the vertebral col- 
umn. Gradually the ankles, elbow and fingers be- 
come affected. Together with this, the spleen and 
glands are enlarged. It seems to be a form of septic 
infection. 
The course of the disease is slow, continuous, or 
intermittent. It may extend over years. The prog- 
ress is more rapid in children than in adults. Death 
is the result of exhaustion, or secondary tuberculosis. 
Radiograph does not show change in the bones. SYPHILIS 
Hereditary syphilis: This form is usually found in 
children. The infection comes from either parent, or 
both. If only the father had the disease, the mother 
acquires it, although there may be no symptoms ex- 
cept a Wassermann positive reaction. Codes’ law of 
mother’s immunity no longer holds. 
If the mother acquires syphilis late in pregnancy, 
the baby is apparently immune while nursed by the 
mother (Profeta’s law). Here also the baby shows 
a positive Wassermann reaction, and therefore really 
has syphilis. Bacteriologically, the lesions are caused 
by the presence of Spirochseta pallida. 
Foetal syphilis: There is diffuse proliferation of 
cells in all the organs and at growing points of the 
bony system; also around small bloodvessels. This 
cell proliferation fills the connective tissue spaces and 
exerts pressure on the organ cells, causing atrophy. 
Groups of cell proliferation form syphilomata, not 
gummata, which belong to the tertiary stage. 
We do not get the characteristic secondary symp- 
toms, as the infection follows the foetal development. 
Death of the foetus usually takes place between the 
4th and 7th months. 
Syphilis in infancy: A. Cases carried over from 
foetal syphilis. 
B. Cases which seem normal at birth, and later 
get -symptoms. 
208 SYPHILIS 
209 
Eruption in these cases appears during the first 
three months, most frequently between the 2nd and 
6th week of life. 
Rhinitis usually appears at birth, even before the 
eruption. 
Rhinitis may be only hyperplastic, or it may be 
ulcerative with resulting saddle nose. 
The eruption is similar to that of the acquired form. 
The appearance of the eruption is not the first mani- 
festation of the disease, as it may have been present 
in the viscera, bones and nose. 
Skin lesions: Some of these lesions are found only 
in the congenital form. 
Pemphigus. 
Diffuse skin infiltration: The skin is yellowish, 
thick and cracked. Skin on the soles of the feet may 
be very smooth (no lines), cherry red or dark blue 
red. 
Scalp: Sebum forms rapidly and is darker in color 
than in simple seborrhoea. There is a copper-colored 
area between the crusts. The crusts come off with- 
out bleeding. • 
Paronychia is often present. 
Circumscribed lesions may be in the form of pem- 
phigus, or maculopapular syphilides. The latter are 
found most frequently on the flexor surfaces of the 
arms and in the crural region. Where the two gluteal 
sides touch they form the so-called condylomata. 
The favorite location of the maculopapular syphil- 
ides is on the forehead and scalp, where it has us- 
ually been preceded by the diffuse skin infiltration. 
In early congenital syphilis, the roseola of the ac- 
quired form is never found. 210 
CLINICAL PEDIATRICS 
Papulo-pustular eruption appears in bad cases. 
Ulceration is not uncommon in the crural region. 
Small papular syphilides may appear in recurrences 
during the second year. 
Lesions of the mucous membrane: The mucous 
membrane of the nose is most frequently involved. 
Sometimes the larynx is involved, causing aphonia. 
Peyer’s patches may be affected. 
Blood: There is a diminution of haemoglobin and 
erythrocytes. Nucleated red blood cells are found. 
There is also an increased number of leucocytes, espe- 
cially eosinophiles, and myelocytes. 
Bone lesions: Where bone forms cartilage, affection 
begins in intrauterine life; where bone forms in mem- 
branes, it begins after birth. 
Epiphyseal borders are affected (osteo-chondritis). 
There is a proliferation of the cartilage cells, necrotic 
processes, and pathological calcification and thick- 
ened periosteum. When cranial bones are affected, 
we get exostoses. 
The marrow at the cartilage borders is often re- 
placed by connective tissue. 
Phalanges are often’affected (Dactylitis). 
The affection is only in the bone and never affects 
the soft parts, and always begins in the proximal pha- 
langes. This gives the fingers a bottle-shaped appear- 
ance ; if the distal phalanges are also affected, the 
fingers assume the appearance of a ten-pin. (In tu- 
berculous dactylitis, the fingers are knob-shaped.) 
Dactylitis usually appears early in infancy. There 
is no pain or suppuration. 
Clinically, only those cases where there is involve- 
ment of the periosteum may be recognized, as the SYPHILIS 
211 
finer changes in the cartilage are disclosed only by 
a radiograph. 
Clinical changes consist of swelling of the epiphyses 
or middle of long bones. The elbow joint is fre- 
quently involved. The swollen portion is nearly al- 
ways tender. 
Associated with the joint affection, there may be 
some affection of the muscles, causing flaccid paraly- 
sis, with more or less pain. When the shoulder joint 
is affected, the condition is known as Parrot’s disease, 
or pseudoparalysis. In the lower extremities we may 
have myotonia, or spastic paralysis. The clinical signs 
of the affection are: swelling of the bones, restricted 
motion, swelling of the soft parts, separation of the 
epiphyses and crepitation. The paralyses are the 
result of muscle affection only. 
Skull changes—Four types: 
Rickets. 
Protuberance of the frontal and parietal emi- 
Periosteal swelling and rarefaction of bone (area§ 
nences. 
of wasting surrounded by thickened areas). 
Hydrocephalus. 
Liver affections: The liver is large. It will recede 
under treatment. 
Another form at birth is a large, hard liver with 
nodules, accompanied by icterus. 
Kidney: There is a congestion, simultaneous with 
the eruption. Later there may be an interstitial in- 
flammation with formation of connective tissue. 
Endarteritis: Often present in later infancy, affect- 
ing the cerebral vessels and causing encephalomalacia. 212 
CLINICAL PEDIATRICS 
Changes in the central nervous system; During the 
eruptive stage, or just at the end of it, we may get 
meningitis, serosa, external or internal. This may 
be acute or insidious. The arachnoid or choroid 
plexus may be involved, causing hydrocephalus. Hy- 
drocephalus is not as large as in other forms, owing to 
the hyperostosis. 
The condition improves with treatment. 
Lumbar puncture discloses high intraspinal pressure, 
with clear fluid. 
Sometimes hydrocephalus is present at birth. 
Ocular affections: Plastic iritis, choroiditis, and 
also diffuse optic neuritis, which may occur during 
the first few months. 
Keratitis belongs to late syphilis. 
Lymph nodes: All the glands in the body are en- 
larged. 
Syphilitic relapse in earliest childhood: This, as a 
rule, does not appear later than the fourth year. As 
the early symptoms of hereditary syphilis are in utero, 
most of the manifestation during infancy are really 
recurrences. There may be an eruption, but the older 
the child the less likely it is to have an eruption. The 
most common skin lesions between the ages of two 
and four years are condylomata in the ano-crural re- 
gion. There may be mucous patches in the throat 
and chorioretinitis up to the sixth year of life. 
We may have recurrences in the joints, liver (nodu- 
lar), spleen (large and hard, with anaemia). 
The larynx may be the seat of recurrences, causing 
croup and aphonia. 
The kidneys and testicles may be affected. SYPHILIS 
213 
Late hereditary syphilis: Eyes—Keratitis, chorio- 
retinitis, gumma of the iris, optic neuritis. 
Ears—Neuritis acoustica, with deafness (Meniere’s 
disease). 
Bones—Hyperplastic ostitis, or periostitis. The 
tibia is most frequently affected, and often becomes 
bent. 
Less frequently we get caries sicca of the cranial 
bones, causing a rough surface. 
Just as in acquired syphilis, we may get gummata 
of the tibia, which becomes soft and tender to touch 
in the centre. This results in excavated ulcer and 
later healing with raised edges. 
Other bones may be affected. Affection of the car- 
pus and phalanges may be present, but is not as char- 
acteristic as in early syphilis. 
Joints—Swelling may be caused by hydrops only, 
or the swelling of the bone ends. There is less pain 
than in tuberculous lesion, and there is no suppura- 
tion. 
Skin lesions: Similar to tertiary lesions of acquired 
syphilis. There are two main forms: the small nodu- 
lar and the large nodular syphilides. The small nodu- 
lar form is of the size of a pea to that of a lentil. It 
is hard and skin is brownish. At first the skin shows 
desquamation; later it becomes covered with a crust, 
simulating lupus vulgaris. The nodules usually show 
a serpigenous arrangement. It is a most intractable 
lesion. 
The large nodular form is simple subcutaneous gum- 
mata, which soften and ulcerate. 
The mucous membrane may show gummatous ul- 
ceration. 214 
CLINICAL PEDIATRICS 
Atrophic rhinopharyngitis and ozsena may be found 
between the ages of 6-15 years. 
Ulceration of the mucous membrane must be dis- 
tinguished from tuberculosis, in which condition the 
outline of the ulcers are ragged and very painful. 
Hutchinson’s teeth: This is an anomaly found in 
the upper central incisors of second dentition. The 
dentine is laid bare and there is a crescentic notch 
at the lower border. The teeth are short and stumpy. 
Treatment: For infants it is best to start with calo- 
mel 1/10 gr. t. i. d. After a few weeks we may give 
neosalvarsan gr. intravenously. After that con- 
tinue the mercury for at least a year. For the intra- 
venous it is necessary to expose the vein. 
In older children we may give the mercury in the 
form of intramuscular injections, which may be ad- 
ministered at intervals of ten days to one week. For 
this purpose we may use a 20% mixture of salicylate 
of mercury in albolene. 
The dose given is Rj-i gr., according to age. This 
may be continued for two years. After each lapse of 
six months we stop the injections for one month, 
during which time we give Pot. lodide. 
In older children it may be advisable to repeat the 
neosalvarsan three or four times at intervals of two 
weeks. 
I 
Skin lesions may be treated by the application of 
a 25% blue ointment, or 5% ammoniate of mercury 
ointment. 
After the treatment is completed, examine blood for 
Wassermann reaction. If the result is negative, stop 
treatment. Examine blood again after 4 months. TUBERCULOSIS 
Infection: A few hereditary cases have been re- 
ported, the infection taking place in utero. In the 
large percentage of cases the infection takes place 
during the first three years of life, after which it may 
remain dormant in some gland. About 75% of chil- 
dren under the age of 10 years will give a positive 
tuberculin reaction. 
Development of tuberculosis depends on weak power 
of resistance, due either to poor heredity or some ex- 
hausting disease. The dormant tuberculous focus be- 
comes active. 
The affections in order of frequency are: Tuber- 
culosis of the glands, bones and joints, acute miliary 
tuberculosis, tuberculous meningitis, tuberculosis of 
the lungs, larynx and pleura, tuberculous peritonitis. 
Diagnosis: Sometimes clinical and physical signs 
are so well defined that there is little difficulty in rec- 
ognizing the condition. In incipient cases and in 
those in which there is an element of doubt, the Von 
Pirquet cutaneous tuberculin test is of the greatest 
value as an aid in diagnosis. The method of pro- 
cedure is as follows: The flexor surface of the fore- 
arm is cleansed with ether; the Von Pirquet borer 
is sterilized by holding over a flame; the point of 
the borer is then applied to the skin of the forearm 
midway between the elbow and the wrist; one 
or two turns of the instrument will shave off the 
215 216 
CLINICAL PEDIATRICS 
epidermis; this is the control; the borer is then dipped 
in Koch’s old tuberculin, and the shaving process is 
repeated in two places, one on each side of the con- 
trol, iy2 inches away from it; the tuberculin is then 
allowed to dry. 
If active tuberculosis is present, we note in 24 hours 
the appearance of an area of redness Y\ inch in diam- 
eter around the point of scarification, with central in- 
duration. This becomes intensified during the next 
24 hours, and then gradually fades, disappearing after 
about 10 days, leaving a slight pigmentation of the 
skin. 
If the tuberculosis is not active, but dormant, the 
reaction is delayed and may not be well defined until 
48 hours after scarification have elapsed. Then it is 
only 54 inch in diameter, with slight induration. The 
reaction is the result of an attempt of the circulation 
to keep the tuberculin out by bringing antibodies to 
the surface. 
In the presence of very active and general tuber- 
culosis, no reaction takes place. This is due to the 
fact that all the antibodies have been used in fighting 
the disease and the blood cannot produce any more. 
Tuberculous adenitis: Cervical and mediastinal 
glands are most frequently affected. It is often a 
prominent factor of the symptom complex known as 
scrofula. Following infectious diseases, particularly 
whooping cough and measles, the mediastinal glands 
are often the seat of tuberculosis, with caseation fol- 
lowed by calcification. These glands often cause a 
reflex cough, with afternoon temperature and delay 
in convalescence. Pus may form and rupture into 
the bronchi, causing sudden death. TUBERCULOSIS 
217 
Cervical adenitis is a very common condition in 
children. 
The portal of entry for infection may be the throat, 
nose, ear, abrasions on face, scalp and mouth. 
The enlargement of the glands is slow and gradual 
and painless, with slight rise in temperature. 
One or all the glands in the neck may be involved. 
The glands are hard at first. From this point, with 
the improvement of the general condition, the tu- 
berculous process may recede, with encapsulation and 
calcification of the tuberculous foci. On the other 
hand, softening and caseation often results. The 
glands become adherent to the surrounding tissues 
and bloodvessels. This terminates in the formation 
of tuberculous pus. Fluctuation is present. The 
swelling gradually increases in size, the skin over it 
becomes thinner with bluish discoloration. The 
ultimate outcome is the development of a simis, which 
continues to discharge for an indefinite period. This 
usually becomes complicated by the invasion of pus- 
forming organisms. When healing finally takes place, 
the opening is replaced by a depressed scar. 
Bone and joint tuberculosis; The parts most fre- 
quently affected are; the phalanges, the hip joint, the 
spine; less frequently, the knee, elbow and ankle. 
Dactylitis: The distal phalanges are usually af- 
fected, thus differing from the syphilitic form, in 
which there is a predilection for the proximal phalan- 
ges. In the tuberculous variety, therefore, the fingers 
are knob-shaped. There is a rarefaction of the bone; 
the periosteum is not affected. This may be demon- 
strated by means of a radiograph. There may be case- 
ation of the bone, suppuration, and involvement of 218 
CLINICAL PEDIATRICS 
the soft parts. The condition is more painful than 
the syphilitic form. 
Coxitis (tuberculosis of the hip joint) : The usual 
history is that following some slight traumatism, the 
child becomes lame, and often complains of pain in 
the knee. Upon stripping the child, we note the fol- 
lowing: The patient seems to favor one leg; there 
is apparent lengthening of the leg on the affected side; 
the normal gluteal fold is either shorter than that on 
the normal side or completely effaced; there is atrophy 
of the thigh muscles on the diseased side (measure cir- 
cumference and compare with normal side) ; upon 
passive motion of the thigh, we note limitation of 
motion and rigidity; with the patient on his back, 
extension of the thigh causes arching of the lumbar 
region of the spine; any attempt to overcome the 
limitation of motion causes pain. In incipient cases 
the child frequently cries out at night. In advanced 
cases, walking and standing is very painful. In ad- 
vanced cases, there is actual shortening of the leg; the 
distance from the greater trochanter to the horizontal 
line, drawn at the level of the anterior superior spines 
(Bryant’s line) is short, as compared with the normal 
side. The bone lesion may be demonstrated by means 
of the X-ray, and it is usually found in head of the 
femur. As the disease progresses, there is caseation 
or softening of the bone. This results in the develop- 
ment of a cold abscess of varying size. A large abscess 
may open externally and result in the formation of 
a sinus. 
It is very important to recognize this disease early. 
It is often treated for rheumatism. When in doubt, 
apply the Von Pirquet test, and obtain a radiograph. TUBERCULOSIS 
219 
A non-tuberculous arthritis simulating tuberculous 
disease has been described (Taylor). The X-ray dis- 
closes no change in the bones. These cases usually 
get well after one year. 
Treatment: Immobilization, by means of ortho- 
pedic braces. Large cold abscess should be aspirated, 
with careful aseptic precautions. Attention should 
be given to the general condition. This means fresh 
air, good food, cod liver oil, etc. 
Pott’s disease (spondylitis) : Tuberculosis develops 
in the body of the vertebrae. The disease is common 
in scrofulous children and probably has its origin in 
some glandular tuberculous focus. 
Symptoms vary according to the location of the 
lesion. 
Cervical Pott’s: The neck is stiff and sometimes 
held to one side. There is pain, which radiates down 
the arms. Rigidity of the upper part of the spine 
makes the child look awkward. 
As the disease progresses, there is caseation of the 
vertebrae, with development of cold abscesses and an- 
gular curvature. The abscess usually extends to the 
retropharyngeal region and sometimes into the cra- 
nium, with serious results. It frequently finds its way 
to the side of the neck, and opens along the posterior 
border of the sterno-cleido-mastoid muscle. Pressure 
on the spinal cord will cause paralysis, which usually 
disappears with favorable progress of the disease. 
Dorsal Pott’s: The spine is rigid and over-erect; 
as the disease progresses, the shoulders appear too 
straight, and angular kyphosis develops. The child 
usually complains of pain in the region of the epi- 
gastrium and there may be a respiratory grunt. The CLINICAL PEDIATRICS 
220 
walk is characteristic. The child walks as if he were 
stepping on ice. Any jarring of the spine is extremely 
panful. On examination, we note that the spine has 
lost its normal flexibility, and any attempt to overcome 
the rigidity is painful. Pressure over the spines of the 
affected vertebrae is painful. As the disease pro- 
gresses, there is a collapse of the diseased vertebrae 
with resulting angular curvature. An abscess forms 
and may burrow down along the psoas muscle and 
find its way out through the inguinal ring, the triangle 
of Petit above the crest of the ilium, or Scarpa’s tri- 
angle below Poupart’s ligament. The dorsal kyphosis 
is associated with a compensatory lordosis (concavity 
of the lumbar portion of the spine). Pressure mye- 
litis may develop, with resulting paralysis. 
Lumbar Pott’s: The symptoms are similar to those 
of dorsal disease. Pain is often referred to the hip 
and thigh, lower part of the abdomen and genitals. 
Sometimes there is a unilateral spasm of the psoas 
muscle, causing a limp. 
Diagnosis: We must bear in mind the following 
conditions; Rickets, rheumatoid arthritis, typhoid 
spine, fractures and dislocations,. congenital prom- 
inence of certain spinous processes, inflamed bursas 
over the spinous processes, perinephritis, appendicitis, 
sacroiliac disease, hernise, simple weakness, injury to 
the cord, tumors of the cord. 
In diagnosis, X-ray photograph and the Von Pir- 
quet tuberculin test will aid greatly. 
Treatment: Rest in bed; extension on a Bradford 
frame; plaster jacket with body in over-extended po- 
sition ; braces. For cervical Pott’s support by means TUBERCULOSIS 
221 
of a jury mast, which relieves the spine of the weight 
of the head. 
Abscesses may be left alone; may be aspirated; 
may be treated by the injection of iodoform emulsion; 
large abscesses may be drained by free incision, irri- 
gated and sutured, unless the infection is mixed, in 
which case they should be drained. Cases may re- 
cover after four or five years. 
Tuberculous affection of the joints are marked by 
slow progress, pain, swelling, rigidity, atrophy of the 
muscles. The tuberculous focus may be detected by 
means of the X-ray. The Von Pirquet test shows 
an active reaction. 
Treatment: Immobilization. 
Skin of tuberculous infants is often exceptionally 
dry. It may present tuberculous infection in the form 
of tuberculids. These appear like acne pustules, or 
furuncles, but more sluggish in progress and of a 
bluish tint. 
Acute miliary tuberculosis may develop from a 
tuberculous focus in the body. There is rapid ema- 
ciation, fever; later delirium, stupor, coma and death, 
which takes place in two or three weeks. 
Von Pirquet reaction is usually negative. 
Meningitis: May be only a part of general tubercu- 
losis, or the meninges may be infected per se. The 
symptoms are described under the head of menin- 
gitis. 
Tuberculosis of the lungs, pleura and larynx are not 
as common as in adults. The base of the lungs is 
often the seat of the disease, instead of the apex. In 
infants, the disease not uncommonly develops after 
a prolonged attack of whooping cough. In some cases 222 
CLINICAL PEDIATRICS 
mediastinal glands seem directly to infect the con- 
tiguous lung as evidenced by X-ray. 
The physical signs differ in no way from those of 
adults. 
Tuberculous peritonitis: Described under the head 
of peritonitis. 
Treatment of tuberculosis. We rely principally on 
fresh air and good food. In glandular affections tu- 
berculin treatment has met with some success. We 
may begin with one-millionth of a milligramme, in- 
creasing the dose very gradually, so that the twelfth 
dose should be 1/10,000 mgm. Doses may be given at 
weekly intervals, intravenously or subcutaneously. DISEASES OF THE NERVOUS SYSTEM 
Acephalia: Absence of the brain and spinal cord. 
Anencephalia: Absence of the brain : 
Porencephalia: This may be congenital or acquired. 
The brain substance may in some part be replaced 
by a cavity. 
Microcephaly: The origin of#this affection is ar- 
rested development (not premature ossification of the 
cranial bones, with closure of the fontanelles). The 
true form is simply arrested development. The pseu- 
doform is the result of intrauterine disease, resulting 
in degeneration, cicatrization, cyst formation and 
hydrocephalus. The pseudoform shows spasticity, or 
flaccid epilepsy, athetoid movements and 
pseudo-bulbar symptoms (dysphagia, etc.). 
Both forms show marked idiocy. 
The skull is brachiocephalic, the forehead receding; 
the occiput is flattened and the circumferential meas- 
urement is less than normal in. at birth). 
Hydrocephalus: This may be congenital or ac- 
quired ; external or internal; acute or chronic. 
Prognosis is bad. The body may develop normally. 
Congenital Hydrocephalus: Usually it is internal, 
but it may be external (intrauterine meningitis). The 
internal is probably caused by some inflammation 
causing a vascular disturbance, with excessive secre- 
tion from the choroid plexus of the brain. 
The quantity of fluid may be as much as five litres. 224 
CLINICAL PEDIATRICS 
The symptoms depend upon the amount of destruc- 
tion of brain tissue by pressure. The fontanelles are 
open, and the head is large. Intelligence may range 
from normal to imbecility. There is strabismus, spas- 
ticity, and paralysis. 
In favorable cases the child may grow up to be 
pretty nearly normal. 
Acquired external—Acute—'Meningitis, 
Chronic—Tumors and syphilis. 
Acquired internal—Acute—Meningitis. 
Chronic—Syphilis, trauma, tumors. 
Treatment: Potassium iodide. Lumbar puncture, 
repeated every two or three weeks, depending upon 
the rapidity of recurrence of intraspinal pressure. 
This has yielded some favorable results. 
If, owing to some inflammatory process, there is an 
obstruction of the foramen of Majendie, cutting off 
the communication between the ventricles and the 
subarachnoid space, lumbar puncture will be of no 
avail. We may then tap the ventricles, by puncturing 
through the anterior fontanelle. 
Operations have been devised for drainage of the 
ventricles into the venous sinus (cisterna magna). Re- 
sults from these have not as yet placed them beyond 
the stage of experimentation. 
Meningocele: N aso-f rental,—N aso-orbital,—Sagit- 
tal,—Occipital. This is a protrusion of a sac through a 
weak spot in the cranial suture. The wall of this 
sac consists of dura mater and meninges, and contains 
cerebrospinal fluid. The sac is covered with aponeu- 
rosis and skin. The chief characteristics are; Dis- 
appearance on pressure, increase in tension when the 
baby cries, and pulsation. DISEASES OF NERVOUS SYSTEM 
225 
Encephalocele: This condition is similar to the 
preceding, but the sac contains cerebral substance. It 
does not, therefore, disappear on pressure. 
Encephalo-cystocele: Much larger than the pre- 
ceding, and includes the ventricle. 
Spina Bifida: A defect in the bony arch results in 
the protrusion of some of the contents of the spinal 
canal. There are various degrees. 
Thus we may have: meningocele, myelocele, myelo- 
cystocele. 
Marked cases are accompanied by symptoms of 
myelitis, with club feet, bladder and rectal symptoms, 
etc. 
Spina bifida occulta; There is a defect in the ver- 
tebral arch, over which a small spherical protrusion 
is found. This has a central depression and is cov- 
ered with cicatricial tissue and sometimes hair. There 
is no paralysis, but we may have pes equinus and 
sensory disturbances. Bladder symptoms may ap- 
pear in later childhood, probably due to the formation 
of cicatricial bands in the course of the growth of the 
child, causing pressure on the cord. Removal of these 
bands is followed by recovery. ENDOGENOUS DISEASES OF THE NERVOUS 
SYSTEM 
They may appear after a few months or years of 
normal function. 
These may involve the spinal cord, nerves, muscles. 
It is evidently due to the fact that the nervous sys- 
tem becomes used up in a short time and has no power 
of regeneration. 
Endogenous conditions are hereditary and are not 
dependent on any inflammation. They are also not 
dependent on any outside or exogenous influence. 
A. Spastic family affection. 
1. Spinal. 
2. Cerebrospinal symptom complex. 
B. Hereditary Ataxia (Friedreich’s disease). 
C. Muscular atrophies. 
I. Spinal muscular atrophies. 
b. Early infantile spinal muscular atrophy. 
2. Neural form of progressive muscular atro- 
a. Cases in adults not occurring in families. 
3. Dystrophy of muscles. 
phy. 
D. Bulbar diseases. Progressive bulbar paralysis. 
Also: 
a. Myasthenia. 
b. Amaurotic family idiocy. 
c. Thomsen’s myotonia. 
d. Periodic paralysis of the extremities. A.—SPASTIC FAMILY AFFECTION 
i. Spinal symptom complex: Hereditary symp- 
toms do not always appear in childhood, but may 
make their appearance in mature age. 
The development is normal at first. Then pyram- 
idal tract sclerosis develops. This is followed by 
weakness of limbs, with dragging and awkwardness. 
Then gradually and slowly, spasticity, with pes equi- 
nus, develops. Arms rarely become involved. Blad- 
der and rectum remain normal. Reflexes are very 
much increased. Mental development is somewhat 
below par. The patients finally drag their feet with 
great difficulty, with the aid of a cane. The walk is 
spastic. They are rarely bedridden. Life is not short- 
ened. 
2. Cerebrospinal symptom complex (family spastic 
paralysis) : There are extensive segments of degen- 
eration in the pyramidal and lateral cerebellar tracts 
and posterior columns. 
Symptoms are variable. We have spasms of legs, 
which interfere with walking and result in contrac- 
tures. We may get nystagmus, slow speech, strabis- 
mus, optic atrophy, awkwardness of the hands, trem- 
ors, choreic and ataxic movements, intelligence af- 
fected, symptoms of bulbar paralysis (disturbance of 
deglutition or speech, forced laughter), weakness of 
sphincters. There may be also muscular atrophy and 
pseudohypertrophy. The progress of the disease is 
227 228 
CLINICAL PEDIATRICS 
very slow and does not materially interfere with the 
patient’s comfort. 
When the disease is fully developed and the patient 
is confined to bed, bedsores, cystitis and pneumonia 
are apt to become serious complications. The prog- 
ress of the disease may be arrested for weeks or 
months. B.—HEREDITARY ATAXIA (FRIEDREICH’S) 
There are two forms: 
a. The original Friedreich’s ataxia. The lesion is 
in the posterior column, and sometimes in the pyram- 
idal tracts. 
b. Cerebellar form. In addition to the posterior 
columns, the cerebellum is also involved. 
Symptoms of the first form appear during child-* 
hood; those of the latter form in later years (at 2Q 
years). 
In Friedreich’s ataxia, there is absence of patellar 
reflex, nystagmus, slow scanning speech, pes equinus, 
Argyle-Robertson pupil, the Romberg symptom, 
static ataxia, and sometimes choreic, or athetoid 
movements. In the cerebellar form there is more 
ataxia (cerebellar gait), reflexes are increased, and 
there is strabismus, optic atrophy, more tremor and 
wabbling of the body. 
Sensory symptoms are rare. Muscle sense is intact. 
Bladder and rectal symptoms are present only in 
advanced cases. 
The progress of the disease is very slow. It usually 
takes five to ten years. 
The patients remain bed-ridden only in the last 
stages. 
Death is generally the result of some intercurrent 
disease (frequently pneumonia). 
229 C.—MUSCULAR ATROPHIES 
i. Spinal muscular atrophy. 
a. The adult form, not occurring in families, and 
rare in children. The lesion is in the anterior horn 
of the cord (spinal nerve cells). There is atrophy in 
the thenar and hypothenar muscles, atrophy of mus- 
cles of the shoulder girdle. Paralysis is preceded by 
fibrillary twitchings. There is a reaction of degenera- 
tion (change in the electrical reaction, i. e., no response 
to the faradic current; with the galvanic current, there 
is a stronger reaction to the closure of the positive 
pole (anode), than the negative pole (kathode)). 
The progress of the disease is very slow, and 
takes years for full development. 
The Amyotrophic form also involves the pyramidal 
tracts, and therefore shows spasticity in the partially 
paralyzed muscles. The course is more rapid. Death 
is due to bulbar palsy (paralysis of the diaphragm), or 
some intercurrent disease. 
b. The infantile spinal atrophy. The lesion is in 
the anterior horn of the cord. Symptoms appear in 
the second half of the first year. This form is familial. 
There is weakness in the legs and back, shoulder, 
then the back of the neck, and finally hands and feet. 
Fibrillary twitchings are not constant. Reaction of 
degeneration is present. The course is one to four 
years. There is no chance of recovery. Death occurs 
as a result of bulbar palsy, or some intercurrent dis- 
ease. 
230 MUSCULAR ATROPHIES 
231 
2. The neural form of muscular atrophy (Peroneal 
Type) (Charcot-Marie-Tooth). There is degeneration 
of the nerves. Sometimes there is also some spinal 
degeneration. The peroneal group of muscles is us- 
ually affected, causing a drop foot, with high-stepping 
walk. The extensors of the hand may also be affected, 
causing the claw hand. We get fibrillary twitching: 
Reaction of degeneration is usually present, or there 
may be absence of any electrical reaction, faradic or 
galvanic. 
There may be pain and hypersesthesia, or absence of 
pain and tactile sense. 
Progress is very slow, and may be interrupted by 
remissions and exacerbations. 
3. Muscular Dystrophy: 
Juvenile form (Erb’s); It usually appears in late 
childhood, or puberty. It first affects the muscles of 
the shoulder girdle. There is true or false hypertrophy 
of the muscles, followed by degeneration. Later it 
affects the muscles of the pelvic girdle, and lastly the 
thigh and back, rarely the abdominal muscles. 
There is no fibrillary twitching or reaction of de- 
generation in any of the muscular dystrophies. 
Facio-scapulo-humeral form (Landouzy-Dejerine): 
The face assumes a mask-like appearance. The lips 
may be hypertrophied. Later the muscles of the shoul- 
der and arms may be affected. 
Hereditary form: Occurs in children 8-10 years of 
age. The muscles of the back are weak, causing lor- 
dosis. There is no hypertrophy. 
Pseudohypertrophy: The calves, shoulders, arms 
and back are affected. The child looks athletic; the 
muscles are weak. The child, to raise itself from a 232 
CLINICAL PEDIATRICS 
sitting posture, must climb up on its legs. It is diffi- 
cult for the patient to raise his arm. There is lordosis 
and a rocking walk. Reflexes are present, but weak. 
There is no reaction of degeneration. Mentally, the 
patients are below par. The disease progresses very 
slowly. D.—BULBAR DISEASES 
It usually occurs in brothers and sisters, appearing 
between the ages of six to ten years. 
I. Infantile progressive bulbar paralysis. 
There is disturbance of the muscles of deglutition 
and speech, as well as those of the face. Respira- 
tion is irregular. The outcome is fatal. 
It may involve all the ocular muscles, or individual 
muscles (usually levator palpebrarum and abducens). 
Life is not endangered. 
2. Progressive ophthalmoplegia. 
Myasthenia pseudoparalytica: This has not been 
seen in children, but in young individuals. The bulbar 
muscles, those of the face, back and extremities may 
be affected. The muscles are weak and not capable 
of more than three contractions in succession. The 
weakness of the muscles progresses and finally the 
patient dies in a manner similar to bulbar palsy. 
There is inanition, asphyxia, and entrance of food 
into the trachea. 
Amaurotic family idiocy (Tay-Sachs disease) ; In 
this condition there is rapid degeneration of nerve 
cells. It is most frequent in Russian Jewish children, 
but does not exclusively belong to that race. 
The onset of the disease is during the second half 
of the first year of life. The child progresses nor- 
mally during the first six months, then goes back. The 
233 234 
CLINICAL PEDIATRICS 
baby cannot bold up its head or sit up. Gradually 
the whole body becomes flaccid. The child becomes 
blind and idiotic. Later we get convulsions and spas- 
ticity. 
Duration of the disease is 18 months to two years. 
Death is usually from some intercurrent disease. 
The characteristic sign is on the retina. There is 
pale discoloration of the macula lutea, with a cherry 
red spot, corresponding to the fovea centralis. 
Myotonia congenita (Thomsen’s disease) : This is 
a congenital condition and more frequent in boys than 
girls. It first appears in the course of athletic work. 
It affects all the muscles, even those of the eye and 
speech. 
There is sudden contraction of the muscles, result- 
ing in a spastic state, which lasts a few seconds to 
half a minute, after which the contraction is normal 
and the intended act, whether brief or sustained, can 
be performed. Thus, when the patient shakes hands, 
he is unable to let go; when he takes a sudden step 
forward, he becomes rooted to the ground. There 
may be sluggish and awkward speech. 
Erb’s myotonic reaction: Tapping of the muscle 
brings out a swelling, with a central depression. A 
mild faradic current brings on a clonic contraction, 
which continues for some time after the cessation of 
the current. Sometimes there is reaction of degenera- 
tion. 
Treatment of endogenous diseases is hopeless. 
We may give massage, hydrotherapy and electricity. 
Syphilis of the nervous system: Any part of the 
nervous system may be affected. Thus we get a DISEASES OF THE NERVOUS SYSTEM 
235 
varied picture, which may resemble almost any form 
of nervous disease. Gumma of the brain may act like 
a tumor. We may get symptoms of multiple sclerosis, 
hydrocephalus, spastic paraplegia, imbecility, etc. The 
Wassermann and luetin tests are of great aid in diag- 
nosis. 
Treatment: Antisyphilitic. 
Tuberculosis of the nervous system: It may affect 
the meninges, or brain substance. Pressure caused 
by tuberculous spondylitis (Pott’s disease) will cause 
symptoms due to pressure on the cord. This is 
brought about by narrowing of the canal by displace- 
ment of the vertebrae, or abscess formation, thickening 
of the dura, etc. 
The symptoms depend on the location of the lesion. 
Cervical spondylitis results in paralysis and atrophy 
of the arms and spastic paresis of the lower extremi- 
ties. Dorso-lumbar spondylitis results in a lesion re- 
sembling transverse myelitis. There is spastic paraly- 
sis, bladder and rectum symptoms, bed sores. In bad 
cases we may have atrophic paralysis caused by actual 
destruction or degeneration of a section of the spinal 
cord. If the lesion is so high as to cause pressure on 
the medulla oblongata, we get symptoms of bulbar 
palsy. 
Prognosis is usually favorable and depends on the 
cure of the causative disease. 
Encephalitis: It may be congenital, infantile, or it 
may occur in older children (2-4 years). The congeni- 
tal form results in cerebral atrophy with hemiplegia, 
imbecility, etc. 236 
CLINICAL PEDIATRICS 
The infantile form is usually very severe and results 
in death in one or two weeks. 
In older children it varies in intensity and outcome. 
Prognosis as to life is usually favorable. 
It is of infectious origin and frequently follows 
measles, diphtheria, pertussis, or scarlet fever. It may 
be a phase of epidemic polio-myelo-encephalitis. 
The onset is sudden and resembles meningitis. 
Temperature is 104-s°. There may be convulsions 
and vomiting, which may be repeated, stupor, coma, 
opisthotonos, Kernig and Babinski sign, fontanelles 
somewhat bulging. After a few days paralysis de- 
velops, and frequently strabismus. The pulse is 
rapid. In severe cases there may be cardiac or res- 
piratory failure. In milder cases there is a sudden and 
unexpected recovery after a week or two. 
Lumbar puncture shows high intraspinal pressure, 
with fluid, which is clear, seemingly sterile, contain- 
ing globulin; microscopically lymphocytes are found. 
Results in cases which recover depend on the extent 
of the disease. Recovery is rarely complete. We 
may have hemiplegia, imbecility, localized palsies, 
strabismus, epilepsy. 
When the third ventricle is involved, the condition 
is called polioencephalitis superior. When the fourth 
ventricle is involved, it is called polioencephalitis in- 
ferior. 
Treatment: Ice-cap, bromides, etc. Later we may 
give iodides. 
Brain abscess: Traumatic. 
Otitic. DISEASES OF THE NERVOUS SYSTEM 
237 
Metastatic—multiple, following suppuration else- 
where, bronchiectasis, peritonitis. 
Infectious—following meningitis, influenza, typhoid. 
Idiopathic—Cause undiscoverable. 
There are three stages: (1) Initial, (2) well de- 
veloped, (3) terminal. 
Symptoms: 1. Initial stage—headache, vomiting, 
chills, fever. This stage lasts one to six days. This 
is usually followed by a latent period, when there are 
no symptoms present, with the exception of occasional 
attacks of headache, chills and fever. Optic neuritis 
may also be present. This period rarely extends 
longer than a few months. 
The second stage then develops. Headache, less 
severe, becomes then localized, sometimes corre- 
sponding to the location of the abscess. Temperature 
is normal, or subnormal. The pulse (irregular, some- 
times -rapid). Convulsions are more frequent in chil- 
dren. Respiration is irregular, sometimes Cheyne- 
Stokes. Vomiting and rigidity of the muscles of the 
back of the neck are more common in cerebellar ab- 
scess ; also unsteady gait, vertigo. Paralysis may de- 
velop, depending on the location of the abscess. 
Thus: In the temporal region—word-deafness 
In the left frontal—aphasia. 
Motor convolutions—hemiplegia, paraplegia, ocu- 
10-motor palsy, facial palsy, etc, 
Occipital lobe—blindness. 
Frontal lobe—psychic changes, loss of memory, in- 
ability to concentrate. 
The medulla and the pons varolii are very seldom 
the seat of the abscess. The abscess usually attains 
great size before the appearance of localized symptoms. CLINICAL PEDIATRICS 
Third stage: The patient sinks into a state of 
stupor and coma alternating with delirium. The ab- 
scess may rupture into the ventricles, causing sudden 
death or death in a few hours. Pus may find its way 
to the surface, causing meningitis. 
Sometimes brain symptoms may be absent and 
death occurs from pyemia and marasmus. 
Treatment: T. he only chance of recovery is the suc- 
cessful outcome of an operative procedure. This may 
be attempted if the abscess is localized and if it is not 
multiple. 
Sinus thrombosis: i. Marantic.—This is found in 
sick babies (endocarditis, prolonged gastroenteritis, 
tuberculosis, syphilis, etc.).- It is rarely recognized. 
Longitudinal sinus is usually affected. 
Symptoms are: Convulsions, somnolence, dilated 
pupils, strabismus. 
2. Secondary form (phlebitic).—Follows otitis 
media, erysipelas, suppuration of the orbit, etc. 
Symptoms are indefinite: Chills, intermittent fever, 
convulsions, eye symptoms, somnolence. The symp- 
toms are obscured by the original condition. When 
the thrombus extends into the jugular vein we may 
have pain on motion of the neck and upon swallowing; 
the vagus, glossopharyngeal and spinal accessory 
nerve (going through the jugular foramen) may be- 
come affected, causing bulbar symptoms. 
It is usually fatal. Early operation in cases affect- 
ing the lateral sinus will save 50%. 
Cavernous sinus thrombosis may be accompanied 
by the following symptoms: Swelling of the eyelids, 
inflammation of the orbital contents with disturbance DISEASES OF THE NERVOUS SYSTEM 
239 
of vision, tri-facial neuralgia. These symptoms may 
be masked by those of general pyemia. 
Poliomyelitis: A disease of infectious origin, show- 
ing predilection for the anterior horns of the cord. The 
specific germ has been found in the cerebrospinal 
fluid. It is so small that it passes through a Berke- 
feld filter. 
Cerebrospinal fluid injected into the cord of the 
monkey will produce symptoms of the disease. 
This disease, while showing predilection for the 
anterior horns of the cord, may affect other parts of 
the nervous system. Thus the disease may be located 
in the cerebrum, cerebellum medulla, sensory ganglia, 
and peripheral nerves. 
The usual onset is fever, anorexia, vomiting, rapidly 
followed by paralysis. Paralysis may come on over 
night, apparently without any initial symptoms. The 
onset may be very severe and may be ushered in by 
convulsions and meningeal symptoms resembling 
meningitis or encephalitis. 
Paralysis may continue to increase for two or three 
days, and then is followed by improvement, which 
varies with the amount of damage effected by the dis- 
ease. 
The distribution of the paralysis, in order of fre- 
quency, is as follows: Two legs, one leg, one arm, one 
leg and one arm (same side or opposite), one arm and 
two legs, muscles of the back, abdominal muscles, 
muscles of the face and neck. 
Paralysis is flaccid. Reflexes are diminished or 
absent. Sometimes reflexes may be present, depend- 
ing on the muscles affected. Reaction of degeneration 240 
CLINICAL PEDIATRICS 
is present. R. D. means failure to respond to the 
faradic current and the presence of a stronger reac- 
tion to the closure of the positive pole than that of the 
negative pole with the galvanic current. Muscles that 
show a normal electrical reaction after a few days will 
recover; muscles that do not improve after six months 
will remain paralyzed for life. 
Sometimes there is pain in the affected muscles at 
the onset. 
The skin of the affected limbs is cold. Joints sup- 
ported by the affected muscles are flail. 
There may be trophic disturbances and arrest of 
development, so that the affected extremity will be 
shorter than normal. When the muscles of the back 
are affected, we get lordosis. When the abdominal 
muscles are paralyzed there is protrusion of the ab- 
dominal walk. 
When the neck muscles are affected, the head drops. 
Bladder and rectum are rarely affected 
Treatment: Rest in bed; urotropin, bromides; 
later massage and electricity, potassium iodide and 
tonics. 
Contractures may be prevented by orthopedic ap- 
pliances. 
Permanent deformities may be dealt with by the 
orthopedic surgeon. 
Myelitis (Softening of the spinal cord): Causes: 
exposure to cold, infectious diseases. What may at 
first appear like myelitis may develop into poliomye- 
litis. 
Myelitis may be transverse or diffuse. DISEASES OF THE NERVOUS SYSTEM 
241 
It begins with high temperature, which may last 
a few days. 
There is paralysis of the muscles corresponding to 
the location of the lesion. Reflexes in these muscles 
are diminished or absent. 
Below the site of the lesion we get degeneration 
of the motor tracts, with corresponding paraplegia, 
and rigidity of the muscles. 
Reflexes of the rigid muscles are increased. 
There are areas of anaesthesia. 
There is also a loss of control of the bladder and 
rectum. 
Cystitis and bedsores are apt to develop. 
Landry’s paralysis (Acute ascending paralysis) : 
The lesions are those of fulminant ascending polio- 
myelitis, with corresponding ascending paralyses, end- 
ing in bulbar palsy in one to one and a half weeks. 
Sensory nerves, bladder and rectum are not affected. 
The disease may follow some infectious disease. 
It is a severe form of anterior poliomyelitis. 
Neoplasms of the central nervous system: More 
common in children than adults. 
The most common form is the tuberculous granu- 
loma. 
The symptoms may be divided into those which are 
caused by pressure, and those caused by the location 
of the tumor. 
Pressure symptoms are: headache, vomiting, ver- 
tigo, choked disk, convulsions, slowing of the pulse. 
Headache may be general or at the seat of the tumor. 
Sometimes pain may be elicited by percussion of the 242 
CLINICAL PEDIATRICS 
skull at the site of the tumor. Headache may be 
constant or intermittent. 
Variation of the intensity of the headache usually 
means a vascular tumor, such as glioma or sarcoma. 
Vomiting means tumor of the cerebellum, crura 
cerebri or base of the brain. This may be accom- 
panied by palsy of the ocular muscles and vomiting. 
Choked disk may not be present. It is most com- 
monly found in tumor of the cerebellum and the base 
of the brain. If the choked disk is unilateral the tumor 
is located on one side of the optic chiasma. 
Hemianopsia means disease of the chiasma. 
Convulsions are frequent at the onset of brain tu- 
berculosis in children. 
There may be hebetude and stupor. 
It may also be a late symptom of the same condi- 
tion. 
At first we get a slow pulse (irritation of the vagus). 
Later we get a rapid pulse (paralysis of the vagus). 
Focal symptoms: These depend on the location of 
the tumor, and are caused by the affection of the brain 
tissue or pressure. 
At first there are irritative symptoms, such as cho- 
reic and athetoid movements; later we get convul- 
sions and finally paralyses. 
Speech centre, motor area, etc., may be involved. 
Diagnosis : From infantile palsy by progress of the 
disease. 
From syphilis—Other symptoms of the disease, 
Wassermann and luetin reactions and treatment. 
Must also distinguish from encephalitis, meningitis 
and abscess of the brain. X-ray and lumbar puncture 
may aid in diagnosis. The latter may not always be DISEASES OF THE NERVOUS SYSTEM 
243 
safe, as removal of a large quantity of fluid may result 
in collapse of the brain. 
Cysticercus floating free in the ventricles will at 
first simulate hysteria or neurasthenia. 
Treatment: Symptomatic. Few cases are oper- 
able. Always try antisyphilitic treatment. 
Tumors of the spinal cord: Symptoms resemble 
myelitis and depend on the location of the tumor. 
Pain is a prominent symptom. 
Multiple sclerosis in children is either endogenous 
or the result of encephalomyelitis. 
Symptoms are paresis, tremors and paresis of the 
eye muscles. 
Cerebral hemorrhage: Causes: instrumental or de- 
layed delivery, whooping cough, purpura, diseases of 
the brain, particularly sinus thrombosis or trauma. 
Infantile paralysis: Terminal condition of various 
diseases of the brain, congenital or acquired thus: 
Symptoms: Microcephalus—General rigidity, idi- 
ocy, convulsions. 
Unilateral Porencephalus—Spasticity, hemiplegia, 
idiocy, convulsions. 
Bilateral Porencephalus—Bilateral hemiplegia, idi- 
ocy, convulsions, sometimes pseudobulbar palsy. 
Intrameningeal hemorrhage (Birth injury)—l. Gen- 
eral rigidity, with little or no dementia, convul- 
sions {Little’s symptom complex). 
2. Paraplegia, rigidity, without dementia or con 
vulsions. 
3. Simple hemiplegia, with feeble mind and 
spasms. 244 
CLINICAL PEDIATRICS 
4. Bilateral hemiplegia, feeble mind, spasms, pos- 
sibly pseudobulbar palsy. 
Premature birth (Intermeningeal hemorrhage) : 
Paraplegia rigidity, without dementia or convulsions. 
Head injury (Extrauterine, with hemorrhage or in- 
jury to the skull) : Hemiplegia, often with spasms and 
feeble mind. 
Inflammatory affection in one-half of cerebrum 
(Hemorrhage and softening); Hemiplegia, with 
hemiplegia and feeble mind, also post-hemiplegic mo- 
tor disturbances. 
Embolism: Hemiplegic convulsions and feeble 
mind. 
Inflammatory affection of both cerebral hemi- 
spheres : Bilateral hemiplegia, feeble mind and con- 
vulsions, possibly pseudobulbar palsy. 
Inflammatory affection in the region of basal gan- 
glia: Hemiplegia, possibly choreic palsy and athe- 
tosis. 
Inflammatory affection of the medulla; Paralysis 
of the ocular muscles and bulbar symptoms, without 
spasms or dementia. 
Facial palsy: 1. Rheumatic (Bell’s). Cases usually 
recover after a few months. 
2. Birth paralysis, due to pressure by forceps. Re- 
covery depends on the amount of injury. 
3, Secondary to ear disease. 
Multiple neuritis: Inflammatory disease of the 
peripheral nerves. The affection is usually symmet- 
rical and sometimes extends up to the anterior horns 
of the spinal cord. DISEASES OF THE NERVOUS SYSTEM 
245 
Causes: It may follow infectious diseases, such as 
diphtheria, scarlet fever, mumps, influenza, typhoid, 
beri-beri. 
It may also be caused by poisoning with alcohol, 
arsenic and lead. 
Sensory symptoms may or may not be present. 
These are: parsesthesise, hyperassthesise, anaesthesia, 
loss of muscular sense with ataxia. 
Motor symptoms: paresis or paralysis of muscles, 
symmetrically distributed. One group of muscles or 
several may be affected. 
Reaction of degeneration is present. Reflexes are 
absent. 
Bladder and rectum are not affected. There are no 
trophic disturbances. Course of the disease usually 
extends four weeks to several months. 
Diphtheritic paralysis may occur early, before the 
recovery from the disease or two or three weeks after 
apparent recovery. 
Prognosis is good. 
This form of paralysis seems to show predilection 
for the muscles of the palate and larynx, but other 
muscles may be affected, particularly those of the neck 
and back. The symptoms are; difficulty in swallow- 
ing, with regurgitation of food through the nose; na- 
sal voice, brassy cough, ocular palsy. There may be 
aspiration of food with secondary pneumonia. There 
is also danger of sudden heart failure. This may be 
•caused by myocarditis or affection of the nerve supply. 
Alcoholic paralysis is rare in children. The charac- 
teristic signs are: Drop foot, pain on pressure of 
muscles, ataxia. Prognosis is good upon withdraw- 
ing the cause and rest in bed. 246 
CLINICAL PEDIATRICS 
Lead palsy: Colic, anaemia, sometimes blue line on 
the gums, drop foot and wrist, dragging pains in the 
limbs. Remove the cause and give iodides. 
Arsenical poisoning: There are symptoms of poly- 
neuritis, little pain, sometimes trophic disturbances 
(hyperidrosis). 
Hemiatrophy of the face: This condition is prob- 
ably due to degeneration of the trigeminal nerve. 
Treatment: Subcutaneous injection of paraffine in 
order to make the face look more symmetrical. DISEASES OF THE MUSCULAR APPARATUS 
Congenital absence of muscles. 
Inflammation of muscles: Primary—Cause, un- 
known. Trichinosis. 
Acute myositis is milder in children than in adults. 
The onset is marked by fever, swelling of the face and 
body; the muscles are hard, doughy and painful. The 
patient is unable to move or swallow. The heart and 
respiratory muscles may become affected, ending in 
death. Recovery may follow after a few weeks, or 
the case may become chronic, with exacerbations. 
Trichinosis: The parasite enters the intestinal tract 
and then finds its way to the muscles by way of capil- 
laries. Once in the muscle, the parasites cause inflam- 
mation and become encapsulated. 
The clinical picture is the same as that of simple 
myositis. 
X-ray may show the encapsulated parasite. Em- 
bryos and eggs may be found in the faeces. The blood 
is characterized by the presence of a large percentage 
of eosinophiles. 
Frequently the encapsulated parasite becomes cal- 
cified and recovery follows. 
Ossifying myositis: Found principally in children. 
The cause is unknown. 
It begins with fever, pain and swelling of the 
247 248 
CLINICAL PEDIATRICS 
muscles, which become hard and remain so. Finally 
bony kernels form. The disease takes years. Prog- 
nosis is grave, as there may be interference with res- 
piration and swallowing. 
Treatment: Hot baths and potassium iodide. FUNCTIONAL DISEASES OF THE NERVOUS 
SYSTEM 
Spasmophilia: This is a condition marked by ex- 
treme irritability of the nervous system. This irrita- 
bility is found most frequently in children suffering 
from rickets. It is manifested by a tendency to de- 
velop : 
i. Convulsions 
2. Tetany 
3. Laryngismus stridulus. 
Convulsions may occur with slightest provocation, 
such as the mildest gastrointestinal disturbance or 
mild febrile condition. 
Tetany is characterized by a tonic contraction of 
the muscles of the upper extremity; the fingers are 
held together; the thumb turned into the palm. 
In laryngismus stridulus there is a sudden cessa- 
tion of respiration; the child turns pale and livid; 
after about a minute there is stridulous inspiration 
and the appearance of the child improves. 
True laryngismus is sometimes simulated by the 
cessation of respiration at the end of a crying spasm. 
This is often found in children with a bad temper. 
The presence of spasmophilia is characterized by the 
following signs: 
Trousseau’s sign; Pressure over the large nerve 
trunks of the arm produces tetanic contraction. 
249 250 
CLINICAL PEDIATRICS 
Chvostek’s sign: Tapping of the branches of the 
facial nerve (with the finger or rubber hammer) re- 
sults in contraction of corresponding facial muscles. 
Erb’s sign: The electrical irritability is very much 
increased. 
Thus; Normally it requires 1.4 milliamperes to pro- 
duce a contraction with the kathode (negative pole) 
on the make of the current; and 2.2 milliamperes with 
the anode (positiye pole). 
In spasmophilic infants only 0.7 milliamperes are re- 
quired for the kathode and 1.1 for the anode. 
Treatment: This requires careful attention to the 
underlying condition, rickets. 
For extreme cases it may be necessary to use bro- 
mides in the beginning. Careful attention to nutri- 
tion is most important. 
Nodding or rotating spasm (Spasmus Nutans, 
Spasmus Rotatorius) : The affection occurs between 
the third and eighteenth month. It seems to be the 
result of a functional affection of the spinal accessory 
nerve. There is an intermittent contraction of the 
sterno-cleido-mastoid muscle. If both sides are af- 
fected we get a nodding spasm; if only one side is af- 
fected we get a rotatory spasm. 
It is associated with nystagmus, unilateral or bilat- 
eral. Sometimes we also find a convergent stra- 
bismus. 
It usually lasts a few months. 
Nystagmus: There is an oscillatory movement of 
the pupil which may be horizontal or vertical. 
Causes: Errors of refraction, disease of the cho- 
roid or retina, hydrocephalus, insular sclerosis, tuber- 
culous meningitis and other diseases in which the eye- DISEASES OF NERVOUS SYSTEM 
251 
sight is impaired. It is found in almost any organic 
disease of the nervous system. In concussion of the 
brain it is transient. 
Only cases caused by some condition in the eye are 
amenable to treatment. Cases of transient nystagmus 
have been reported after diarrhoea, which disappear 
after irrigation. • 
Hiccough (Singultus): Causes: Full stomach, 
swallowing of air, indigestion, cold feet, chilling of 
the surface of the body after a bath, transferring the 
baby from a cold into a warm room. 
In older children it may be a neurotic condition. 
Treatment: Hold the baby up after a feeding to 
aid expulsion of air or gas in the stomach. Avoid 
chilling; hot water bag to the feet. 
In older children chloral and antipyrine may be 
used. 
Chorea minor: A disease of the nervous system 
which seems to be caused by the same infection which 
is the etiological factor in rheumatic fever. 
The affection is frequently associated with tonsilli- 
tis, acute rheumatic fever and endocarditis. It has 
been sometimes called cerebral rheumatism. 
Symptoms: In the ordinary mild cases the child is 
pale, ill-nourished, irritable, restless and fidgety, can- 
not sit still. We often note the change in tempera- 
ment and loss of power of concentration. 
The child may complain of pains in the joints or else 
there may be history of rheumatism. We also note 
that the child is inclined to drop things. There is 
twitching of the hands and face and later also the 
lower extremities. The child may sometimes show CLINICAL PEDIATRICS 
252 
a certain hesitancy of speech. Where speech muscles 
are markedly affected the speech is unintelligible. 
There may be a disturbance of respiratory muscles, 
causing a jerky respiratory movement. 
The following is a good method of evoking twitch- 
ing in incipient cases (Heiman) : Get hold of the 
child’s hands, palm to palm, grasping the patient’s 
thumb firmly between your index and middle fingers; 
then engage the child’s attention by asking a number 
of questions, thus checking cerebral inhibition and 
producing mental excitation. 
The Gordon reflex is sometimes present in severe 
cases. This differs from the normal knee reflex in that 
the reaction is prolonged and the leg remains in ex- 
tended position for a few seconds before dropping. 
In severe cases the twitchings are so pronounced 
that the whole body is involved in the contraction. 
The child is unable to lie still and it is frequently 
necessary to pad the bed to prevent injury. 
Sometimes only half the body is involved, consti- 
tuting hemichorea. Sometimes there is loss of power 
on one side of the body or in the muscles most af- 
fected and the case resembles hemiplegia or poliomye- 
litis. The average duration of the attack is eight to 
ten weeks, but it may extend over a period of six 
months. There is a tendency to recurrence. 
Chorea mollis: The limbs affected are limp. Cho- 
rea electrica: The contractions are short and light- 
ning-like. 
Treatment: Even in mild cases it is best to remove 
the children from school. When there are fever and 
rheumatism, put the patient to bed and give salicy- 
lates. All severe cases should remain in bed. DISEASES OF NERVOUS SYSTEM 
253 
Drugs are of little avail, but arsenic seems to have 
some influence on the disease. It should be given in 
ascending doses. 
Thus: Liq. Kali Arsenitis 
Aquse Menthi pip. aa§i 
Begin with I drop t, i. d.; then increase by one drop 
each day until 20 drops t. i. d. have been given; then 
gradually go down again, etc. 
Thus: 
1- 
1-1-2 
1-2-2 
2- 
2-2-3 
2- 
3- etc. 
In the course of administration of arsenic, it is best 
to examine the urine at regular intervals; a trace of 
albumen indicates the limit of tolerance. 
Epilepsy: Twelve per cent, of the cases occur 
during the first three years of life; 46% during the 
second decade. It seems to be more frequent in fe- 
males, but the difference is only slight. Heredity is 
an important factor. There is usually a history of 
some nervous trouble in the family. 
Infantile convulsions are a small factor in the eti- 
ology. 
When there is predisposition to epilepsy the followr- 
ing may act as exciting causes; Sudden fright, excite- 
ment, falls, blows on the head, heat stroke, phimosis, 254 
CLINICAL PEDIATRICS 
intestinal worms, adenoids, delayed menstruation, 
masturbation. Sometimes it appears after scarlet 
fever, measles or typhoid. It may also occur in syph- 
ilis, even without the presence of any lesions. Intes- 
tinal putrefaction, constipation and intestinal indiges- 
tion may be exciting causes. Epilepsy may be second- 
ary to brain tumors, sclerosis, abscess of the brain, etc. 
Always examine the urine for albumen to exclude 
uraemia. 
Symptoms: 
Grand mal—general convulsions. 
Petit mal—attacks of unconsciousness 
lasting a few seconds. 
Children are usually mentally defective. The ear- 
lier epilepsy begins the worse the child’s development. 
The course of the disease is irregular. At first the 
attacks come at long intervals; later they become more 
frequent. The usual interval is two to four weeks. 
The attacks may come on daily. Sometimes the at- 
tacks come on in the night, and may therefore be over- 
looked for a long time. 
General health is usually normal. 
Death rarely occurs, unless from fall during the at- 
tack. Death may occur from status epilepticus, when 
the seizures follow each other in close succession, 
temperature rising to 105-6° and the patient dying 
from exhaustion or in a state of coma. 
The nocturnal form may be recognized by the cry, 
biting of the tongue, blood on the pillow, spontaneous 
evacuation of the bladder and rectum, and headache 
in the morning. 
Petit mal must be watched sometimes for a long 
time. The characteristic point is the momentary loss DISEASES OF NERVOUS SYSTEM 
255 
of consciousness, mental confusion, pallor, fixed stare, 
and sometimes evacuation of the bladder. Usually it is 
shorter than the ordinary fainting spell. 
Epilepsy may be difficult to distinguish from sec- 
ondary epilepsy (Jacksonian). In the latter the con- 
vulsion may be only partial, or if later it becomes 
general it always begins in the same group of muscles 
or we get a history of localization. We may get signs 
of hemiplegia or increased reflexes on the affected side. 
When convulsions begin suddenly and are accompa- 
nied by vomiting and later followed by the develop- 
ment of optic neuritis, it usually means brain tumor. 
Prognosis: Depends on the severity of the case 
and frequency of the attacks. Petit mal may later 
develop into grand mal. Some cases seem to improve 
or even disappear under treatment. 
Treatment: Bromides, especially strontium bro- 
mide 5-30 gr. t. i. d. continued for two or three years. 
It is important to attend to the general condition 
and to remove all possible sources of irritation, such 
as constipation, indigestion, phimosis, adenoids, mas- 
turbation, etc. 
Neurasthenia: This condition may be briefly char- 
acterized as a state of increased irritability of the 
nervous system, with diminished resistance to fatigue. 
The principal causes are: poor heredity, usually asso- 
ciated with improper and harmful environment and 
poor training. This may mean that the child is al- 
lowed to take part in the amusements of adults or he 
may be allowed to study too hard or to read improper 
books or he may get insufficient sleep or he is sur- 
rounded by absence of harmony at home or he is al- 256 
CLINICAL PEDIATRICS 
lowed to partake of alcoholic beverage regularly. It 
may follow some severe illness or disturbance of nutri- 
tion. Sometimes children develop neurasthenia from 
over-energetic play, in which they are so interested, 
that they take no time to eat. These children are 
usually pale, cry and whine a great deal and suffer 
from frequent headaches. Whatever ailment the child 
may have is exaggerated. There is a tendency to ego- 
tism and hypochondriasis. 
Treatment: Try to find out the cause. 
The child should not be pampered and coaxed to eat 
when it has no desire for food. There is an inclina- 
tion for parents to punish children for not eating. A 
child suffering from anorexia cannot derive any bene- 
fit from food that is forced down the throat. It merely 
causes the child to associate food with something very 
disagreeable. 
Do not give the child any food, candy or fruit be- 
tween meals and allow the child to eat as little as it 
desires at meals, and he will soon begin to eat nor- 
mally. Do not cultivate the child’s palate. He should 
eat, not because he likes the taste of some article of 
diet, but because he is hungry and is appeasing his 
hunger. 
Sometimes these children require a rest cure. This 
means that they should not be allowed to run around, 
skate, etc., but should rest quietly most of the time, 
and should eat their meals slowly. School children 
should be kept at home for a few weeks, and should 
not be allowed to read. 
Sometimes it is wise to remove the child to a new 
environment, away from overanxious parents. DISEASES OF NERVOUS SYSTEM 
257 
Migraine: This is a condition, characterized by 
periodical attacks of severe headache, with vertigo, 
nausea and vomiting. It is rare in children. 
It is known to occur in children who are nervous 
by heredity. These children are “high strung” and 
sometimes possess unusual mental gifts. 
It is most frequent during the period of puberty. 
The pain is usually on one side of the head (hemi- 
crania). 
It may, however, affect the front or the back of 
the head. 
The pain is always associated with nausea and vom- 
iting, which is followed by sleep, after which the pa- 
tient awakens much relieved. 
This condition should not be confused with nervous 
headache, which some children get after too much ex- 
citement of any kind. 
Tic Convulsive: A rhythmical involuntary con- 
traction of a group of muscles. 
It may affect the muscles of the face or the shoulder. 
When it affects the respiratory muscles it is in the 
form of a sob or sigh or a peculiar dry laryngeal 
cough. It may last for months or years or may even 
be permanent. When patient is observed the twitch is 
increased in frequency and intensity. 
Treatment: A cure may be effected by transform- 
ing the involuntary contraction into a voluntary one. 
This is done by having the patient practice his own 
twitch in front of a mirror for an hour or two daily. 
Torticollis (Wry neck) : There is contraction of 
the sterno-cleido-mastoid muscle on one side. The 258 
CLINICAL PEDIATRICS 
muscles of the back, including the trapezius, may be 
affected. There may be a cicatricial contraction from 
burn. Sometimes it may be congenital, in which case 
it is due to malposition in utero. In the newborn there 
may be hsematoma of the sternomastoid. 
It may be caused by irritation of the spinal acces- 
sory nerve by an inflamed gland. 
It may be associated with sore throat, peritonsillar 
abscess, retropharyngeal abscess, Pott’s disease. 
Acute cases coming on suddenly are caused by ex- 
posure to cold (rheumatic). 
Malaria may be a cause, also chorea. 
Treatment: Salicylates, quinine, when malaria; or- 
thopedic head support. In bad chronic cases we may 
have to resort to tenotomy and myotomy. 
Masturbation: In very young children, even in in- 
fants, we sometimes find that, owing to some irrita- 
tion around the genital region, the child will acquire 
the habit of handling and scratching his genitals. This 
scratching will in time produce erection and evidently 
some pleasurable sensation. During the act the child’s 
body is sometimes seen extended and rigid. The ir- 
ritation may be due to lack of cleanliness, worms, ad- 
herent prepuce, etc. In treatment of these cases we 
first try to remove the cause. It may be necessary to 
tie the child s hands or attach some protective pad 
between his limbs. With repeated proper moral sua- 
sion, there is usually no difficulty in overcoming- the 
habit. 
Real masturbation, accompanied by sexual orgasm, 
is found in children as they approach puberty. It may 
begin accidentally when the child, while scratching his DISEASES OF NERVOUS SYSTEM 
259 
genitals, is surprised by the occurrence of a sexual 
orgasm; or it may come through the instruction of a 
playmate. 
Moderate masturbation does not do any harm. 
There is always danger of its becoming excessive, es- 
pecially in children of neurotic temperament. 
When masturbation is continued for a long time and 
is excessively indulged in, it will- cause symptoms of 
neurasthenia. 
Treatment should consist of proper and gentle 
moral instruction, and attempt to divert the child’s 
attention to out-door exercise and harmless amuse- 
ments. 
Greatest harm may result from frightening the child 
too much as to the consequences of his bad habit. 
The fear of these may remain impressed on his mind 
for the rest of his life and have a harmful psychic ef- 
fect. 
Hysteria: This condition is rarely seen before the 
age of seven years. 
Causes: Heredity (alcoholism, insanity, hysteria, 
anaemia or chlorosis in the parents), overpressure at 
school. It may follow infectious diseases, injury, 
fright, masturbation. 
Symptoms: Nervous irritability, laughing and cry- 
ing spells, fits of temper, capricious humor, night ter- 
rors, somnambulism, imitation of symptoms seen or 
read about. There is tendency to deception in most 
trivial matters, which may last for weeks. 
Sensory hyperaesthesia, which may be so great as 
to simulate inflammation. There may be pain in the 
back of the neck, tenderness of the scalp, neuralgias CLINICAL PEDIATRICS 
in various parts of the body. We may also get at- 
tacks of gastralgia with vomiting. There may be loss 
of hearing or sight (of short duration). There is 
usually anaesthesia of the pharynx and conjunctiva. 
Joint symptoms: These may simulate organic 
joint disease. 
Deformities are greater than would be expected. 
The onset is sudden. The contractures are very slight 
or very prominent. There is hypersensitiveness of the 
spine and lower extremities. Pain and deformity in- 
crease upon examination. Under anaesthesia, contrac- 
tures will disappear almost entirely. Other signs of 
hysteria are present. 
Motor and convulsive symptoms: There may be 
tonic and clonic contractions of many varieties; hic- 
cough, torticollis, hysterical cough, irregular respira- 
tion, vomiting, eructations, aphonia, local spasm of 
the face, mouth, eyes, dysphagia, hystero-epilepsy. 
There are areas which are painful and pressure may 
cause convulsions. Consciousness during convulsion 
is not fully lost and hallucinations are usually present. 
May terminate in wonderful recovery. 
Hysterical paralysis is not common, but may occur 
even in very young children as a result of some slight 
injury. 
We may have disorders of secretion of saliva and 
perspiration. We may also have polyuria and incon- 
tinence. 
General condition is usually poor. The children 
are generally anaemic, with poor digestion and capri- 
cious appetites. 
Prognosis is better than in adults. 
Treatment: Out-door exercise; nutritious diet; no DISEASES OF NERVOUS SYSTEM 
261 
school; attention to the bowels. The child is better off 
away from its mother and overindulgent friends. 
For joint trouble—Paquelin cautery, high fre- 
quency current, galvanism and hydrotherapy. 
For hystero-epilepsy—Cold douche, pressure on 
ovary or testicles. Other conditions may require 
moral treatment or psychoanalysis. 
Psychoses: Those found most frequently in chil- 
dren are defective psychoses. 
Congenital mental defects are more common than 
acquired dementia. 
Only dementia due to absence of thyroid secretion 
is amenable to treatment. There are degrees of men- 
tal defect. The worst cases may be classed as idiocy; 
the moderate cases as imbecility; whereas, those 
nearly normal may be called feeble-minded. 
These cases require special training and instruction. 
The worst cases are best cared for in some institution. MENINGITIS 
In connection with this disease there are a number 
of diagnostic signs, which it would be well to define. 
Tache cerebrale: Linear Scratches of the skin will 
after about one minute result in hypereemia of the 
scratch lines. 
Babinski sign: Irritation of the sole of the foot will 
result in extension of the large toe, the normal reflex 
being flexion. This sign is not reliable during the 
first year of life. 
Oppenheim sign: This sign is often found in con- 
nection with Babinski sign, the extension of the large 
toe resulting with pressure on the anterior group of 
muscles of the leg. 
Macewen sign: In the presence of intracranial 
pressure percussion of the skull gives a distinctly tym- 
panitic note. In normal infants percussion gives a 
slightly tympanitic note. We must, therefore, be care- 
ful in interpreting this sign in young infants. 
Kemig sign: In the presence of intracranial pres- 
sure the legs are held in position of flexion at the 
knee; with the thigh at right angles to the body, it will 
be found impossible to extend the legs. 
Brudzinski sign: Usually associated with the Ker- 
nig sign. When raising the head or the body, with 
patient lying on his back, the legs are involuntarily 
drawn up. 
Technique of lumbar puncture: The body is placed 
262 MENINGITIS 
263 
on a table on the side, with the back near the edge of 
the table. The body should he flexed and held in that 
position by an assistant. The Jumbo-sacral region of 
the back should be painted with Tr. lodine. Bichlo- 
ride towels should be laid all around the field of op- 
eration, as well as on the floor next to the table. 
A line tangent to the crests of the ilia will indicate 
the location of the space between the fourth and fifth 
lumbar spinous processes. This is the spot for the 
needle to enter. Now get a firm grip on the lumbar 
puncture needle, with the thumb, index and middle fin- 
gers, the handle of the stilet resting in the palm of the 
hand. Directing the point inward and slightly up- 
ward, push the needle in, with a sudden thrust, to the 
depth of inches. Withdraw the stilet, and if 
the fluid drips out attach the little tube, raising it up 
and holding it in a vertical position. To ascertain the 
amount of intraspinal pressure we measure the dis- 
tance between the level of the fluid in the tube and the 
needle. Normally the fluid does not rise higher than 
5 cm. above the needle. ■ When the cerebrospinal pres- 
sure is high we usually draw off about 30-50 cc. of the 
fluid. During the operation have the patient watched 
closely, as the withdrawal of fluid may sometimes be 
followed by collapse. 
If introducing serum (in the treatment of cerebro- 
spinal meningitis), the amount used must not exceed 
the amount withdrawn. The serum is introduced 
slowly by gravity. 
In doing tbe puncture we may accidentally injure 
a branch of the spinal venous plexus. This will result 
in the flow of bloody fluid or pure blood. If the flow 
does not clear after a half to one minute it will be 264 
CLINICAL PEDIATRICS 
necessary to withdraw the needle and puncture again 
in the space above. 
After the lumbar puncture it is well to have the 
child lying with its head low. 
Inflammation of the meninges may be classified 
according to the character of the infection. 
The following varieties are generally encountered 
in the order of their frequency: 
Tuberculous meningitis 
Meningococcus meningitis (sporadic) 
Pneumococcus meningitis 
Staphylococcus meningitis, also streptococcus 
Influenza meningitis. 
Of common occurrence are also conditions known 
as meningism and meningitis serosa, in which there is 
a congestion of the meninges, without the growth of 
any specific bacteria. This condition often marks the 
onset of some infectious disease, the cerebral symp- 
toms being more severe than usual. It is probably 
produced by the toxins of the disease. It has been 
contended that this condition may be an early and 
undeveloped stage of meningitis. 
Meningism: At the onset of infectious diseases, 
particularly scarlet fever or pneumonia, the cerebral 
symptoms may be so strongly suggestive of menin- 
gitis as to mask the underlying condition. After three 
or four days these symptoms disappear and the real 
condition is then easily recognized. To make an early 
diagnosis it is necessary to do a lumbar puncture and 
make a laboratory examination of the spinal fluid. 
The symptoms usually present are: Headache, rest- 
lessness, convulsions, delirium, rigidity of muscles of MENINGITIS 
265 
the back of the neck, contracted pupils; in infants, 
tense and slightly bulging fontanelles; Kernig sign. 
Lumbar puncture shows the presence of high in- 
traspinal pressure; the fluid is clear, sterile and does 
not show the presence of globulin or cytological 
changes. 
The withdrawal of spinal fluid relieves the menin- 
geal symptoms. 
Meningitis serosa is a condition similar to menin- 
gism and is found sometimes associated with purulent 
otitis media; also with syphilis. 
Tuberculous meningitis: Tuberculous meningitis 
is found most frequently during the spring months. 
Prevalence during this period is probably due to the 
fact that after the catarrhal diseases of the winter sea- 
son the children often develop tuberculous lymph 
nodes, which are the usual source of infection. As a 
general rule the human bacillus is the offending organism. 
The disease is not found in infants under three 
months of age. 
For some months before the onset of the disease 
the child’s condition seems to be below par. There is 
pallor, poor appetite, languor, headache and sometimes 
a slight rise in the afternoon temperature. 
The onset is usually slow. It may or may not be 
marked by convulsions. There is a slight rise in tem- 
perature, loss of appetite, apathy, tendency to som- 
nolence. Rigidity of the neck, Kernig, Babinski and 
Brudzinski signs gradually develop; there is also bulg- 
ing of the fontanelles, with a positive Macewen sign. 
Tache cerebrale is also present. The pulse is irregular 
and unstable. Hemiplegia may develop early or late 
in the disease. 266 
CLINICAL PEDIATRICS 
Ocular symptoms; At first the pupil is contracted, 
later the pupil is dilated, strabismus, fixed stare (ocu- 
lar catalepsy), with absence of conjunctival reflex. 
Ultimately the child drops into a state of coma with 
opisthotonos. 
In the very young symptoms of cerebral irritation 
may be absent and general flaccidity is observed. 
Duration of these cases is short. 
All cases show marked emaciation. 
Von Pirquet reaction is usually positive but may be 
negative in some cases. 
Lumbar puncture: High intraspinal pressure, clear 
fluid, contains globulin. Microscopical examination 
shows the presence of lymphocytes and tubercle ba- 
cilli. The latter are not easily found. 
The average duration of the disease is two and a half 
weeks. The course may be shorter or may last several 
weeks. 
Prognosis is very bad. A few seemingly authentic 
cases of recovery have been reported. 
Meningococcus meningitis: This form may be 
either epidemic or sporadic. 
There is an acute inflammation of the meninges, 
caused by the invasion of membranes by the diplococ- 
cus of Weichselbaum (Diplococcus intracellularis 
meningitidis). 
The point of entry of infection seems to be the con- 
junctiva and the nasal mucous membrane. 
Classification: i. Ordinary-acute, chronic. 
2. Malignant fulminating. 
3. Mild. 
4. Abortive. MENINGITIS 
267 
5. Intermittent. 
6. Posterior basic. 
The onset of the disease is generally sudden, with 
fever and sometimes chills, severe headache, pains in 
the limbs, projectile vomiting. 
The patient is somnolent and may develop delirium. 
There may be twitching of the muscles or general 
convulsions. There are some cases in which the onset 
is slow and intermittent. The pulse is rapid from the 
start and slows down only during the remissions of 
the temperature, thus differing from the pulse in tu- 
berculous meningitis. 
Soon rigidity of the neck develops, and the Kernig, 
Babinski, Oppenheim, Brudzinski signs may be elici- 
ted. The fontanelles become tense and bulging. The 
Macewen sign is positive. This sign is not of great 
value in very young infants, as normal babies often 
show a slightly positive Macewen. 
Hypersesthesia and hyperalgesia are regularly pres- 
ent. The child is irritable and any disturbance causes 
pain. Any attempt to raise the head is very painful. 
Hypersesthesia is often followed by numbness. 
Owing to the retraction of the head swallowing is 
very difficult. 
Instead of rigidity of the muscles we may get par- 
alyses either of the muscles of deglutition or of one or 
more of the extremities. 
Paralysis of the bladder and rectum occur quite fre- 
quently. 
The eyes may show conjunctivitis, keratitis, choroi- 
ditis. At first we get photophobia and contracted pu- CLINICAL PEDIATRICS 
pils; later dilated pupils, insensibility to light, and also 
strabismus and ptosis. 
Hearing is extremely acute during the onset, but 
later becomes dulled or lost. Sometimes otitis is pres- 
ent, which later may result in permanent deafness. 
Head symptoms, restlessness, sleeplessness, deli- 
rium, coma, may be present in varying degrees. 
Bowels are usually constipated, but later there may 
be diarrhoea with involuntary evacuations. 
The pulse in children is usually rapid, but may 
be slow at the start. The temperature is usually high, 
but sometimes the temperature is irregular and the 
patient may be doing badly with a temperature of 
only 990. In young children the temperature is high 
throughout the disease, but may drop just before 
death. 
Sometimes there is an inflammation of the joints. 
Some epidemics have been characterized by the ap- 
pearance of a petechial or ecchymotic eruption. 
Lumbar puncture: High intraspinal pressure; fluid 
is turbid; shows the presence of globulin, pus cells and 
meningococci, also lymphocytes. 
Sometimes lumbar puncture results in a dry tap. 
This is due to occlusion of the foramen of Majendie. 
It is necessary, then, to get the fluid by means of a 
ventricular puncture through the anterior fontanelle. 
This, naturally, is possible only in infants under the 
age of two years. A very early puncture may not 
show the presence of the meningococcus. 
Complications: Bronchitis, pneumonia, pleurisy, 
endocarditis, pericarditis, gastroenteritis, otitis. 
Complications may make the diagnosis difficult, par- MENINGITIS 
269 
ticularly in young infants, unless an early lumbar 
puncture is performed. 
Sequelae: Inflammation of the ependyma of the lat- 
eral ventricles will cause progressive emaciation, fever, 
alternating delirium and stupor. This condition may 
last several weeks and terminate fatally. 
Other possible sequelae are: hydrocephalus, blind- 
ness, deafness, aphasia, anaemia, hysteria, paralysis of 
several groups of muscles, chronic endocarditis. 
Course of the disease: This varies according to the 
severity of the disease, the age of the patient and the 
treatment followed. In infants, under the age of two 
years, and particularly during the first year of life, 
mortality is very high. It is most favorable in babies 
who receive injections of the Flexner serum early 
in the disease but, owing to the delicacy of structure 
of the nervous system in infants, even early treatment 
is often unsuccessful. It is not uncommon for babies 
to die 24 hours after the onset of the disease. 
The average duration of cases ending fatally is a 
week to ten days. 
Treatment: Perform a lumbar puncture as soon as 
possible. If the spinal fluid is cloudy or if the clinical 
picture suggests cerebrospinal meningitis, it is best to 
be prepared to inject the Flexner serum, immediately 
after the puncture, without waiting for the laboratory 
report. 20-30 cc. are used. Two or three injections 
may be given at intervals of 12 to 24 or 48 hours, ac- 
cording to the severity of the case and the effect of the 
treatment. The treatment otherwise consists of 
proper nursing and stimulation, as the case demands. 
Bromides and chloral may be used as sedatives. 
Pneumococcus meningitis: The onset is acute. 270 
CLINICAL PEDIATRICS 
There may be headache for two or three weeks before 
the onset and the development of meningeal symp- 
toms. 
It may be associated with lobar pneumonia. 
The outcome is almost invariably fatal in three or 
four days. 
Lumbar puncture: High intraspinal pressure, fluid 
turbid or purulent, contains globulin, pus cells, diplo- 
coccus lanceolatus. 
Sometimes the inflammation may be limited to the 
convexity of the cerebrum and the puncture will yield 
sterile fluid. 
The blood picture is characterized by a high leu- 
cocyte count. 
Staphylococcus and streptococcus meningitis: The 
disease is characterized by the presence of staphy- 
lococcus or streptococcus in the cerebrospinal fluid. 
It is otherwise similar to pneumococcus meningitis. 
Otitic meningitis: May follow mastoiditis and 
sinus thrombosis. 
Influenzal meningitis: The disease is usually asso- 
ciated with influenzal catarrhal conditions. Symptoms 
are very acute. It usually begins with marked consti- 
tutional symptoms, headache and convulsions. Pulse 
is rapid, temperature is high. There is rigidity of the 
neck, somnolence, delirium, stupor, coma. There may 
be vomiting and eye symptoms. 
Lumbar puncture: High intraspinal pressure, fluid 
cloudy with straw-colored sediment; microscopical ex- 
amination shows the presence of many polynuclears, 
and influenza bacilli (intracellular and extracellular). 
The usual duration of the disease is three to fourteen 
days. MENINGITIS 
271 
The outcome is fatal. 
The disease seems more frequent during the first 
year of life. 
Cases of meningitis caused by Bacillus Coli Com- 
munis, typhoid bacilli and other bacteria have been re- 
ported. DISEASES OF THE SKIN 
Intertrigo: This is an affection found in infants, 
involving the skin around the pubic and anal region, 
as well as the inner aspect of the upper part of the 
thighs. It is caused by uncleanliness and acid stools. 
The skin is uniformly red and inflamed. 
Treatment: Proper attention to infant feeding and 
gastrointestinal disturbance. Cleanliness and no de- 
lay in changing napkins. 
Locally we may use the following lotion 
Zinc. oxid. 
Glycerin aa3v 
Lac. Magnesia ad §iv 
This forms a white coating on the skin, which may 
be washed off with warm water. The lotion may be 
applied twice daily. 
Eczema: This disease is of common occurrence, 
particularly in infants and young children. 
It is caused by some nutritional disturbance. We 
find most frequently that the child is either overfed 
or is intolerant of some particular food. 
At the outset the disease is acute, or subacute. It 
may be followed by recovery after three or four weeks, 
or more frequently it passes into the chronic stage. 
The part most frequently affected is the face. The 
flexor surfaces of the extremities may be affected and 
sometimes some part of the trunk. 
272 DISEASES OF THE SKIN 
273 
At the outset there is a sensation of itching or burn- 
ing. This is followed by the appearance of redness of 
the skin. Upon this area small vesicles appear, which 
become numerous and which may coalesce. Soon the 
entire face, with the exception of the skin around the 
eyes and mouth, becomes covered with this eruption, 
and the skin looks inflamed. 
The vesicles burst and the serous discharge dries 
and forms crusts, and finally the entire face assumes a 
crusty appearance. Some vesicles may not open, par- 
ticularly near the edges of the area involved. These 
become pustular with surrounding infiltration. Itch- 
ing is severe. 
After a few days or weeks the discharge ceases, the 
subjective symptoms abate, the skin pales, scaling 
takes place, with gradual return to normal. The new 
skin retains a somewhat red and tender appearance for 
some time. In chronic cases we find, upon an erythem- 
atous, raw and weeping base, there is formation of 
crusts, which are composed of dried exudate of serum, 
pus, blood and epithelial debris. Later the inflam- 
matory condition subsides and the skin becomes thick- 
ened and scaly. 
Itching is intense and it is difficult to keep the child 
from scratching. No permanent scarring results. 
Treatment: Constitutional treatment consists of 
the administration of a cathartic and strict attention 
to proper feeding. In chronic cases by careful exclu- 
sion of certain foods we may be able to get at the cause 
of the persistence of the disease. 
Local treatment varies according to the stage of the 
disease. 
During the acute stage use the following lotion: 274 
CLINICAL PEDIATRICS 
Calamin Si 
Zinci Oxidi 3ii 
Glycerin 3v 
Aquae Calcis ad §iv 
For the subacute stage; 
Acid Salicylici grv 
Zinci Oxidi 3ii 
Pulv. Amyli Maidis 3ii 
Petrolati X\ 
This may be followed by 
Zinci Oxicli aa 
Glycerin aa3v 
Lac. Magnesise ad §iv 
Ol Rusci (Waldheim) TTLv-sss 
Ung. Zinci oxidi §i 
Liq. Carbonis Deterg. TTj,v 
Or: 
As healing progresses we may increase the strength 
of this lotion by increasing the quantity of Liq. Car- 
bonis detergensis. Full strength, which is i drachm 
to the ounce, may be used when the skin is thick and 
scaly, as found in the chronic stage. 
Sodium citrate and thyroid extract given internally 
seem to have a favorable effect in some cases. 
Eczema orbicularis oris: This is an eczema around 
the vermillion border of the mouth. 
It is caused by the habit of moistening the lip fre- 
quently or the use of strongly aromatic tooth paste. 
The skin is squamo-erythematous and has a tendency 
to crack. The symptoms are burning, itching and pain 
due to cracking. DISEASES OF THE SKIN 
275 
Treatment: Application of Ceratum camphori com- 
positum (Camphor ice). 
Eczema seborrhoicum: The skin, particularly that 
of the face and scalp, is oily and there is a tendency 
to the formation of dandruff on the scalp. Adherent 
dirty yellowish scales form. These are composed of 
sebaceous material and epithelial debris. These are 
surrounded by an inflammation of the adjacent skin. 
On the face the disease is usually irregularly diffused; 
it may occur in oval patches of varying size. Attempt 
to remove the scales will cause bleeding, thus differing 
from the syphilitic affection of the scalp, which re- 
sembles seborrhoea, but is of a brownish or copper 
color. 
Treatment: Soften scales with oil or vaselin or 
camphor ice. Then apply a 3-5% solution of resorcin 
in diluted alcohol. 
Urticaria: This is a common affection in children. 
It may be caused by some gastrointestinal disturbance, 
some special food (strawberries, shell food, pork, 
cheese, pastry, oatmeal, candy, vinegar, sour wines). 
It may also be caused by drugs and antitoxins. Local 
irritation by insects, jellyfish, nettles, etc., is a frequent 
cause of the disease. 
The condition is characterized by the appearance of 
wheals. These may be round, oval or irregular in 
form, and vary in size from that of a pinhead to that 
of spots two or three inches in diameter. 
There is an oedema of the corium, resulting in the 
formation of circumscribed spots, which are pink or 
white in color and which are surrounded by a red area. 
In severe cases the oedema may go on to the formation 
of blebs (urticaria bullosa). Also in severe cases we 276 
CLINICAL PEDIATRICS 
find that scratching will result in the appearance of 
wheals along the line of the scratch. 
This is called dermographia. 
Severe itching is a prominent symptom of the dis- 
ease, and the consequent scratching aggravates the 
condition. 
Any part of the skin may be affected, there being 
no special predilection for any particular location. 
The usual duration is a few hours to a few days. 
Rarely we find cases which may last for months, caus- 
ing much distress through constant itching. 
Treatment: It is best to begin with thorough ca- 
tharsis. This may be followed by the administration 
of mist. Rhei et Sodse or Sodium citrate. For the re- 
lief of itching we may use a 3-5% resorcin solution in 
dilute alcohol. 
Impetigo contagiosa: Contagious disease appear- 
ing on the exposed portions of the body. 
Face and hands are usually affected. 
There is a formation of vesiculo-pustule, which is 
soon surmounted by a central crust. This is at first 
surrounded by a red area. Later, however, the sur- 
rounding skin becomes normal and the drying pustule 
with the crust remains. A few spots usually appear 
on the face and one or more on the hands. The pus- 
tules are usually inch in diameter. After the 
pustule bursts the crust may be removed and leaves a 
raw superficial ulcer, which heals without leaving a 
scar. 
During the first few days fresh vesiculo-pustules 
may appear, but after that it is unusual for them to 
do so unless, owing to some concomitant itching dis- DISEASES OF THE SKIN 
277 
ease, the child’s scratches cause the spreading of infec- 
tion. 
Treatment: Remove the crusts with the aid of soap 
and warm water. Then apply Ung. Hydrarg. Ammon. 
5% strength. 
Molluscum contagiosum: The disease begins as 
a little nodule, the size of a pinhead. It is waxy and 
pinkish yellow. It is located most commonly on the 
face or genitals but may appear in other parts of the 
body, except the palms of the hands and soles of the 
feet. 
These nodules grow until they attain the size of a 
pea. Later, they may become pedunculated. They are 
marked by a central depression from which cheesy 
material may be expressed. A few usually appear at a 
time. These may persist for months, or years, and 
finally disappear by absorption or become inflamed 
and discharge their contents. 
The disease is contagious but the pathology is un- 
known. 
Treatment: Curettage and touching the base with 
pure carbolic acid. Another form of treatment is by 
fulguration or 10% resorcin ointment. 
Acne: Acne is generally associated with come- 
dones. They are commonly found upon a seborrhoic 
skin about the age of puberty, and have a tendency to 
disappear around the age of thirty. 
Comedones are commonly called blackheads. They 
are oblong masses of inspissated sebum obstructing 
the ducts of sebaceous glands. The exposed ends of 
these masses become pigmented and appear most fre- 
quently on the face, neck and back and sometimes on 
the breast. Sooner or later they become infected and 278 
CLINICAL PEDIATRICS 
result in the formation of the acne papule and pustule. 
The papules do not necessarily suppurate, but remain 
indurated and are absorbed after two or three weeks. 
Suppuration results in rupture and discharge of a mix- 
ture of pus and sebaceous material. 
The disease varies in degree of severity. 
Treatment: Attention to general health. Daily 
scrubbing of the face with soap and hot water, and ex- 
pression of the comedones. This should be followed 
by cleansing the skin with absolute alcohol. 
The best lotion to use is 
Potassium sulphide 
Zinc sulphate 
aa 1 drachm 
Glycerin 
3 drachm 
Rose water ad 
4 oz. 
Pediculosis capitis: A condition of the scalp caused 
by the presence of the pediculus capitis (head-louse) 
on the scalp. This insect is about 1-3 mm. in length, 
translucent and grayish in color, except around the 
borders, where it is almost black. Immediately after 
feeding the body assumes a red tinge from the in- 
gested blood. On either side of the body we find three 
strong, hairy, jointed legs, provided with curved book- 
lets. The flat, oval body is provided with seven seg- 
ments, defined by deep lateral notches. The eggs, 
or nits, are minute gray or yellowish, shiny, pear- 
shaped bodies, visible to the naked eye. Each is firmly 
attached to the hair with the large end projecting out- 
ward and towards the distal extremity of the hair. 
The eggs hatch in about one week and the parasite 
becomes mature in two or three weeks. The eggs are 
deposited near the roots of the hair. Thus the nits DISEASES OF THE SKIN 
279 
furthest away from the scalp are the oldest. The para- 
site gets its nourishment by inserting its haustellum 
into a follicle, sucking up a small quantity of blood, 
causing a small punctate wound. As a result of 
scratching to relieve the intense itching, we may get 
secondary infections and enlargement of cervical 
glands. 
Treatment: Soak the hair over night with Tr. Del- 
phinium, or equal parts of kerosene and olive oil. In 
the morning wash the hair with soap and water, soak 
with dilute acetic acid, and fine-comb to get out the 
nits. 
Pediculosis corporis: Resembles the scalp variety, 
but is somewhat larger and inhabits the underclothing, 
laying eggs in the seams of the garments. Itching is 
intense, especially on the neck and the back of the 
shoulders, around the waist and upper part of the 
thighs. Scratch marks on the back of the shoulders 
are characteristic. Scratching often results in second- 
ary infection. 
Treatment: Cleanliness of the body and clothing. 
Infected clothing should be boiled. 
Scabies (itch) : A contagious animal parasitic dis- 
ease, caused by the itch mite (acarus scabiei), char- 
acterized by intense itching. The lesions are caused 
by the presence of the acarus in the skin and scratch 
marks. The lesion peculiar to the disease is the forma- 
tion of burrows by the female acarus. This burrow is 
1/10 mm. long, straight, curved, or elevated, dotted 
with black specks. It lengthens, as the female mite 
continues to bore ahead, depositing eggs and faeces. 
In a well-developed case, numerous burrows may be 
found, and are seen most frequently in the interdigital CLINICAL PEDIATRICS 
folds. The identity of these burrows is soon de- 
stroyed by scratching and they are converted into 
papules, which are often infected. The favorite loca- 
tions of the infections seem to be: the flexor surfaces 
of the arms and wrists, dorsum of the hands, axillary 
folds, areola of the nipples, the abdomen, the penis 
and inner aspect of the thighs. Only in nursing in- 
fants are they ever found on the face. In infants they 
may also be found on the feet, especially the soles. 
Ihe eiuption is papular, but may become vesicular 
and pustular, especially on the palms of the hands. 
Infection may give some spots an impetigenous ap- 
pearance. Itching is severe only at night, particularly 
when warm bedclothes are used. 
Treatment; Have the patient soak in a hot bath 
one-half to one hour at bed-time, using soap and the 
scrubbing brush generously. After throughly drying 
the skin, apply Sulphur ointment, 10-20% strength. 
Leave this on all night and give a cleansing bath in 
the morning. Repeat this for three nights in succes- 
sion. If after a few days some spots still remain, re- 
peat the process once or twice. 
ointment of Balsam Peru in vaseline may be 
used. Sulphur ointment used too often may result 
in a papular eruption. 
Trichophytosis capitis (ringworm of the scalp, 
Herpes tonsurans) ; Found only in children. If un- 
treated it usually clears up when patient reaches the 
age of fifteen. It starts as one or more somewhat 
scaly and perhaps slightly elevated spots. The hair 
on these spots becomes lusterless and fragile, and soon 
breaks off close to the level of the scalp. The long 
hair around the edges of the patch may be extracted DISEASES OF THE SKIN 
281 
with little difficulty. The hair follicles may be some- 
what elevated, giving the skdn the appearance of goose- 
flesh. The patches spread slowly and may coalesce. 
There is no change in the color of the skin and no 
tendency to clear in the center, as in trichophytosis 
corporis. The disease sometimes becomes diffused. 
In rare cases the patches may become inflamed, pus- 
tular and crustaceous. Healing does not result in bald- 
ness. 
Treatment: Ointment containing 1 drachm of io- 
dine crystals to 1 oz. of goose grease. This should 
be rubbed into the patches with a soft tooth brush. 
Trichophytosis corporis (ringworm of the body) : 
Generally appears on the exposed surfaces, face, neck, 
and arms. It begins as a small, slightly scaly hy- 
persemic spot. This spot gradually grows peripherally 
at the same time becoming pale and scaly in the center, 
thus assuming the appearance of a ring. The advanc- 
ing edge is elevated, and sometimes may consist of a 
succession of papules, or vesico-papules. Adjacent 
spots may merge, giving the lesion a gyrate appear- 
ance. In other cases new lesions appear within the 
old ones. Sometimes it reaches a diameter of four or 
five inches. Large lesions may remain stationary for 
a long time and then may disappear spontaneously. 
Treatment: Paint the spot with Tr. lodine, or apply 
vigorously a 10% ointment of ammoniate of mercury; 
or apply pure carbolic acid for a few seconds, and then 
remove it with absolute alcohol. 
Favus: A contagious disease caused by a fungus, 
Achorion of Schoenlein. This fungus grows on the 
skin in pure culture, forming cup-shaped, sulphur-col- 
ored colonies, varying in size from that of the head of 282 
CLINICAL PEDIATRICS 
a pin to that of a pea. These colonies are friable and 
mortar-like. The earliest lesion is a red patch, cov- 
ered with grayish scales. These colonies appear as 
bright yellow specks at the mouths of hair follicles. 
Hair becomes lustreless and friable and soon falls out. 
The loss of hair is permanent. When the crusts fall 
off or are removed they leave a bleeding depression 
in the skin which ultimately heals and leaves a thin 
white scar. Colonies may coalesce and involve an 
extensive portion of the scalp, resulting in shiny bald- 
ness of the part affected. If untreated, the affection 
persists for a good many years. It seems more com- 
mon in males, and usually begins before the age of 
fifteen. The infection may sometimes be carried to 
non-hairy regions of the skin. The affection has the 
characteristic odor of mice. The sources of infection 
are infected domestic animals, such as cats, dogs, birds, 
rabbits, horses, cattle, mice and rats. 
Treatment: Remove the crusts with soap and water. 
Then an ointment of 3i of crystal lodine to 1 oz. of 
goose grease should be well rubbed into the affected 
parts for at least a month; or for three months into 
the whole scalp. Before completing a course of treat- 
ment, watch closely for a possible recurrence, and 
renew treatment if necessary. It may take years be- 
fore a complete cure is effected. 
Pityriasis rosea (Herpes tonsurans maculosus) ;An 
acute mildly inflammatory disease, characterized by an 
eruption of small, rose-red, slightly elevated macules, 
many of which increase to coin-sized, round or oval 
patches. After the lesion has attained a moderate 
size, it becomes yellow, or salmon-colored, while the 
border remains bright red. The epidermis of the cen- DISEASES OF THE SKIN 
283 
tral part of the lesion becomes dry *and shiny, with 
fine desquamation, especially towards the periphery. 
Large macules sometimes clear up entirely in the mid- 
dle. Lesions may coalesce and form large irregularly 
outlined patches. Most of the lesions usually cease 
to increase in size after about a week. They do not 
all attain the same stage of development. Fresh lesions 
generally cease to appear after one or two weeks. 
The lesions are very superficial and there is no in- 
filtration of the skin. The eruption usually appears 
on the trunk, but may also appear on the neck, arms 
and thighs. As a rule it is not found on the face, or 
below the knees. 
Occasionally we find that one spot will appear four 
to twelve days before the general eruption. 
There may be a moderate amount of itching, but 
usually only when the skin is moist with perspiration. 
The eruption persists for three to six weeks, or 
longer. 
The disease is common in the young and very un- 
usual in older individuals. 
Treatment: Recovery is usually spontaneous. It 
may perhaps be hastened by the use of a 5% ointment 
of sulphur. 
Ichthyosis: This is a congenital dryness of the skin, 
resulting in desquamation, which may vary in severity 
from furfuraceous to plate-like scales. It may not be 
noticed for one or two years after birth. It is often 
hereditary. 
Treatment is of little avail. Some improvement may 
be obtained by the use of frequent warm baths and 
inunction of lanoline. 
Dermatitis exfoliativa (Pityriasis rubra) : Derma- 284 
CLINICAL PEDIATRICS 
titis exfoliativa begins upon any part of the body, but 
usually in the flexures about the joints, as patches of 
erythema which spread and coalesce. New patches 
appear and follow a similar course until the whole sur- 
face of the body may become involved. The onset is 
often with a rise of temperature and a more or less 
pronounced fever may be present throughout the 
course of the disease. After a week or ten days, des- 
quamation begins. The scales are either small and 
bran-like or in the form of thin flakes which are often 
so plentiful that a handful can be collected from the 
patient's bed or clothing. The thicker epidermis of 
the palms and soles is sometimes cast off in the sheets, 
exposing a dry, vivid red and shiny surface. The 
affected skin is not at first palpably infiltrated and even 
in the later stages the infiltration is seldom pronounced. 
The patches are at first rather a bright red, but soon 
acquire also a yellowish or brownish hue from the 
deposit of pigment. The scales are usually dirty gray. 
Skin infections, pustules and boils are not uncommon 
complications. The sensibility of the skin remains 
intact, but there are generally subjective symptoms of 
tingling, smarting, burning, or pain; itching is less 
common. Cases of dermatitis exfoliativa vary greatly 
in extent, severity and duration. The mildest may 
remain localized and run a short course of only a few 
weeks or months. At the other extreme are the cases 
usually described as pityriasis rubra, which invariably 
terminate fatally. Most cases eventually become uni- 
versal, though the time required varies from a few 
days to a couple of years. Recovery is the rule, but 
convalescence is usually protracted and recurrences 
are frequent. A few cases progress to a persistent DISEASES OF THE SKIN 
285 
universal dermatitis from which the patient never re- 
covers. In the advanced stage of the severe form the 
skin appears shrunken and tense and may be fissured 
about the joints. The nails are distorted and the hair 
is shed. The buccal mucous membrane becomes red, 
and cracked upon the lips. 
Symptoms develop which may indicate involvement 
of the internal tissues, i. e., vomiting, diarrhoea, al- 
buminuria, bronchitis, arthritis, etc. The patient dies 
of exhaustion or some intercurrent disease. Not in- 
frequently dermatitis exfoliativa follows an attack of 
psoriasis, eczema, pityriasis rubra pilaris, lichen planus 
or dermatitis venenata, but once developed this sec- 
ondary form is clinically indistinguishable from the 
idiopathic variety and runs a similar course. 
Treatment: General tonic treatment is indicated 
and externally the blandest preparations, such as petro- 
latum, to which one-half per cent, carbolic acid may 
be added. 
Erythema nodosum: An inflammatory affection, 
marked by the appearance of erythematous nodes, 
varying in size from one-half to two inches in diameter. 
The appearance of the rash may be accompanied by 
constitutional symptoms of rheumatic fever, with 
swelling and pains in the joints, ihe skin lesions de- 
velop rapidly and symmetrically on the extensor sur- 
faces of the legs. Sometimes they may also appear 
on the thighs and the upper extremities. The lesions 
are not numerous, only a few appearing. The lesions 
are at first bright red and indurated and painful as well 
as sensitive to the touch. The border is never distinctly 
defined, but merges gradually with the surrounding 
skin. The nodes have a tense appearance and after 286 
CLINICAL PEDIATRICS 
a couple of days assume a purplish color. After a 
few days the spots turn green and yellow. The entire 
course of the lesion is like that of an ecchymosis. Dur- 
ing resolution, the nodes may show fluctuation, but 
abscess formation and ulceration never results, the 
nodes being slowly absorbed. 
Duration of the disease is usually two to four 
weeks, but new crops may appear, prolonging the 
affection to two or three months. They may be asso- 
ciated with other lesions and form a part of the symp- 
tom complex known as purpura rheumatica. 
Treatment: Internal administration of salicylates, 
rest in bed. For painful nodes, we may use a wet 
dressing with Liq. Aluminii acetatis. 
Dermatitis venemata (ivy poisoning) : This is a 
form of irritation caused principally by contact of the 
skin with a plant called Rhus Toxicodendron, or 
poison ivy. Other substances, such as drugs or dye 
stuffs, may produce a similar effect. There is a differ- 
ence in susceptibility in different individuals, some 
not being susceptible at all. The skin which comes in 
contact with the leaves is affected. The hands may 
transfer the poison to other parts of the body. 
The symptoms develop after a few hours. At first 
there is a feeling of warmth and itching, then the skin 
becomes erythematous and swollen. Sometimes wheals 
appear. The inflammatory symptoms gradually in- 
crease, and the burning and itching become intense. 
The erythematous skin becomes covered with minute 
discrete vesicles, which rarely become confluent. After 
a few days the acute inflammation subsides, the skin 
becomes pale and covered with crusts, which ulti- 
mately drop off without any scar formation. DISEASES OF THE SKIN 
287 
Treatment: The substance that causes the irrita- 
tion is soluble in alcohol, and is precipitated by lead 
acetate. The exposed surface should, therefore, be 
bathed with a saturated solution of lead acetate in 
alcohol. The parts which have already become in- 
flamed should be treated by the application of calamin 
and zinc oxide lotion. 
Ecthyma: A pyogenic infection of the skin, char- 
acterized by the eruption of deep-seated pustules, with 
markedly inflammatory and hard, bright red bases and 
areolae. Each lesion starts as a papule, or more fre- 
quently as a flat, not fully distended pustule. This is 
followed by considerable infiltration and formation of 
slightly bloody pus. The head of the pustule becomes 
covered with crust, which later drops ofif and leaves 
a crater-like ulcer with bluish and elevated edges. The 
ulcers heal after a few days and leave pigmented scars. 
New crops appear, prolonging the course of the dis- 
ease. Only a few pustules appear at a time. They 
are usually seen on the legs and sometimes on the 
upper part of the back and also the arms. The consti- 
tutional symptoms are insignificant. The disease oc- 
curs in debilitated children. 
Treatment: Cleanliness and Ung. Hydrarg. Am- 
mon. (5-10%), Remove the crusts. 
Erysipelas: An acute contagious dermatitis, caused 
by infection with the Streptococcus pyogenes (Ery- 
sipelatis). The infection enters through some abra- 
sion in the skin. 
The appearance of the rash is preceded by malaise, 
headache, vomiting, chills and fever, which may pre- 
cede the skin lesion twenty-four hours. We first notice 
a coin-sized patch, peculiarly smooth, shiny and red, 288 
CLINICAL PEDIATRICS 
with a well-defined border, which is usually elevated. 
The lesion is hot and tender and causes burning, pain 
or itching. The redness is rosy at first, later becoming 
crimson. It disappears on pressure, but leaves a some- 
what yellowish tinge. 
The patch may retain its original size, but more fre- 
quently it spreads peripherally. In cases of moderate 
severity, the inflammation continues for about a week, 
accompanied by constitutional symptoms, the tempera- 
ture ranging between 103-106°. With resolution, all 
symptoms disappear, the skin becoming pale and des- 
quamating, with gradual return to normal. In severe 
cases, vesicles and bullae may form. Their contents 
usually become purulent and result in crust formation. 
Occasionally there is a deep infiltration and gan- 
grene of the skin. 
Erysipelas migrans has a tendency to spread rapidly 
and may even extend to the mucous membrane of the 
mouth, larynx and lungs and possibly to the meninges. 
These cases are generally fatal. In a well developed 
case, the skin is red and very much swollen and death 
may occur from exhaustion, toxaemia, septicaemia, or 
metastatic abscesses. The condition is not uncommon 
in the new-born, the point of entry of infection being 
the umbilicus. 
Treatment: Local application of ichthyol ointment, 
or 25% solution. We may paint the borders of the 
red area with Tr. lodine, 5-10%. Potassium lodide 
(10%) may be added to the ichthyol ointment. DISEASES OF THE SKIN 
289 
TABLE OF WEIGHT AND HEIGHT 
Age 
At birth 
rA 
lbs. 
20 
inches 
3 
months 
12 
ii 
6 
a 
16 
ii 
9 
“ 
17^2 
a 
12 
a 
20 
a 
29 
inches 
2 
years 
26 
a 
32 
ii 
3 
ii 
30 
a 
35 
ii 
4 
a 
35 
a 
38 
ii 
5 
a 
39 
a 
4i 
ii 
6 
a 
43 
« 
44 
ii 
7 
a 
47 
a 
46 
ii 
8 
ii 
52 
a 
48 
ii 
9 
ii 
57 
a 
50 
ii 
IO 
ii 
62 
a 
52 
ii 
ii 
ii 
68 
a 
54 
ii 
12 
ii 
73 
a 
56 
ii 
13 
“ 
79 
a 
58 
ii 
14 
ii 
88 
a 
61 
ii 
i5 
ii 
103 
a 
63 
ii 
16 
ii 
114 
a 
65 
4i 
Average weight 
Average height INDEX 
A 
Atelectasis, acquired, 119 
Atheroma, 134 
Abscess, of the liver, 96 
of the brain, 236 
Atresia, anal, 69 
rectal, 69 
ischiorectal, 74 
intestinal, 67 
Acephaly, 223 
Acetonuria, 70, 136 
Achondroplasia, 160 
Acne, 277 
B 
Acute yellow atrophy, 96 
Adenoids, 61 
Babinski sign, 262 
Addison’s disease, 148 
Bacterial contamination of in 
testinal tract, 45, 49 
Albumen milk, 48 
Albuminuria, orthostatic, 135 
Amaurotic family idiocy, 233 
Balanitis, 150 
Band’s disease, 167 
Anaemia, simple, 161 
pernicious, 164 
Barley water, 22 
Basedow’s disease, 159 
Bednar’s aphthae, 54 
pseudoleukemia, x6i 
Anaemic murmurs, 133 
Beef-juice, 22 
Blood, diseases of, 161 
Anaphylaxis, 46 
Anencephaly, 223 
Breast feeding, 23 
Bronchiectasis, 107, 118 
Angina, pseudomembranous, 60 
gangrenous, 60 
Bronchitis, acute, 105 
chronic, 107 
Anuria, 137 
fibrinous, 106 
capillary, no 
Appendicitis, 77 
Arteries, small, 134 
Bronchopneumonia, acute, 109 
chronic, 118 
Arthritis, 206 
Artificial feeding, 27 
Broth, 22 
Asthma, 107 
Brudzinski sign, 262 
Asphyxia, congenital, 14 
acquired. 
Buhl’s disease, n 
Bulbar disease, 233 
Atelectasis, congenital, 15 
Buttermilk, 22 
291 INDEX 
292 
C 
Dilatation of the colon, con- 
genital, 66 
Calculus, vesical, 154 
renal, 146 
Diphtheria, streptococcus, 188 
true, 188 
Cancrum oris, 53 
Caput succedaneum, 1 
Dysentery, 198 
Catarrh, of the large intes- 
E 
Cephalhsematoma, 1 
Cerebellar ataxia, 229 
tines, 72 
Ecthyma, 287 
Eczema, 272 
Cerebral hemorrhage, 15, 243 
Cerebro-spinal symptom com- 
Eczema seborrhoicum, 275 
plex, 227 
Emphysema, 120 
Empyema, 121 
Charcot-Marie-Tooth paraly- 
sis, 231 
Encephalitis, 235 
Encephalocele, 225 
Chicken-pox, 187 
Endocarditis, acute, 127 
chronic, 130 
Cholera infantum, 49 
Chlorosis, 163 
malignant, 129 
Enuresis, 152 
Chorea, 251 
Cirrhosis of the liver, 97 
Colitis, acute, 73 
Epilepsy, 253 
membranous, 73 
mucous, 73 
Epistaxis, 100 
Erb’s palsy, 3 
type of dystrophy, 231 
Erysipelas, 287 
Communicable diseases, 178 
Condensed milk, 22 
Erythema nodosum, 285 
Erysipelas of the newborn, 9 
Constipation, of infants, 65 
of older children, 73 
F 
Coryza, 99 
Cough, nervous, 107 
Cow’s milk, 20 
Facial palsy, 244 
Cretinism, 158 
Fatty liver, 96 
Favus, 281 
Feeding, 23 
mixed, 25 
D 
supplemental, 31 
Dermatitis exfoliativa, 283 
Dermatitis venenata, 286 
Diabetes mellitus, 173 
Fissure in ano, 63 
Foreign body in the larynx, 104 
insipidus, 176 
Friedreich’s ataxia, 229 
Functional disorders of the 
Diarrhoea, 45, 71 
heart, 133 INDEX 
293 
Hodgkin’s disease, 166 
Hutchinson’s teeth, 56 
Hydrocele, 83 
Gangrene of the lungs, 119 
Geographical tongue, 55 
Genital organs, diseases of, 149 
Genito-urinary system, dis- 
Hydrocephalus, 223 
Hydronephrosis, 137 
Hydronephrosis, traumatic, 146 
Hypostatic pneumonia, 118 
German measles, 183 
Glycosuria, 135 
eases of, 135 
Hysteria, 259 
Goitre, air, 104 
Granuloma, of umbilicus, 
Grave’s disease, 159 
I 
Grippe, 200 
Icterus neonatorum, 4 
Ichthyosis, 283 
Impetigo, 276 
H 
Inanition, acute, of infants, 32 
fever, 17 
Hsematoma of the sterno- 
cleido-mastoid, 1 
Indicanuria, 136 
Indigestion, gastric, 70 
chronic, 71 
Hsematuria, 135 
Haemoglobinuria, epidemic, 12 
paroxysmal, 135, 172 
Infantile paralysis, 243 
Infantilism, 159 
Infectious diseases, 178 
Haemolytic jaundice, 168 
Haemophilia, 169 
Intertrigo, 272 
Hanot’s disease, 97 
Harelip, 52 
Intestines, diseases of, 63 
Influenza, 200 
Heart, diseases of, 124 
functional disorders of, 133 
Hemiatrophy of the face, 246 
Hemorrhage from the um- 
Intussusception, 68 
Ischiorectal abscess, 74 
Itch, 279 
bilicus, 7 
J 
Hemorrhoids, 74 
Hernia, 80 
Jaundice, catarrhal, 95 
Hernia of the umbilical cord, 4 
of the umbilicus, 7 
epidemic, 95 
haemolytic, 168 
inguinal, 80 
Herpes, of the vulva, 152 
tonsurans maculosus, 280 
K 
Hiccough, 251 
Hirschsprung’s disease, 66 
Kernig sign, 262 
Kidney, diseases of, 138 294 
INDEX 
Kidney, tumors of, 145 
malformations of, 137 
Migraine, 257 
Milk, condensed, 22 
L 
cow’s, 20 
pasteurized, 21 
peptonized, 21 
skimmed, 22 
sterilized, 21 
woman’s, 18 
Landry’s paralysis, 241 
Landouzy-Dejerine type, 231 
Laryngitis, catarrhal, 101, 102 
croupous, 102 
Molluscum contagiosum, 277 
submucous, 103 
Larynx, new growths of, 103 
Mongolism, 160 
Mouth, diseases of, 52 
Multiple neuritis, 244 
Multiple sclerosis, 243 
Leukemia, 165 
Lithuria, 136 
Little’s disease, 243 
Muscular apparatus, diseases 
Liver, diseases of, 95 
Lumbar puncture, 262 
Lungs, diseases of, 105 
Muscular atrophy, 230 
Muscular dystrophy, 231 
of, 247 
Myaesthenia, 233 
M 
Myelitis, 240 
Myocarditis, 132 
Macewen sign, 262 
Myotonia, Thomsen’s, 234 
Myxidiocy, 159 
Malaria, 203 
Malnutrition, 33 
Myxoedema, 159 
Marasmus, 35 
Mastitis, 4 
N 
Masturbation, 258 
Measles, 178 
Nervous system, diseases 
Meatitis erosiva puerorum, 150 
of, 223 
Melaena neonatorum, 12 
Meningism, 264 
tumors of, 241 
Neuraesthenia, 255 
Nutrition, 18 
Meningitis, tuberculous, 265 
Meningococcus, 266 
diseases of, 32, 42 
Nystagmus, 250 
Pneumococcus, 269 
Streptococcus, 270 
staphylococcus, 270 
influenza bacillus, 270 
0 
Meningocele, 224 
Obstetrical paralyses, 3 
(Edema, general, 148 
(Esophagus, diseases of, 61 
Microcephaly, 223 
Micromelia, 160 INDEX 
295 
Omphalomesenteric duct, S 
Ophthalmia neonatorum, 10 
Oppenheim reflex, 262 
Respiratory organs, diseases 
of, 99 
Retropharyngeal abscess, 61 
Rheumatism, 204 
p 
Rhinitis, chronic, 99 
syphilitic, 100 
Parasites, intestinal, 85 
Parotitis, 57, 202 
membranous, 100 
Rickets, 37 
Pediculosis, 278 
Pemphigus, 17 
Pericarditis, 125 
Perinephritis, 146 
Ringworm, 280 
Peritoneum, diseases of, 92 
Peritonitis, 92 
s 
Perleche, 54 
Pertussis, 201 
Salivary glands, diseases of, 56 
Scabies, 279 
Pityriasis, rosea, 282 
Scarlet fever, 179 
rubra, 283 
Sclerema, 16 
Scleroedema, 16 
Phimosis, 149 
Pleurisy, 120 
Scrofula, 176 
Scurvy, 35 
Pleuropneumonia, 118 
Pneumonia, lobar, 114 
Poliomyelitis, 239 
Sepsis, of the newborn, n 
Sinus, thrombosis, 238 
Skin, diseases of, 272 
Porencephaly, 223 
Prematurity, 13 
Small-pox, 185 
Prepuce, adherent, 149 
Proctitis, 74 
Spasmophilia, 249 
Spasmus nutans, 250 
rotatorius, 250 
Prolapse, of rectum, 64 
Psychoses, 261 
Spina bifida, 225 
Spinal cord, tumors of, 243 
Purpura, 170 
Pyelitis, 145 
Spinal symptom complex, 227 
Spleen, enlargement of, 167 
Pyloric stenosis, 75 
Pyuria, 135 
Status lymphaticus, 155 
Stenosis of anus, 69 
of rectum, 69 
Q 
of intestines, 67 
Still’s disease, 207 
Quinsy sore throat, 59 
Stomach, diseases of, 63, 70 
Stomatitis, 52 INDEX 
Stridor, congenital, 104 
Supplementary diet, for in- 
Umbilicus, diseases of, 6 
hernia of, 7 
Syphilis, 208 
fant, 31 
Undescended testicle, 149 
Urachus, fistula, 5 
Syphilis of the nervous sys- 
Urethritis, 150 
tem, 234 
Uric acid infarction, 137 
Urticaria, 275 
Tache cerebrale, 262 
Teething, 55 
T 
V 
Tetanus neonatorum, 9 
Thomsen’s myotonia, 234 
Thrush, 53 
Vaccination, 187 
Thymus, diseases of, 155 
Thyroid, diseases of, 157 
Tic convulsif, 257 
Vomiting of blood, 12, 63 
Vomiting, recurrent, 70 
Vincent’s angina, 60 
Von Jaksch anaemia, 161 
Vulvitis, gangrenous, 152 
Vulvo-vaginitis, 150 
Tongue, anomalies of, 55 
Tonsillitis, 58 
Tonsils, hypertrophy of, 60 
Torticollis, 257 
Trichophytosis, 280 
Tuberculosis, 215 
Tuberculosis of the intes- 
W: 
Weaning, 25 
of the nervous system, 235 
of the kidney, 144 
tines, 74 
Weight, 13, 289 
Weil’s disease, 95 
Wet-nurse, 25 
Typhoid, 194 
Typhus, 192 
Whey, 22 
Whooping cough, 201 
Winckel’s disease, 12 
Worms, 85 
u 
Ulcer of the stomach, 63 
Wry neck, 257